DEHYDRATION AND

FLUID REPLACEMENT

Prepared and presented by Dr Hala Hjaija

Supervised by Dr Samer Abed Al Raziq &
Sara Amro
Contents

• Revision of body fluids composition and compartments

• Types of Fluid replacement.

• Dehydration, it’s types and severity .

• Approach to dehydration management.

• Examples

• Final management protocol

 Body fluid composition

- Total body water (TBW) as a percentage of body weight

varies with age.
By 1 year of age, the ECF volume is 20% to 25% of body weight, ICF
volume is 30% to 40% of body weight .
Solutes distribution
Regulation of intravascular volume and osmolality

Water
balance
Osmolality

Sodium
balance
Volume status
Plasma osmolality is tightly controlled between 285 and 295 mOsm/kg

• If plasma osmolality increases

Urinary water
losses

water intake
In summery..
 Maintenance fluids

• Maintenance fluids are composed of a

solution of water, glucose, sodium, potassium,

and chloride.

• They replace electrolyte losses from the urine

and stool, as well as water losses from the

urine, stool, skin, and lungs.

 Goals of maintainance fluids

• Prevent dehydration

• Prevent electrolyte disorders

• Prevent ketoacidosis

• Prevent protein degradation

• Maintenance fluids do not provide adequate calories,

protein, fat, minerals, or vitamins.

• Parenteral nutrition should be used for children who

cannot be fed enterally for more than a few days

 Maintenance electrolytes

Sodium

• 3 mEq/kg/day

Potassium

•2 mEq/kg/day
 • After calculation of water needs and electrolyte

needs, children typically receive either 5% dextrose

(D5) in 1/2 normal saline (NS) plus 20 mEq/L of
potassium chloride (KCl)or D5 in NS plus 20 mEq/L
of KCl.
• Children weighing less than 10 kg do best with the

solution containing ¼ NS (38.5 mEq/L) because of

their high water needs per kilogram.
• larger children and adults may receive the solution

with ½ NS (77 mEq/L).

Nelson Textbook ,chp 32 , page 107
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.

A variety of clinical situations modify normal maintenance
water balance
 While on fluid therapy monitor the
following :-

Weight changes

Oral intake

Urine output

Signs of dehydration or volume overload

Serum electrolytes
Replacement therapy
• Output from surgical drains and chest tubes, when

significant, should be measured and replaced.

• Third space losses and chest tube output are

isotonic and replacement should be with an

isotonic fluid, such as normal saline or Ringer’s

lactate.
Dehydration
• It is a common complication of illness among children.

• Most often due to gastroenteritis.

• May be also caused by :-

 Poor oral intake due to diseases such as stomatitis

Insensible losses due to fever

Osmotic diuresis from uncontrolled diabetes mellitus

Definition

Dehydration is a deficit of total body water with an

accompanying disruption of metabolic processes. It occurs
when free water loss exceeds free water intake
 Pediatric patients are particularly
susceptible

• Higher metabolic rates.

• Increased body surface area.

• Higher body water contents

• Clinical assessment of dehydration is only an

estimate.

• Patient must be continually re-evaluated during

therapy.

• Degree of dehydration is underestimated in

hypernatremic dehydration
 Specially at risk are children
who : -
• Are younger than 1 year, especially < 6 months
• low birth weight
• Passed six or more diarrhoeal stools in the past
24 hours
• Vomited three times or more in the past 24 hours
• Have not been offered or have not been able to
tolerate supplementary fluids before presentation
• Have stopped breastfeeding during the illness
• Have signs of malnutrition.
 Types of dehydration

Dehydration

Isonatremic Hyponatremic hypernatremic

 Isonatremic dehydration

It is the commonest type (70–80%)

Has the best prognosis

Diagnosis :-
Normal tonicity 275–290 mOsm/kg
Normal serum sodium concentration ( 135 and 145
mmol/L )
 Hyponatremic dehydration

• 10–15% of cases of dehydration.

• Occurs in children who have diarrhea and consume a

hypotonic fluid (water or diluted formula).

• Volume depletion stimulates secretion of antidiuretic

hormone, preventing the water excretion that should correct

the hyponatremia.
Both Na and Only water is Hyponatremic
water are lost replaced dehydration
Neurological symptoms in hyponatremic
dehydration
• Nausea and malaise are typically seen when sodium
level acutely falls below 125–130 mmol/L.
• Headache, lethargy, restlessness, and disorientation
when sodium concentration falls below 115–120
mmol/L.
• Cerebral edema, seizure, brain stem herniation,
respiratory arrest, coma, and death may occur with
severe and rapidly evolving hyponatraemia
 Hypernatremic dehydration
It is usually a consequence of an inability to take fluid

Lack of access

Poor thirst mechanism

Intractable emesis

Anorexia
• Mild hypernatremia ( Na 146-149 )

• Moderate hypernatremia (Na 150–169 mmol/L )

• Severe hypernatremia when serum sodium is > 169

mmol/L.
 Symptoms of hypernatremic
dehydration
• Lethargy
• Irritability
• Fever
• Hypertonicity
• Hyperreflexia
• Seizures
• Cerebral thrombosis or bleeding may occur
 Be careful !

The movement of water from the intracellular

space to the extracellular space during
hypernatremic dehydration partially protects the
intravascular volume
Which
Means
Urine output may be preserved longer
Less tachycardia
Work up
 Serum Electrolytes

 A rise in BUN and creatinine.

 Increased urine specific gravity (≥1.025).

 Urine analysis may show hyaline and granular casts, few WBCs

and RBCs , proteinuria

 CBC shows hemoconcentration.

 ABGs

• May show :-

 normal anion gap metabolic acidosis from loss of bicarbonate in diarrhea stool.

 Increased anion gap metabolic acidosis from ketoacidosis

 Lactic acidosis (poor tissue perfusion)

• There could be compensatory respiratory alkalosis

• Serum HCO3 < 17 mEq/L occurs in moderate or severe hypovolemia but never

mild hypovolemia.
• Do not routinely perform blood biochemistry.

• Measure plasma sodium, potassium, urea, creatinine and

glucose concentrations if:

1. Intravenous fluid therapy is required
2. There are symptoms or signs suggesting

hypo/hypernatremia.
• Measure venous blood acid–base status and chloride

concentration if shock is suspected or confirmed.

 Management aims

• Ensure adequate tissue perfusion.

• Restore circulating intravascular volume

• Replace further losses

 The survival of a child with severe
volume depletion at the emergency
department depends on the competency
of the first responder to recognize and
promptly treat hypovolemic shock.
 Death among volume depleted children
with diarrheal disease is the second
leading cause of death among the under-
five children word wide
 Approach to managing
dehydration
Is the patient in shock ?
What is the degree of dehydration
( mild ,moderate ,severe ) ?
Is the patient tolerating oral intake ?
Should the patient be given oral intake ?
In case needed , what is the value of serum
sodium ?

Proceed in management accordingly

Ongoing
Deficit
losses

Maintenance
Deficit calculation

• Deficit = wt (kg ) * percentage of dehydration

For 10 kg child with 10 % dehydration

Deficit =0.1 * 10 = 1 L =1000 ml
Maintenance calculation
 On going losses replacement

 Should be replaced milliliter-for milliliter.

 Fluid administered should be suitable to the fluid lost.

 For those tolerating oral intake :-

• 10 mL/kg of ORS is given for each stool.
• 2 ml/kg of ORS after each vomit.

 For those not tolerating oral intake :-

 Gastric fluid is replaced with normal saline + 10 meq /L KCL
 Diarrhea is replaced with ½ normal saline + 20 meq/L KCL
 Mild to moderate dehydration

• Diarrheal dehydration can be effectively managed with

Oral rehydration solution if patient tolerates oral intake.

• Oral rehydration therapy has significantly reduced the

morbidity and mortality from acute diarrhea.

• Oral rehydration is less expensive and has less

complication rate .
Oral rehydration solution
a miracle cure
• In 1960, American chemist Dr. Robert K. Crane discovered
the sodium-glucose cotransport system when he noticed that
the body’s absorption of sodium was dependent on glucose..
• In 1978, WHO issued a recommendation to use a single
ORS formulation to treat clinical dehydration from acute
diarrhoea of any origin and at any age, except when it is
severe.
• In 1984, the mixture was changed (tri-sodium citrate
replaced sodium bicarbonate) to make it more stable in hot
and humid climates.
• In 2004, the mixture was further modified (reduction in the
concentrations of both sodium and glucose) to make it more
efficacious.
• water can be absorbed across the intestinal lumen by the

co-transport of sodium and glucose via the SGLT1 protein

and by active transport via the sodium-potassium ATPase

pump

• Optimal glucose transport at concentrations: glucose 2–

2.5 gm/L and Na 45–90 mEq/L

 Oral rehydration therapy
• 50 mL/kg of the ORS should be given within 4 hours
to patients with mild dehydration.

• 100 mL/kg should be given over 4 hours to patients

with moderate dehydration.
• When rehydration is complete, maintenance therapy

should be started

• Breastfeeding or formula feeding should be maintained

and not delayed for more than 24 hours.

 IV fluid therapy
Required in :-
• Severe dehydration.
• Cases of mild to moderate dehydration not tolerating
oral intake. 1. Uncontrollable vomiting
2.Gastric or intestinal distension
3.Extreme fatigue,stupor or coma
• Electrolyte disturbances
Severe isonatremic dehydration
 Case scenario
AB, a 11- month old child presented at emergency unit with
3 days history of vomiting , diarrhea and decreased urine
Physical examination : lethargic child , dry mouth, no
tearing, sunken eyeballs and anterior fontanel, rapid and
weak, pulse
BP was 45mmHg/inaudible diastolic, CRT was in excess
of 4 s.
Weight = 8 kg.
The laboratory results revealed Na 138 mmol/L, K 1.8
mmol/L, Cl 95 mmol/L
AB has severe isonatraemic dehydration with
hypokalemia. AB also presented in hypovolaemic
shock
Rapidly expand the intravascular space with
0.9% N/S 20 mL/kg = 160 mL, given over 10
min

Calculate the deficit at 15%( 15 × 10 × 8 =

1,200 ml – 160 ml = 1,040 mL

Calculate the maintenance fluid volume, i.e.,

100 × 8 = 800 mL
• Give 1/2 remaining deficit (1/2 × 1,040 = 520 ml) + 1/3
maintenance (1/3 × 800 = 267 mL) = 787 mL in the first 8
h
• Follow with 1/2 remaining deficit (1/2 × 1,040 = 520 mL) +
2/3 maintenance (2/3 × 800 = 533) = 1,053 ml over the
remaining 16 h
• Add KCL 40 mmol/L because of the hypokalemia (1.9
mmol/L).
• Once the serum K rises to 3.5, i.e., hypokalemia
corrected) decrease KCL to 20 mmol/L .
• Regular monitoring is required.
• Replace ongoing losses
 Hypovolemic shock
• Must be treated once recognized regardless of
whether the child is having isonatremia,
hyponatremia, or hypernatremia.
• Give 20 mL/kg of IV Normal saline over 5–10 min or
as rapidly permitted by the vascular access.
• Up to 60 mL/kg (3 boluses of 20 mL/kg) may need to
be given within the first hour before the plasma
volume is restored.
• Any child requiring more than 60 mL/kg in fluid
boluses should be carefully reviewed to consider the
need for a vasopressor or inotropic support (Septic
shock)
• Patient should be monitored closely for lung edema during
resuscitation phase
•
• Use of hyponatremic fluids is forbidden.

• Potassium is also not given at this phase.

• Administer 100 % oxygen

Asymptomatic Hyponatremic
dehydration
 Case scenario
SR, an 8 week old infant weighing 4 kg presented with
1 week history of vomiting and passage of loose stool.
Mother was advised to give water as frequently as the
child could tolerate it.
He was found with moderate dehydration on
examination.
Laboratory results revealed Na 130 mmol/L, Cl 94
mmol/L, K 1.9 mmol/L, and HCo3 8 mmol/L.
SR has moderate hyponatremic dehydration with
hypokalemia

Deficit fluid volume: 10 × 10 × 4 =

400 ml

Maintenance fluid volume: 100 × 4 =

400 mL

Give 1/2 deficit (200 mL) + 1/3 of

maintenance (133 mL) in the first 8 h

Give 1/2 of remaining deficit (200 mL)

and 2/3 of the remaining maintenance
(267 mL) in the next 16 h
• Add KCL 40 mmol/L because of the hypokalemia (1.9
mmol/L).
• Once the serum K rises to 3.5, i.e., hypokalemia
corrected) decrease KCL to 20 mmol/L .
• Regular monitoring is required.
Symptomatic hyponatremic
dehydration
 Case scenario
JK is a 5 month old child brought to the emergency
unit with a 7 day history of vomiting and diarrhea.
JK had stopped breastfeeding in the last 48 h which
made JK’s mother to institute tea and water which JK
took poorly.
15 min before presentation, JK was said to have
convulsed, generalized tonic-clonic which lasted for 15
min.
On examination :-
dry tongue, sunken eyes and depressed anterior fontanel
and tenting of the skin, weight = 5 kg
HR =160 beat/min, cold and pale extremities.
 BP= 45 mmHg/inaudible diastolic

Laboratory evaluation revealed serum Na of 105 mmol/L,

CL 95 mmol/L, K 3.5 mmol/L, serum HCO3 8 mmol/L.
 JK is having severe hyponatremic dehydration with
serum Na < 120 mmol/L, and metabolic acidosis.

give 20 mL/5 kg = 100 mL of Normal Saline

over 10 minutes

Calculate JK fluid deficit at 15% deficit = 15

× 10 × 5 = 750 mL
Actual deficit left is (750–100) = 650 ml

Calculate JK Na deficit = 120–105 × 0.6 ×

body weight = 15 × 0.6 × 5 =
45 mmol of Na
Give 90 ml of 3 % NaCL over 30 minutes.

This can be repeated until the serum sodium

becomes 120–125 mmol/L

Calculate maintenance fluid volume = 100 × 5 kg

= 500 mL

Give the remaining deficit, 560 mL (650–90 mL) to

go in the first 8 h

Give the maintenance of 500 ml to go over the

remaining 16 h
The fluid choice for the deficit and maintenance volume is
isotonic saline (0.9%) with 5% glucose
The rate of rise in serum sodium should be monitored
hourly as the serum sodium should not rise more than 0.5
mmol/L every hour or 12 mmol/L over 24 h (from 120 to
132 mmol/L).
Once child is making urine, add 20 mmol/L of KCL into
isotonic saline with 5% dextrose.
Regular monitoring is required.
 The initial goal in treating hyponatraemia is the
correction of intravascular volume depletion with
isotonic normal saline.
 Urgent treatment of hyponatraemia is required in all
patients who :-
 Exhibit neurological changes
 Serum sodium level is < 120 mmol/L
 Most frequently, hypertonic 3% NaCl (513 mmol/L)
is used and should be given through a central
venous line.
 The goal is to raise the serum sodium to 120–125
mmol/L or until the seizure stops
 Hypertonic saline is given over 15–30 min to gain
rapid control of the seizures
• 4 mL/kg of 3% NaCl increases serum Na by 3 mmol/L
• This is followed by a slower correction (10–12
mmol/L/day) to normal level.
• Slow correction is essential to prevent central pontine
myelinolysis (CPM).
• CPM is characterized by neurologic symptoms including
confusion, agitation, flaccid or spastic quadriparesis, and
death.
• CPM is commoner in patients treated for chronic
hyponatremia than in those treated for acute
hyponatremia.
Hypernatremic dehydration
Case scenario
TP is a 3 month old child has 3 weeks history of fever and
occasional vomiting. Mother also noticed that the child has not
been suckling well as before and she also felt light in her breasts.
TP mother complained to her neighbor who advised her to buy
infant formula , TP mother was adding little water to many scoops
of the infant formula,However, TP continues to get worse and she
was rushed to the EPU by 3 am.
 Examination : dry tongue , doughy feeling skin.
 Weight = 5 kg.
 The house officer treated TP for malaria fever and asked the
mother to come back later in the day.
 Labs showed malaria parasitaemia of 1 + , Na of 170 mEq/L, K
3.7 mEq/L, Cl 104 mEq/L.
 Senior doctor examined the child later and found the baby to be
in hypovolemic shock.
20 mL/kg of NS was given over 20 min = 100
mL

free water deficit = (170/145−1) × 0.6 × 5 =

0.517 L = 517 mL

The remaining deficit = 517 – 100 = 417 mL

Maintainance = 100 mL × 5 = 500 mL

Give (1/3 of 417 mL) 139 mL of deficit + 500

mL of maintenance = 639 mL in the first 24 h
• Another (1/3 of 417) 139 mL of deficit + 500 mL of
maintenance = 639 mL in the next 24 h (+ongoing losses)
• Remaining (1/3 of 417 mL) 139 mL of deficit + 500 mL of
mainte-nance = 639 mL in the next 24 h (+ongoing
losses)
Free water deficit was spread over 72 h (i.e., severe
hypernatremia) from the time of treatment
commencement, while the child continued to receive
his daily maintenance and ongoing losses
• In cases of hypernatremic dehydration :-
 While on IV fluid therapy
monitor the following :-
• Regular monitoring of the vital signs
• Strict fluid balance and urine output
• Daily weight
• Daily assess for edema
• Laboratory (serum electrolytes and glucose)
monitoring every 4 h is required in hyponatraemic
and hypernatraemic dehydration until serum values
become normal.
Closure of rehydration therapy

• Normalization of vascular status

• Restoration of normal mental status,
• Lack of clinical signs and symptoms of
fluid deficit
• Adequate urinary output
Causes of poor fluid management

1. Poor understanding of the basic principles of fluid balance.

2. Poor fluid balance (chart) documentation

3. Poor interpretation of laboratory results

4. Inadequate involvement of senior clinicians in fluid management and

delegation of fluid

5. Prescription to junior members of the team.

6. Little formal training and education in IV fluid management to support

correct prescribing.
References
• Nelson textbook for Paediatrics
• Dehydration: Isonatremic, Hyponatremic, and
Hypernatremic Recognition and Management Karen S.
Powers, MD, FCCM* .Pediatric Critical Care, Golisano
Children’s Hospital, University of Rochester School of
Medicine, Rochester, NY.
• Management of Diarrhoeal Dehydration in Childhood:
A Review for Clinicians in Developing Countries
Emmanuel Ademola Anigilaje* Nephrology Unit,
Department of Paediatrics, College of Health Sciences,
University of Abuja, Abuja, Nigeria