Emergency Medicine/Pediatric Rehydration

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Pediatric Rehydration[edit]

  • Alex Flaxmanman==

Clinical Eval of Dehydration[edit]

  • Mild (3–5%): HR nl or ↓, ↓ UO, thirsty, nl PE ==
  • Moderate (7–10%): cool and pale, tachy, delayed cap refill, little or no UO, irritable/lethargic, sunken eyes and fontanel, ↓ tears, dry MM, mild skin tenting ==
  • Severe (10–15%): cold and mottled, pulse rapid and weak, ↓ BP, no UO, very sunken eyes and fontanel, no tears, parched MM, skin tenting, very delayed capillary refill ==

Oral rehydration[edit]

  • Pick a fluid (more later) ==
  • Mild dehydration- 50 mL/kg within 4 hr ==
  • Moderate dehydration- 100 mL/kg over 4 hr ==
  • Additional fluids as per clinical condition ==
  • Vomiting with the first 2 hrs of ORS → 1 teaspoon q1-2min ==

Oral Rehydration Solutions[edit]

After Rehydration[edit]

  • Resume breast feeding, or usual formula/milk ==
  • Resume feeding, if appropriate ==

Parenteral Rehydration[edit]

  • (IVF) ==

Bolus[edit]

  • 20 ml/kg, over 20 min ==
  • Use isotonic fluids- NS or LR ==
  • Blood, 5% albumin, plasma ==

End Points[edit]

  • “Adequate intravascular volume” ==
  • Clinical improvement ==
    • ↓ HR ===
    • Normal BP ===
    • Improved tissue perfusion (UO) ===
    • More alert affect ===

Post-acute Treatment[edit]

  • Must complete initial rehydration ==
  • Calculate amount of fluids needed ==
    • Dehydration % ===
    • Maintenance ===
    • Ongoing losses (e.g. cont’d V/D) ===
  • Give ½ minus any boluses in first 8 hrs ==
  • Give ½ in following 16 hrs ==

Monitoring- Give enough[edit]

  • Vitals ==
    • Pulse ===
    • BP ===
    • CVP- if critically ill ===
  • I/O’s ==
    • Fluid balance ===
    • UO and specific gravity ===
  • Physical Exam ==
    • Daily weight ===
    • Clinical signs of depletion or overload ===
  • Electrolytes ==

But not too much[edit]

  • Edema ==
  • Pulmonary congestion ==

Calculations- Where to start[edit]

  • Mild 3–5% → 5% ==
  • Moderate 7–10% → 10% ==
  • Severe 10–15% → 15% ==

Calculating Deficits[edit]

  • Water Deficit = % dehydration × weight ==
  • Sodium Deficit = Water deficit × 80 mEq/L ==
  • Potassium Deficit = Water deficit × 30 mEq/L ==

Maintenance Fluids- Goals[edit]

  • Prevent dehydration ==
  • Prevent electrolyte disorders ==
  • Prevent ketoacidosis ==
  • Prevent protein degradation ==

Maintenance Fluids- Calculations[edit]

  • “100/50/20” rule ==
    • 100 ml/kg for up to the 1st 10 kg of body weight* ===
    • 50 ml/kg for up to the 2nd 10 kg of body weight ===
    • 20 ml/kg for up to the 3rd 10 kg of body weight ===
  • Max total fluid/day usually 2-2.5L cc ==

Maintenance- Rate[edit]

A calculator exists for this calculation.

  • “4/2/1” Rule ==
    • 0–10 kg: 4 mL/kg/hr
    • 10–20 kg: 40 mL/hr + 2 mL/kg/hr × (wt-10 kg)
    • >20 kg: 60 mL/hr + 1 mL/kg/hr × (wt-20 kg)

IV Fluids[edit]

  • NS ==
    • [Na] 154 mEq ===
    • [Cl] 154 mEq ===
  • LR ==
    • [Na] 130 mEq ===
    • [Cl] 109 mEq ===
    • [K] 4 mEq ===
    • [Ca] 3 mEq ===
    • [Lactate] 28 mEq ===

Special Cases[edit]

  • Metabolic Acidosis (RTA, renal insufficiency) ==
    • Replace some NaCl with NaHCO3 or Na-acetate ===
  • If acidosis caused by lactic acidosis, be careful giving HCO3 ==
  • As correct acid-base problems, watch K ==

Special Cases (cont’d)[edit]

  • Fever ==
  • Premature infants ==
    • Radiant warmers ===
    • Phototherapy ===

Special Cases- Lungs[edit]

  • ↑ Fluids requirement ==
  • Tachypnea ==
  • Tracheostomy ==
  • ↓ Fluids requirement ==
  • Mist tent ==
  • Vent ==

Special Cases (cont’d)[edit]

  • NGT ==
  • Surgical drains ==

Special Cases (cont’d)[edit]

  • Diarrhea dehydration ==
    • Isotonic 60-70% ===
    • Hyponatremic 10-15% ===
    • Hypernatremic 10-20% ===

Hyponatremic dehydration[edit]

Hypernatremic Dehydration[edit]

IVF for Ongoing Losses[edit]

  • D5 1/4 NS + 15 mEq/L bicarbonate + 25 mEq/L KCl ==
  • Replace stool mL/mL every 1–6 hr ==

Summary[edit]

  • Restore intravascular volume ==
    • NS 20 mL/kg over 20 min (repeat until intravascular volume restored) ===
  • Calculate water deficit ==
  • Calculate 24-hr water needs ==
  • Calculate deficit sodium and potassium ==
  • Calculate 24-hr electrolyte needs (Na, K) ==
  • Select fluid (based on total water and electrolyte needs). ==
  • Give ½ calculated fluid minus boluses during first 8 hrs ==
  • Give ½ calculate fluid over the next 16 hrs ==
  • Replace ongoing losses as they occur ==