# 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 ==

# 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% ===

# 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 ==