Urgent care for

dehydration in children

Prof. dr D Bokonjic
Distribution of fluid
newborn Small kid
ECT 25% ICT 40% plazma 5% ostalo
ECT 45% ICT 35% plazma 5% ostalo

adults
ECT 20% ICT 40% plazma 5% ostalo
The trend of change with aging
Homeostasis
Water-electrolyte balance factors-
children vs. adults

 Surface
 Metabolism
 Kidney function
 Needs for water
Clasification

 Hypotonic – loss of electrolytes,

especially Na
 Hypertonic - primarily water loss
 Isotonic - equal loss of water and
electrolytes
Dehidratation

 Mild (DO 5% TT)

 Moderate (10% TT)

 Severe (15% TT)

Level of dihdratation-clinical aspect
Mild Moderat Severe
e
Loss of <50ml/kg 50-90ml/ >100
volume kg ml/kg
Collor of pale grey marbled skin

skin
Elasticity reduced bad very bad

Lips dry Very dry chapped

Diuresis reduced oliguria intensive

oliguria

TA normal normal/ reduced

reduced
Worrying signs of dehydration

 Tachycardia
 Dry skin and mucous membranes
 Retracted fontanelle
 Circulatory weakness (cold extremities)
 Loss of elasticity
 Prolonged capillary filling
 Hypovolemia is the most common cause
of poor perfusion.
 Inadequate organ perfusion is the basis of
organic dysfunction.
 What is optimal?

 Systolic pressure
 <1year.:70mmHg
 1year.-10years. 70mmHg+(2 x age in years.)
 >10years 90mmHg
 Strong peripheral pulse
 Good skin perfusion (warm, cap. fill.<2sec.)
 Normal mental status
 Diuresis 1ml/kg/h
Mild dehidratation(loss 5% TT)

 dry skin and mucosa, thirst

 fluid replacement 50ml-100ml/kg during 4h

 Moderate (loss 10% TT)

 cold periphery, prolonged capillary filling, loss

of skin elasticity, inflammation of the eyeballs
and fontanela, oliguria, tachypnea
 Introduce 100ml/kg
 Severe (loss 15% TT)

 Shock state, unresponsive to pain, deep

(acidotic) breathing

 Decrease TA-late sign

 Replacement 150ml/kg
 Physiological needs

Holliday-Segar formula for maintaining of physiological needs accroding to weight

TT (kg) Water Electrolytes

(mEq/L H2O)
mL/day mL/h
0–10 kg 100/kg 4/kg Na 30, K 20
11–20 kg 1000 + 50/kg for 40 + 2/kg for Na 30, K 20
each kg >10 eachkg > 10

> 20 kg 1500 + 20/kg for 60 + 1/kg for each Na 30, K 20

each kg > 20 kg > 20
Needs duirng first days of life
ml/kg/day

Day Neonatus Preterm

1 60 90

2 90 120

3 120 150

4 150 180-200
 Needs are enhanced:

 Fever for 12% for 1 Co > 37 Co

 Hyperventilation in hypermetabolic states (25-

75%)

 Warming (25%)
 Needs are reduced:

 On MV with humidifier by 30-35%

 In hypothermia
 In edema
 Increased ICP (CPP = MAP-ICP)
 In antidiuretic conditions (30-40%)
DONOT GIVE
HYPOTONE
SOLUTIONS!!!
Treatment

1 Status assessment
What is the volume status?
What is the rate of loss?
Can Rehydration PO?
Is there a need for IV rehydration?

2: Access
Peripheral IV
Central venous line
Intraosseous?
3: Selection of fluid

4: Speed
Resuscitation

 Patients with signs of hypoperfusion

 Bolus of isotonic solutions (0.9% NaCl or Ringer-lactate)
 Restore circulating volume, TA and perfusion
 The goal is  deficit loss of ~ 8% TT
 Moderate: 20 mL / kg (2% TT) IV over 20 - 30 min,
reduces from 10% deficit to 8%
 Serious: 3 bolus of 20 mL / kg (2% TT)
 5% glucose solution leads to complications,
even death!!!

 Moritz M. Preventing neurological complications from

dysnatraemias in children. Paed Nephr 2005;20:1687-1700
Replacement of deficit

 Na + deficit about 80 mEq / L from fluid deficit

 K + deficit about 30 mEq / L from fluid deficit
 After the resuscitation phase, the remaining deficit is
compensated by 10 mL / kg (1% TT) / h for 8 h

 K + with 20 - 40 mEq K + / L (when diuresis is

established)
 Cureent fluid losses

 The volume of current losses should be

measured directly (eg NGT, catheter, stool) or
assessed (eg 10 ml / kg for diarrhea)
 Replacement should be milliliter by milliliter at
appropriate intervals following the rate and
extent of loss
Unvisible losses

 Through skin and respiratory tract

 Around 10ml/kg per day
 Total
Water deficit:
Determine TBW:% TT
Free water deficit: (Na + - 140) / 140] x TBW
Compensation during 48-72 h
Current water losses:
Free water clearance
V - V x (TNa + TK) / 140
Invisible losses:
approx. 10mL / kg per day
 Shock
 0.9% NaCl, Hartman's solution or Ringer
 Repeat 20ml / kg boluses with perfusion control.
 Colloids
 After 3 bolus, intubate, CVP
 Monitor gas analysis and KKS

 In diabetic ketoacidosis - 10ml / kg isotonic fluid within

1h
 There is no evidence that increased fluid replacement
(> 40ml / kg) increases the incidence of pulmonary
edema
 Glucose application?

 Serum osmolality = 2 (Na +) + Glucose / 18 + BUN / 2.8

 The effect of Na on osmolality is greater
 Therefore G5 ½ NS is unsuitable for most patients who are
hypovolemic.
 Glucose is metabolized into water and CO2 that pass into
the circulation, so it is not long osmotically active
Vulnerabile groups
 neonatus, prematurus
 in malnourished children of
 children with renal insufficiency
 the main consequence of bleeding is a
deficiency of interstitial fluid, and that the
replacement of interstitial loss with a
crystalloid is important for survival.
 Colloids?

 0.9% NaCl increases ECT in a 1: 1 ratio; only 20%

remains
 5% albumin increases ECT two times more and is
distributed in intersticium and in iv. equally
 Colloids are given to patients with capillary leakage or
hypoalbuminemia who do not respond to crystalloids
 Colloids?

 Yes septic shock

 No in case of head and other
trauma

 Rachel M.Kruer, Christopher R.Ensor.Colloids in the intensive

care unit. American Journal of Health-System Pharmacy,
2012;69(19): 1635-42.
Edema?

 Crystalloids - distribution in the interstitium

 Colloids (albumins) - the main oncotic force
 -> ½ albumin in the human body is in the interstitial fluid
also distribution in the interstitium
 - capillary permeability is impaired which is common in
critically ill patients.

 Despite this risk, edema (e.g., pulmonary edema) is not

common regardless of fluid selection during resuscitation
when capillary hydrostatic pressure is not excessive.
Reinhart K. et all. Consensus statement of the ESICM task force on colloid volume therapy in critically
ill patients. ESICM, 2012.38: 368-83.
 Hyponatremia
 Symptoms (lethargy, nausea, headache)
 Children develop symptoms before adults (Na> 125mmol / l)
 (normal Na (mEq) - measured Na (mEq)) x 0.6 x TT (kg)

 Caution with hypertonic Na (osmolarity) plasma normal or high)

fatal
 1ml / kg 3% NaCl raises serum Na level by 1mmol / l (up to Na
125mmol / L)
 Correction up to max.10mmol / L / 24h
 DEMIELINIZATION
 DI SIADH CSW
Diuresis poliuria reduced poliuria
Serum Na enhanced reduced reduced
Urin Na reduced enhanced enhanced
Serum enhanced reduced reduced
osm /normal
Urin osm reduced enhanced reduced
/normal
CVP normal/reduced enhanced reduced
 Hypernatremia

 Symptoms are more severe when they occur

rapidly, or if Na> 160mmol / l.
 Bolus 20ml / kg to normovolemia
 Correction max. 12 mmol / kg / 24h for 2 days
Slika A: Normalna ćelija. Slika B: Inicijalno ćelija na hiperosmolarnost ekstracelularnog
prostora odgovara pasivnom osmozom vode i skupljanjem ćelije. Slika C:Ćelija aktivno
reaguje kako bi se ograničio gubitak vode kroz transport organskih osmotski aktivnih
supstanci preko ćelijske membrane, kao i kroz intracelularnu proizvodnju. Slika D: Prebrzo
ispravljanje ekstracelularne hipertonije dovodi do pasivnog kretanja molekula vode u
relativno hipertonični intracelularni prostor, izaziva oticanje ćelija, oštećenja, i na kraju
 Hypokalemia (<3,5mmol/l)

 Lethargy, muscle weakness, arrhythmias

 Speed ​max. 0.5 mmol / kg / h (in severe hypoK
 Hyperkalemia (>5,5mmol/l)

 Reduced taking K

 Apply:
 10% Ca gluconate (0.5ml / kg)
 Glucose 0.5g / kg / h with 0.05 IU / kg / h insulin.
For
 15-20min
 Salbutamol
 Rhesonium 250 mg - 1 g / kgTT
 Replacement of renal function
 Sy short intestine
 Ileostoma
 Cyanogenic heart defects
 Renal failure and transplantation
 Infants
Conclusion
Disorders of water and electrolyte regulation are common in critically ill patients

. The diagnostic approach must be carefully considered for each patient

. Effective and safe therapy