Dehydration and fluid

therapy
Dr. Jumana Albaramki
 Body composition
◼ TBW varies with age
◼ Water 50-75 % of body weight,more young age
◼ average 60 % : 40 % intracellular, 20 %
extracellular .There is osmotic eq. between
ICF,ECF freely permeable to water
◼ extracellular :(15% interstitial, 5 % blood)
◼ There is a balance between hydrostatic and
oncotic pressure.
◼ Nephrotic syndrome (decrease OP): edema
◼ GN,heart failure :(increase HP) :edema
◼ Na ,CL main extracellular
◼ K, Phosphate main intracellular

◼ Serum electrolytes don’t reflect total body

stores…(DKA)
Blood osmolality (mmol/l)=2 × Na +glucose
(mg/dl)/18 +BUN (mg/dl)/2.8
normal: 286-295
Urea : ineffective osmsole
In DKA: shifting of fluid cause hyponatremia
◼ Effective circulatory volume : sustain
perfusion,doest correlate with ECF
◼ Nephrotic,liver disease :TBW (interstitial)
high,decreased ECV
◼ Tachycardia and delayed cap refill precede signs
of ineffective circulation as hypotension,oligurea
 Regulatory mechansim
◼ Glomerular hypoperfusion: < Na to macula
densa. Renin and aldosterone salt
reabsorption

◼ Osmoreceptors in hypothalamus : ADH and

thirst
 maintenance
◼ Daily maintenance estimated and based on
energy expenditure 1 ml/kg= 1 Kcal of energy
expenditure
 Maintenance fluids
◼ Maintenance =insensible water (ISW) + urine
output (UOP)
◼ ISW : evaporative losses from skin and
respiratory,unmeasured

◼ UOP: 2/3 maintenance,

◼ measured
 Maintenanace
◼ Maint: to prevent dehydration, elect imbalance, prevent
ketoacidosis, protein degradation
◼ Daily Na req: 2-3 mmol/kg
◼ Daily K req: 1-2 mmol/100 ml. We should check urine output

Glucose 5% saline .45 %: contain 75 mmol/ 1 l

In small infants G 5%.18 % may be used: contain 30 mmol/l ( a 5
kg child will have 500 ml with 15 mmol)
Maintenance lack proteins,fat : need enteral feeds /TPN
◼ A child weighs 7 kg
◼ Maintenace 700 ml
◼ So a child with a weight of 15 Kg has a
maintenance of : 100 x 10=1000 , 5*50=250
◼ Total = 1250 ml
◼ If a child weighs 25 Kg
◼ maint= 1000 + (10*50) 500+ (5*20=100)=
1600
◼ Maximum 2.5 L
 Causes of dehydration
◼ 1.losses : vomiting, diarrhea, third spacing as in
burns, bleeding

◼ 2. renal losses :polyuria as in osmotic

diuresis,DKA,post obstructive diuresis,diabetes
insipidus
 Types of dehydration
◼ Types :
◼ according to sodium level
◼ 1.isotonic
◼ 2.hypotonic/hyponatremic :Na< 130 mmol/l
◼ 3.Hypertonic /Hypernatremic : Na > 150
mmol/l
 Degree of dehydration
◼ mild :no signs,only symptoms ,< 5 %

◼ Moderate dehydration: 5-10 %

◼ Severe dehydration : > 10%

 Assessment of dehydrayion
◼ Assess dehydration : history of losses, intake and feeding, thirst,
urine output, activity of child, lethargy

◼ Exam: HR, RR (increased from metabolic acidosis,LA in

gastroenteritis),postural hypotension. Hypotension seen in severe
dehydration

◼ Capillary refill, sunken eyes, tented skin,crying with tears, weight

loss, lethargy, dryness mucus membranes, sunken fontanelle
Volume depletion in dehydration
◼ Repletion : replaces ongoing losses ,deficit
◼ maintenance :
◼ Emergent repletion phase: in severe
hypovolumeia with delayed capillary refill
◼ Management by rapid restoration of IVS by 20
ml/kg normal saline bolus over 20 min and then
reassessment up to three boluses up to 60 ml/kg
◼ Route intravenous /intraosseous
 Volume repletion
◼ After saline boluses fluid is initiated according to
deficit
◼ Deficit= weight x 10 x % of dehydration
◼ Oral rehydration solution can be used in
children with mild to moderate dehydration, but
intravenous route is needed if the child was oral
intolerant and has moderate dehydration and in
children with severe dehyration
Oral Rehydration solution (ORS)
◼ Used in children with mild to moderate
dehydration
◼ Has decreased mortality and morbidity from
gastroenteritis in developed countries
◼ Uses glucose in formulation to facilitate sodium
absorption through Na-Glucose channel
◼ There are many formulations: WHO with high
Na content,newer has lower sodium
 Intravenous Fluid contents
Each 1 l NS .9% HAS 154 mmol Na
Each ONE ML HTS 2.7%= .45 mmol Na
Each 1l GS.45% has 75 mmol Na
Each 1l GS.3% has 50 mmol Na
Each 1l GS.18% has 30 mmol Na
◼ A child weighs 17 kg,presents to E/R with
vomiting and diarrhea.On exam he wasn’t
dehydrated.He is intolerant to oral
intake.Calculate fluid?
◼ maint: 1000 + (7*50)=1350
◼ Degree of dehydration mild,deficit=
5%*17*10=850
◼ Total fluid=850+1350=2200 ml GS 0.45% we
divide half over first 8 hours and the remaining
over 16 hours
 Isotonic dehydration
management
◼ A child presents with gastroenteritis.On exam he
was tachycardiac.Serum Na was 140, his weight
20 kg.How to calculate fluid?
◼ maint= 1500 ml
◼ Deficit= 20 x10 x 7%= 1400
◼ Total=2900 G5 .45 %, we divide half over first
8 hours and the remaining over 16 hours.
◼ A 6 month old boy presents with excessive
vomiting,lethargy and diarrahe.On exam
capillary refill 5 seconds,Bp un
recordable,weight 7 kg?
◼ What is your next step of management
◼ 1.give normal saline bolus 140 ml and reassess
◼ 2.maint=700 ml,deficit 7*10%*10=700
◼ Total 1400 over 24 hours
You were called to write the fluids of a 1 year old
boy,who has not passed urine,his weight is
12 Kg?

insensible losses as 400 ml/m2 and replacement

of urine output?
 hyponatremia
◼ Factitious Hyponatremia in DKA.
◼ Causes:
◼ 1. loss of sodium in excess to water

◼ 2.Gain of water in excess of sodium

Decreased ECF,loss of salt in excess
of water
◼ 1.extrarenal losses as GIT losses,skin losses as
CF,third space losses .Una < 20,high urine
osmolality

◼ Renal losses as osmotic

diuresis,diuretics,adrenal deficiency
(hypoaldosteronsim) ,salt losing CRF , Una > 20
Normal ECF,gain of water in excess
of salt
◼ Non edematous state as
◼ SIADH
◼ Psychogenic polydipsia,compulsive water
drinking have dilute urine
◼ Hypothroidism
◼ Una > 20
◼ Treatment :fluid restriction
 ECF increased as gain of water in
excess of salt
◼ Edematous state as nephrotic
syndrome,CHF,liver failure.Una< 20,high urine
osmolality

◼ Renal failure as ARF,CRF .Una > 20.

◼ Treatment: diuretic and fluid and sodium
restriction
◼ s
 Hyponatremic dehydration
Symptoms:acutely seizures due to brain swelling,edema
treated wuth hypertonic saline
Nausea,malaise,lethargy
◼ Signs and symptoms are more evident

◼ Hyponatremic : shift of fluid to ICS,cerebral edema

◼ Correct hyponatremia by 10-12 mmol/day to avoid

central pontine myelinolysis
◼ If symptomtic hyponatremia as seizures : use HTS 3% (
1 ml contains .45 mmol)
◼ Use formula for mmol: (desired-actual) x weight o .6
 hypernatremia
◼ 1.loss of water in excess of salt,decreased ECW
◼ Children are irritable,doughy skin
◼ Have cerebral thrombosis and intracranial
hemorrhage
◼ Hypocalcemia and hyperglycemia
◼ Renal vein thrombosis is another complication
loss of water in excess of salt and low
ECW

◼ A. extrarenal loss (urine osmo high,Una < 20 )

in diarrhae and inadequate water intake

◼ B.Renal losses
◼ Central and nephrogenic DI
◼ hyperglycemia, diuretics, intrinsic renal disease
 Gain of salt in excess of water

◼ Have high urine Na

◼ Excessive oral ingestion
◼ Excess Minerlacorticoid
◼ Excessive intravenous saline
◼ Rapid correction by using diuertics,dialysis
 Hypernatremic dehydration
◼ Avoid use of hypotonic solutions. use GS .3% -
GS .45%
◼ Start at a rate of 1.25- 1.5 maintaince over 24
hours
◼ Correct hypernatremia over 48-72 hours
◼ Adjust rate of drop by altering rate of fluids and
concentration
◼ If drop too quickly : decrease rate of fluids or
increase saline concentration
 What other labs need to be done in a child with
dehydration ?

◼ 1.elecrolytes
◼ 2. capillary blood gas : gastroenteritis causes
metabolic acidosis from diarrhaea losses and
dehydration cause lactic acidosis
◼ Dehydrated children are tachypnea
◼ The acidosis will be corrected by hydration
◼ 3. Hypokalemia : use 3- 4 mmol/100 ml
◼ 4. urea and creat: prerenal azotemia is
seen,oliguria
◼ 5. urine specific gravity ,osmolarity
◼ Uirne sodium :low
◼ A child presents with gastroenteritis and severe
dehydration. Weight was 10 kg,Na was 125
◼ Total fluid :1000 +1000= 2000L GS.45%
◼ Sodium =10*.6 *10 = 60 mmol
◼ 2 l has 150 mmol
 SIADH
◼ Result from CNS,pulmonary
disorders,cancer,drugs
◼ Have low blood osmolality
◼ Urine osmolality is in appropriately high
◼ Urine Na is high,serum uric acid is low
❑ condition of exclusion – must have no
dehydration, no pituitary, adrenal, renal or liver
disease. Not on diuretics or some other drugs.
Not hypothyroid
❑ Treatment by fluid restriction
 Acid base disorders
◼ Normal ph: 7.35 -7.45
◼ Pco2 :35-45
◼ HCO3 : 20-28
◼ 1. know of academia or alkalemia
◼ 2.know if metabolic or respiratory
◼ 3.know compensatory response
 Causes of metabolic acidosis
◼ 1. increased endogenus /exogenous acid
production

◼ 2. increase biocarbonate losses

◼ 3.decrease acid excretion

Proximal tubule
Distal tubule
 Metabolic acidosis
Anion gap=(Na) –(CL + bicarbonate)
Normal up to 14-16
1.high anion gap acidosis
◼ Endogenous sources of acid (DM,organic
acidemia,lactic acidosis
◼ Exogenous acids:ethylene glycol

◼ Defective acid excretion: uremic acidosis

 Normal anion gap metabolic
acidosis
◼ Extrarenal :diarrhael disease

◼ Renal RTA : proximal RTA ,distal RTA

◼ Type 4 RTA :hyperkalemia; transient in

UTI,urinary obstruction
 Proximal RTA

◼ Decrease reabsorptive capacity

◼ Require huge doses of HCO3
◼ Isolated or part of Fanconi with
hypophosphatemia,glucosuria,aminoaciduria
◼ high HCO3 losses, obligate Na, k losses,volume
depletion,increase aldoest…hypokalemia
◼ urine ph < 5.5 ,
 Distal RTA

◼ Defect acidification mechanism

◼ Can not acidify urine below 5.5
◼ Require 1-3 mmol/kg
◼ Nephrocalcinosis,hypocitraturia,hypercalcurea
◼ Etiology: congenital +,- deafness,acquired
◼ Positive urine anion gap (Na+ K-CL ) negative
 A seven year old boy was noted to have excessive thirst and
polyuria. He was admitted in a semi-conscious state, with
dehydration.

Na 147 mmol/L (135 – 145)

K 5.7 mmol/L (3.7 – 5.4)
Cl 98 mmol/L (98 – 110)
pH 7.15 (7.34 – 7.43)
pCO2 23 mm Hg (32 – 45)
Actual HCO3 7.0 mmol/L (18.0 – 25.0)
Base Excess -19.7 mmol/L (-4 - +3)
Urea 70 mg/dl (15-45)
 Metabolic alkalosis
◼ Chloride responsive hypokalemic hypochloremic
metabolic alkalosis :
◼ Loss of acid from stomach: vomiting,nasogastric
suction
◼ Congenital Chloride diarrhoea
◼ Cystic fibrosis
◼ Urine CL < 10 mmol
Chloride resistant metabolic alkalosis

◼ Normal BP : Bartter, gitelman

◼ High BP : renal artery stenosis, Primary
hyperaldosteronism,Liddle syndrome

◼ Urine Cl > 20 , volume replete

Decreased ECF,loss of salt in excess
of water
◼ 1.extrarenal losses as GIT losses,skin losses as
CF,third space losses .Una < 20,high urine
osmolality

◼ Renal losses as osmotic diuresis,

diuretics,cerebral salt wasting,adrenal def ,salt
losing CRF , Una > 20