Dehydration

Paul R. Earl
| Biológicas
Facultad de Ciencias

Universidad Autónoma de Nuevo

León

San Nicolás, N. L., Mexico

pearl@dsi.uanl.mx
 Dehydration or volume depletion is classified as mild,
moderate or severe based on how much body fluid is
lost. When severe, dehydration is a life-threatening
emergency. Volume depletion denotes lessening of the
total intravascular plasma, whereas dehydration denotes
loss of plasma-free water disproportionate to the loss of
sodium. Potassium and other electrolytes including buffers
líke phosphates need to be considered. Children,
especially those younger than 4 years old, are more
susceptible to volume depletion as a result of vomiting,
diarrhea or increases in insensible water losses.
 Dehydration can be caused by losing too much fluid, not
drinking enough water or fluids, or both. Vomiting and diarrhea
are common causes.
 Dehydration is classified as mild, moderate or severe based on
how much body's fluid is lost. Symtons include:
 Dry or sticky mouth.
 Dizziness.
 Low or no urine output; concentrated urine is dark yellow.
 Not producing tears.
 Sunken eyes.
 Markedly sunken fontanelles (the soft spot on the top of the
head in a baby).
 Lethargic or comatose.
 In addition to the symptoms of actual dehydration, you may
also have:
– vomiting and
– diarrhea.
 Drinking fluids is usually sufficient for mild dehydration. It is
better to have frequent, small amounts of fluid (using a
teaspoon or syringe for an infant or child) rather than trying
to force large amounts of fluid at one time. Drinking too
much fluid at once can bring on more vomiting.
 Electrolyte solutions or freezer pops are especially
effective. These are available at pharmacies. Sport drinks
contain a lot of sugar and can cause or worsen diarrhea. In
infants and children, avoid using water as the primary
replacement fluid.
 Intravenous fluids and hospitalization may be necessary for
moderate to severe dehydration. The doctor will try to
identify and then treat the cause of the dehydration.
 Treatment includes starting NS@20ml/kg slow push until
signs of severe dehydration disappear. Avoid Ringer
Lactate till patient passes urine. Maintainence fluid depends
on body weight. Either DNS or RL may be used 10kg and
less 100ml/Kg 10-20 Kg 1000mL+50ml/kg 20+ Kg 1500ml+
20 ml/kg It may be advisable to give half the calculated fluid
in the first 8 hours and the remaining over the next 16 hours
 Precautions
 check for pulmonary oedema replenish Potassium as
required Chills may occur due to fluid administration rule out
infectious causes
 Most cases of stomach viruses (also called viral
gastroenteritis) tend to resolve on their own after a few
days.
 Boxers under hot lights sip water, then usually spit it out.
They don`t seem to know that that water could save them
from a coma during heat prostration !
 Pathophysiology

 Pediatric dehydration is frequently the result of

gastroenteritis, characterized by vomiting and diarrhea.
However, other causes of dehydration may include poor oral
intake due to diseases such as stomatitis, insensible losses
due to fever, or osmotic diuresis from uncontrolled diabetes
mellitus.
 Volume depletion denotes lessening of the total
intravascular plasma, whereas dehydration denotes loss of
plasma-free water disproportionate to the loss of sodium.
The distinction is important because volume depletion can
exist with or without dehydration, and dehydration can exist
with or without volume depletion.
 In children with dehydration, the most common underlying
problem actually is volume depletion, not dehydration.
Intravascular sodium levels are within the reference range,
indicating that excess free water is not being lost from plasma.
Rather, the entire plasma pool is contracted with solutes (mostly
sodium) and solvents (mostly water) lost in proportionate
quantities. This is volume depletion without dehydration. The
most common cause is excessive extrinsic loss of fluids.
 Pediatric patients, especially those younger than 4 years,
tend to be more susceptible to volume depletion as a
result of vomiting, diarrhea, or increases in insensible
water losses. Significant fluid losses may occur rapidly.
The turnover of fluids and solute in infants and young
children can be as much as 3 times that of adults. This is
because of the following:
 Higher metabolic rates
 Increased body surface area to mass index
 Higher body water contents (Water comprises
approximately 70% of body weight in infants, 65% in
children, and 60% in adults.)
 Sodium considerations

 Volume depletion can be concurrent with

hyponatremia. This is characterized by plasma
volume contraction with free water excess. An
example is a child with diarrhea who has been given
tap water to replete diarrheal losses. Free water is
replenished, but sodium and other solutes are not.
 In hyponatremic volume depletion, the person may appear more ill clinically
than fluid losses indicate. The degree of volume depletion may be clinically
overestimated. Serum sodium levels less than 120 mEq/L may result in
seizures. If intravascular free water excess is not corrected during volume
replenishment, the shift of free water to the intracellular fluid compartment may
cause cerebral edema.

With true dehydration, plasma volume contracts with disproportionate further

free water loss. An example is the child with diarrhea whose fluid losses have
been replenished with hypertonic soup, boiled milk, baking soda, or improperly
diluted infant formula. Volume has been restored, but free water has not.
 In hypernatremic volume depletion, the patient may appear
less ill clinically than fluid losses indicate. The degree of
volume depletion may be underestimated. Usually, at least a
10% volume deficit exists with hypernatremic volume
depletion.

As in hyponatremia, hypernatremic volume depletion may

result in serious central nervous system (CNS) effects as a
result of structural changes in central neurons. However,
cerebral shrinkage occurs instead of cerebral edema. This
may result in intracerebral hemorrhage, seizures, coma, and
death. For this reason, volume restoration must be performed
gradually over 24 hours or more. Gradual restoration
prevents a rapid shift of fluid across the blood-brain barrier
and into the intracellular fluid compartment.
 Potassium considerations
 Potassium shifts between intracellular and extracellular fluid
compartments occur more slowly than free water shifts. Serum
potassium level may not reflect intracellular potassium levels.
Although a potassium deficit is present in all patients with
volume depletion, it is not usually clinically significant.
However, failure to correct for a potassium deficit during
volume repletion may result in clinically significant
hypokalemia. Potassium should not be added to replacement
fluids until adequate urine output is obtained.
 Acid and base problems
 Clinicians may observe derangements of acid-base balance with
volume depletion. Some degree of metabolic acidosis is common,
especially in infants.

Mechanisms include bicarbonate loss in stool and ketone production.

Hypovolemia causes decreased tissue perfusion and increased lactic
acid production. Decreased renal perfusion causes decreased
glomerular filtration rate, which, in turn, leads to decreased hydrogen
(H+) ion excretion. These factors combine to produce a metabolic
acidosis.
 In most patients, acidosis is mild and easily corrected with
volume restoration (as increased renal perfusion permits
excretion of excess H+ ions in the urine). Administration of
glucose-containing fluids further decreases ketone
production.
 Frequency
United States
 Pediatric dehydration, particularly that due to
gastroenteritis, is a common ED complaint.
Approximately 200,000 hospitalizations and 300
deaths per year are attributed to gastroenteritis each
year.
International

According to the Centers for Disease Control and

Prevention (CDC), for children younger than 5 years,
the annual incidence of diarrheal illness is
approximately 1.5 billion, while deaths are estimated
between 1.5 and 2.5 million. Though these numbers are
staggering, they actually represent an improvement
from the early 1980s, when the death rate was
approximately 5 million per year.
 Mortality/Morbidity
 Morbidity varies with the degree of volume depletion and
the underlying cause.
 The severely volume-depleted infant or child is at risk for
death from cardiovascular collapse.
 Hyponatremia resulting from replacement of free water
alone may cause seizures.
 Improper management of volume repletion may cause
iatrogenic morbidity or mortality.
 Age
 Infants and younger children are more susceptible to
volume depletion than older children.
 Clinical History
 The goal of the history and physical examination is to
determine the severity of the child's condition. Classifying
the degree of dehydration as mild, moderate, or severe
accurately allows for appropriate therapy and disposition of
the patient in a timely fashion.

 Obtaining a complete history from the parent or caregiver

is important because it provides clues to the type of
dehydration present.
The emergency physician should be diligent in obtaining the
following information:

 Feeding pattern and fluids given

 Number of wet diapers compared with normal
 Fluid loss (eg, vomiting, oliguria or anuria, diarrhea)
 Possible ingestions
 Activity
 Medications
 Heat and sunlight exposures
 Physical
 The following table highlights the physical findings seen
with different levels of pediatric dehydration.
 Mild (<3% body Moderate (3-9% body Severe (>9% body
Symptom
weight lost) weight lost) weight lost)
Mental Restless or fatigued, Apathetic, lethargic,
Normal, alert
status irritable unconscious
Tachycardia or
Heart rate Normal Normal to increased
bradycardia
Quality of Weak, thready,
Normal Normal to decreased
pulse impalpable
Tachypnea and
Breathing Normal Normal to increased
hyperpnea

Eyes Normal Slightly sunken Deeply sunken

Fontanelle
Normal Slightly sunken Deeply sunken
s

Tears Normal Normal to decreased Absent

Mucous
Moist Dry Parched
membranes

Skin turgor Instant recoil Recoil <2 seconds Recoil >2 seconds

Capillary
<2 seconds Prolonged Minimal
refill

Extremities Warm Cool Mottled, cyanotic

Mild (<3% body Moderate (3-9% body Severe (>9% body

Symptom
weight lost) weight lost) weight lost)

Restless or fatigued, Apathetic, lethargic,

Mental status Normal, alert
irritable unconscious

Tachycardia or
Heart rate Normal Normal to increased
bradycardia
 Normal to Weak, thready,
Quality of pulse Normal
decreased impalpable

Tachypnea and
Breathing Normal Normal to increased
hyperpnea
Eyes Normal Slightly sunken Deeply sunken
Fontanelles Normal Slightly sunken Deeply sunken
Normal to
Tears Normal Absent
decreased

Mucous
Moist Dry Parched
membranes

Instant
Skin turgor Recoil <2 seconds Recoil >2 seconds
recoil

Capillary refill <2 seconds Prolonged Minimal

Extremities Warm Cool Mottled, cyanotic

 Of these, the most accurate in identifying the level of
dehydration are capillary refill, skin turgor, and breathing.
The least accurate are mental status, heart rate and
fontanelle appearance.
 Causes
 In most cases, volume depletion in children is from fluid losses from vomiting
or diarrhea.
 Vomiting may be caused by any of the following systems or processes:
 CNS (eg, infections, space-occupying lesions)
 GI (eg, gastroenteritis, obstruction, hepatitis, liver failure, appendicitis,
peritonitis, intussusception, volvulus, pyloric stenosis, toxicity [ingestion,
overdose, drug effects])
 Endocrine (eg, diabetic ketoacidosis [DKA], congenital adrenal hypoplasia,
Addisonian crisis)
 Renal (eg, infection, pyelonephritis, renal failure, renal tubular acidosis)
 Psychiatric (eg, psychogenic vomiting) - This is not seen in infants and is
rare in children compared with adults.
Diarrhea may be caused by any of the following
systems or processes:

 GI (e.g., gastroenteritis, malabsorption, intussusception,

irritable bowel, inflammatory bowel disease, short gut
syndrome)
 Endocrine (eg, thyrotoxicosis, congenital adrenal
hypoplasia, Addisonian crisis, diabetic enteropathy)
 Psychiatric (eg, anxiety)
 Volume depletion not caused by vomiting or diarrhea may be divided
into renal or extrarenal causes.

– Renal causes include use of diuretics, renal tubular acidosis, and

renal failure (eg, trauma, obstruction, salt-wasting nephritis). The
effects of diabetes insipidus, hypothyroidism, and adrenal
insufficiency also fall into this category.
– Extrarenal causes include third-space extravasation of
intravascular fluid (eg, pancreatitis, peritonitis, sepsis, heart
failure); insensible losses from fever, sweating, burns, or
pulmonary processes; poor oral intake; and hemorrhage.