Emergency Medicine/Pediatric Rehydration

Pediatric Rehydration Alex Flaxmanman== Clinical Eval of Dehydration 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 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 After Rehydration Resume breast feeding, or usual formula/milk == Resume feeding, if appropriate == Parenteral Rehydration (IVF) == Bolus 20 ml/kg, over 20 min == Use isotonic fluids- NS or LR == Blood, 5% albumin, plasma == End Points “Adequate intravascular volume” == Clinical improvement == ↓ HR === Normal BP === Improved tissue perfusion (UO) === More alert affect === Post-acute Treatment 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 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 Edema == Pulmonary congestion == Calculations- Where to start Mild 3–5% → 5% == Moderate 7–10% → 10% == Severe 10–15% → 15% == Calculating Deficits Water Deficit = % dehydration × weight == Sodium Deficit = Water deficit × 80 mEq/L == Potassium Deficit = Water deficit × 30 mEq/L == Maintenance Fluids- Goals Prevent dehydration == Prevent electrolyte disorders == Prevent ketoacidosis == Prevent protein degradation == Maintenance Fluids- Calculations “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 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 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 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) Fever == Premature infants == Radiant warmers === Phototherapy === Special Cases- Lungs ↑ Fluids requirement == Tachypnea == Tracheostomy == ↓ Fluids requirement == Mist tent == Vent == Special Cases (cont’d) NGT == Surgical drains == Special Cases (cont’d) Diarrhea dehydration == Isotonic 60-70% === Hyponatremic 10-15% === Hypernatremic 10-20% === Hyponatremic dehydration Hypernatremic Dehydration IVF for Ongoing Losses D5 1/4 NS + 15 mEq/L bicarbonate + 25 mEq/L KCl == Replace stool mL/mL every 1–6 hr == Summary 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 ==