Download types of dehydration

Fifth stage
‫اثل‬.‫د‬
Pediatric
Lec-2
1/11/2015
DIARRHOEA in INFANCY & CHILDHOOD
Objectives of Lec.2
A/ correction of dehydration
To differentiate between the types of dehydration.
How you can correct different types of dehydration & how you
manage the emergency?
To know the types of oral & I.V. fluid.
B/ Prevention of GE
How you can decrense the occurance of GE
C/ Complication of GE
To enumerate the complication of GE.
TYPES OF DEHYDRATION
 ISOTONIC (ISONATRAEMIC).
= mmol/L
 HYPERTONIC (HYPERNATRAEMIC).
)151(mmol/L
 HYPOTONIC(HYPONATRAEMIC).
mmol/L.
S . Na
135-145
S . Na > 145
S . Na < (135)130
CORRECTION OF DEHYDRATION
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ORAL REHYDRATION THERAPY
 Mild to moderate dehydration from diarrhea of any cause can
be treated effectively using a simple, oral rehydration solution
(ORS) containing glucose and electrolytes. The ORS relies on
the coupled transport of sodium and glucose in the intestine
(Facilitated transport of SODIUM by absorption of
GLUCOSE )
 ORT is less expensive than IV therapy and has a lower
complication rate.
 IV therapy still may be required for patients with severe
dehydration; patients with uncontrollable vomiting; patients
unable to drink because of extreme fatigue, stupor, or coma;
or patients with gastric or intestinal distention.
Physiologic Basis of ORT
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ORS

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NaCl:
3.5 gm
NaHCO3: 2.5 gm
KCl:
1.5 gm
Glucose: 20 gm
Add 1 Liter of pure water
ORS ( WHO 2005)

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
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[Na]
[Cl]
[HCO3]
[K ]
Glucose
Osm
75mmol/L
65mmol/L
10mmol/L
20mmol/L
13.5 g/L
245 mosm/L
Choices of ORS
ORT
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REHYDRATION PHASE
 For MILD Dehydration :
50 cc /Kg/ 4 Hr.
 For MODERATE Dehydration:
100 cc /Kg/ 4 Hr
MAINTENANCE PHASE
MILD Diarrhea : 100 cc /Kg/24Hr
SEVERE Diarrhea : 10-15 cc /Kg/ Hr
in addition to milk feeds until diarrhea stops.
INTRAVENOUS REHYDRATION
INTRAVENOUS
REHYDRATION
DEFICIT
MAINTENANC
E
ONGOING LOSS
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DEFICIT
Calculated According to The Clinical Assessment For Severity of
Dehydration
Water Deficit
Percent dehydration × weight
Resuscitation Phase
 The child with dehydration requires acute intervention to
ensure that there is adequate tissue perfusion. This
resuscitation phase requires rapid restoration of the circulating
intravascular volume. This restoration should be done with an
isotonic solution, such as normal saline or Ringer's lactate.
Blood is an appropriate fluid choice for a child with acute blood
loss.
 The child is given a fluid bolus, usually 20 mL/kg of the isotonic
solution, over about 20 minutes. A child with severe
dehydration may require multiple fluid boluses and may need
to receive fluid at a faster rate.
 The initial resuscitation and rehydration is complete when the
child has an adequate intravascular volume. Typically the child
has some general clinical improvement, including a lower heart
rate, normalization of the blood pressure, improved perfusion,
and a more alert affect.
 Potassium is not usually included in the intravenous fluids until
the patient voids.
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NOTE
The resuscitation phase (treatment of shock state ) is same in iso,
hypo, & hypernatremic dehydration
MAINTENANCE
 Maintenance fluids are composed of a solution of water,
glucose, sodium potassium, and chloride. This solution replaces
electrolyte losses from the urine and stool and water losses
from the urine, stool, skin, and lungs. The glucose in
maintenance fluids provides approximately 20% of the normal
caloric needs of the patient. This percentage is enough to
prevent the development of starvation ketoacidosis and
diminishes the protein degradation that would occur if the
patient received no calories. Glucose also provides added
osmoles, avoiding the administration of hypotonic fluids, which
may cause hemolysis.
 Maintenance fluids do not provide adequate calories, protein,
fat, minerals, or vitamins. Because of inadequate calories, a
child on maintenance IV fluids loses 0.5% to 1% of real weight
each day. Patients should not remain on maintenance therapy
indefinitely; parenteral nutrition should be used for children
who cannot be fed enterally for more than a few days.
Parenteral nutrition is especially important in a patient with
underlying malnutrition.
Goals of Maintenance Fluids




Prevent dehydration
Prevent electrolyte disorders
Prevent ketoacidosis
Prevent protein degradation
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Body Weight Method for Calculating Daily
Maintenance Fluid Volume
First
10 Kg
100 cc /Kg/24Hr
Second
10 Kg
50 cc /Kg/24Hr
> than
20 Kg
20 cc /Kg/24Hr
NOTE: The maximum total fluid per day is normally 2,400 mL.
Maintenance requirements of electrolytes:
 Sodium:
 Potassium:
2 - 3 mEq/kg/day
1 - 2 mEq/kg/day.
Composition of Maintenance fluids:
Child WT < 10Kg:
D5 + ¼ NS (38.5mEq/L) + 20 mEq/L of [K]
Child WT > 10Kg:
D5 + ½ NS (77mEq/L) + 20 mEq/L of [K]
NOTE: These guidelines assume that there is no disease process
present that would require an adjustment in either the volume or the
electrolyte composition of maintenance fluids
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ONGOING LOSSES
 Calculated CC for CC and mmol for mmol and added to the
rehydrating solution.
 Replacement solutions should have approximately the same
electrolyte composition as the fluid that is lost. Electrolyte
content can be measured directly, or a solution can be selected
based on the typical electrolyte composition of diarrhea or
gastric losses
REPLACEMENT OF LOSSES
 < 10Kg BW: 60-120 mL ORS for each diarrheal stool or
vomiting episode
>10 kg BW: 120-240 mL ORS for each diarrheal stool or
vomiting episode
 if unable to drink, administer through nasogastric tube or
administer 5% dextrose in normal saline with 20 mEq/L
potassium chloride IV
Fluid Management of Dehydration
 Restore intravascular volume
Normal saline: 20 mL/kg over 20 min (repeat until intravascular
volume restored) (maximum = 1 L over 2 hr)
 Calculate 24-hr water needs
Calculate deficit water
Calculate maintenance water
 Select an appropriate fluid (based on total water and electrolyte
needs)
 Administer half the calculated fluid during the first 8 hr, first
subtracting any boluses from this amount
 Administer the remainder over the next 16 hr
 Replace ongoing losses as they occur
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TYPES OF IV FLUID
solution
Glucose (g/l)
Na+
K+
Ca+2
Cl-
Lactate
D5W
50
0
0
0
0
0
D10w
100
0
0
0
0
0
NS
0
154
0
0
154
0
½ NS
0
77
0
0
77
0
¼ NS
0
38.5
0
0
38.5
0
D5NS
50
154
0
0
154
0
D5 ½
NS
50
77
0
0
77
0
0.2 NS
0
31
0
0
31
0
3%NaCl
0
513
0
0
513
0
LR
0
130
4
3
109
28
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HYPONATREMIC DEHYDRATION
Hyponatremic dehydration produces more substantial intravascular
volume depletion due to the shift of water from the extracellular
space into the intracellular space. In addition, some patients have
symptoms, predominantly neurologic, as a result of hyponatremia
Treatment
 Treatment of hypovolemic hyponatremia requires
administration of IV fluids with sodium to provide maintenance
requirements and deficit correction and to replace ongoing
losses
 Most patients with hyponatremic dehydration do well with the
same basic strategy for correction of Isonatremic dehydration.
 The initial goal in treating hyponatremia is correction of
intravascular volume depletion with isotonic fluid (NS or LR).
 An overcorrection in the serum sodium concentration
(>135mMol/L) is associated with an increased risk of central
pontine myelinolysis (CPM).
 The risk of CPM also increases with overly rapid correction of
the serum sodium concentration, so it is best to avoid
increasing the sodium by >12 mEq/L each 24 hr.
 Emergency treatment of symptomatic hyponatremia, such as
seizures, uses IV hypertonic saline to increase the serum
sodium concentration rapidly, which leads to a decrease in
brain edema.
 Each 1 ml/Kg of 3% sodium chloride increases the serum
sodium by approximately 1 mEq/L.
 A child often improves after receiving 4 to 6 mL/kg of 3%
sodium chloride.
 The aim should be to increase the serum sodium concentration
to not more than 130 mEq/L.
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HYPERNATREMIC DEHYDRATION
Hypernatremic dehydration is the most dangerous form of
dehydration due to complications of hypernatremia and of therapy.
Hypernatremia can cause serious neurologic damage, including
central nervous system hemorrhages and thrombosis. This appears to
be secondary to the movement of water from the brain cells into the
hypertonic extracellular fluid, causing brain cell shrinkage and tearing
blood vessels within the brain
Clinical Manifestations
Children with hypernatremic dehydration often appear less ill than
children with a similar degree of isotonic dehydration. Urine output
may be preserved longer, and there may be less tachycardia. Children
with hypernatremic dehydration are often lethargic and irritable
when touched. the pinched abdominal skin has a "doughy" feel.
Hypernatremia may cause fever, hypertonicity, and hyperreflexia.
More severe neurologic symptoms may develop if cerebral bleeding
or thrombosis occurs.
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Treatment
 Too rapid treatment of hypernatremic dehydration may cause
significant morbidity and mortality.
 Idiogenic osmoles are generated within the brain during the
development of hypernatremia. These idiogenic osmoles increase
the osmolality within the cells of the brain, providing protection
against brain cell shrinkage secondary to movement of water out
of cells into the hypertonic ECF. They dissipate slowly during
correction of hypernatremia.
 With rapid lowering of the extracellular osmolality during
correction of hypernatremia, there may be a new gradient created
that causes water movement from the extra-cellular space into
the cells of the brain, producing cerebral edema. Symptoms of the
resultant cerebral edema can produce seizures, brain herniation,
and death.
 To minimize the risk of cerebral edema during correction of
hypernatremic dehydration, the serum sodium concentration
should not decrease more than 12 mEq/L every 24 hours. The
deficits in severe hypernatremic dehydration may need to be
corrected over 2 to 4 days
 the initial resuscitation-rehydration phase of therapy remains the
same as for other types of dehydration.
Typical fluids:
D5 in ¼ NS ( ½ NS) + 20 mEq/L [K]
 Seizures are the most common manifestation of cerebral
edema from an overly rapid decrease of the serum sodium
concentration during correction of hypernatremic dehydration
 Acutely, increasing the serum concentration via an infusion of
3% sodium chloride can reverse the cerebral edema.
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Monitoring Therapy

o
o
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o
o
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o
o
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Vital signs:
Pulse
Blood pressure
Intake and output:
Fluid balance
UOP & specific gravity
Physical examination:
Weight
Clinical signs of depletion or overload
Electrolytes
DRUG THERAP
ANTIMICROBIALS
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Campylobacter
Clostredia difficle
Salmonella
Shigella
V cholerae
G lambilia
E histolytica
Erythromycin
Vancomycin, Metronidazol
Amp, TMP-SMZ ,Chloram,3rd GCS
Co-TMZ,Nalidixic acid, 3rd GCS
Tetracycline,Co-TMZ
Metronidazole
Metronidazole
Nitazoxanide, an anti-infective agent, has been effective in the
treatment of a wide variety of pathogens including G. lamblia, E.
histolytica, C. difficile, and rotavirus.
Although preliminary data suggest that nitazoxanide may be of use in
nonspecific acute secretory diarrhea, these data need replication in
further studies.
Medications that slow gut motility diphenoxylate, loperamid &
anticholinergics are COTRAINDICATED
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Racecadotril, an enkephalinse inhibitor, has inconsistently been
shown to reduce stool output in patients with diarrhea. Experience
with this drug in children is limited, and for the average child with
acute diarrhea it may be unnecessary.
Antiemetic agents such as the phenothiazines are of little value and
are associated with potentially serious side effects (lethargy,
dystonia, malignant hyperpyrexia). Nonetheless, ondansetron is an
effective and less-toxic antiemetic agent. Because persistent vomiting
can limit oral rehydration therapy, a single sublingual dose of an oral
dissolvable tablet of ondansetron (4 mg 4-11 yr and 8 mg for children
>11 yr [generally 0.2 mg/kg]) may be given.
However, most children do not require specific antiemetic therapy;
careful oral rehydration therapy is usually sufficient.
Probiotic
The use of probiotic nonpathogenic bacteria for prevention and
therapy of diarrhea has been successful in developing countries. In
addition to restoring beneficial intestinal flora, probiotics can
enhance host protective immunity.
A variety of organisms (Lactobacillus, Bifidobacterium) have a good
safety record.
Enteral Feeding and Diet Selection
Continued enteral feeding in diarrhea aids in recovery from the
episode, and a continued age-appropriate diet after rehydration is
the norm.
Once rehydration is complete, food should be reintroduced while oral
rehydration can be continued to replace ongoing losses from emesis
or stools and for maintenance. Breast-feeding or nondiluted regular
formula should be resumed as soon as possible. Foods with complex
carbohydrates (rice, wheat, potatoes, bread, and cereals), lean
meats, yogurt, fruits, and vegetables are also tolerated. Fatty foods
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or foods high in simple sugars (juices, carbonated sodas) should be
avoided.
COMPLICATIONS
 Renal Failure
o Dehydration
o Acute Tubular Necrosis
o Haemolytic-Uraemic Synd.
o Renal Vein Thrombosis
 Hypokalaemia and Paralytic Ileus.
 Secondary Lactose Intoleranc
 Fluid Overload and Pulmonary Edema
 Convulsions
o
o
o
o
o
o
o
o
Fever.
Hypoglysemia.
Hypocalcemia.
Hyponatremia.
Hypernatremia.
Hypomagnesemia.
Meningitis.
Cerebral Vascular Thrombosis.
Prevention
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Promotion of Exclusive Breast-feeding
Improved Complementary Feeding Practices
Rotavirus Immunization
Improved Water and Sanitary Facilities and Promotion of
Personal and Domestic Hygiene
 Improved Case Management of Diarrhea
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