# Emergency Medicine/Pediatric Rehydration

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## Contents

- 1 Pediatric Rehydration
- 2 Clinical Eval of Dehydration
- 3 Oral rehydration
- 4 Oral Rehydration Solutions
- 5 After Rehydration
- 6 Parenteral Rehydration
- 7 Bolus
- 8 End Points
- 9 Post-acute Treatment
- 10 Monitoring- Give enough
- 11 But not too much
- 12 Calculations- Where to start
- 13 Calculating Deficits
- 14 Maintenance Fluids- Goals
- 15 Maintenance Fluids- Calculations
- 16 Maintenance- Rate
- 17 IV Fluids
- 18 Special Cases
- 19 Special Cases (cont’d)
- 20 Special Cases- Lungs
- 21 Special Cases (cont’d)
- 22 Special Cases (cont’d)
- 23 Hyponatremic dehydration
- 24 Hypernatremic Dehydration
- 25 IVF for Ongoing Losses
- 26 Summary

# 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 ==