Dehydration


  • When children show signs of dehydration from diarrhea, the first step is to assess its extent.
  • Four factors predicted dehydration:
    • A capillary refill time >2 seconds,
    • The absence of tears,
    • Dry mucous membranes, and
    • An ill general appearance;
  • The presence of two or more of these signs indicates a fluid deficit of at least 5%.
  • Early oral rehydration therapy is recommended and can be started at home. This should be done using an oral rehydration solution that is designed for children.
  • Adult oral rehydration solutions should not be used in children.
  • Water and other clear liquids, even those with sodium, such as chicken broth, should not replace an oral rehydration solution because they are hyperosmolar.
  • These fluids do not adequately replace potassium, bicarbonate, or sodium, and can sometimes cause hyponatremia.
  • Antidiarrheal medications are usually not recommended for use in children with acute gastroenteritis because they delay the elimination of infectious agents from the intestines.

Source: ITE 2014, Question 17

 


ED Care & Disposition

  1. Treat dehydration and hypoglycemia.
    • Vomiting is not a contraindication for oral rehydration; the key is to give small amounts of the solution frequently. Use of a commercially available oral rehydration solution (ORS) containing 45-60 mmol/L of sodium is recommended. Many other beverages traditionally suggested for children with vomiting & diarrhea, such as tea, juice, or sports drink, are deficient in Sodium & may provide excessive sugar, resulting in amplified fluid losses.
    • Give 50-100 mL of ORS/kg of body weight, plus additional ORS to compensate for ongoing losses. Aim for about 1 oz (30 ml) or ORS per kg of body weight per hr.
    • Administer IV or IO isotonic crystalloid to children with severe dehydration, hemodynamic compromise, or when altered mental status precludes safe oral administration of fluid.
      • Give IV NS as 20 cc/kg bolus over 20 min. until perfusion improves and urine output is adequate.
    • Treat hypoglycemia with 10% dextrose (5 mL/kg) in infants or 25% dextrose (2 mL/kg) in toddlers and older children.
  2. Mild Diarrhea with NO dehydration:
    • Continue routine feeding
    • Do not withhold feeding > 4 hours in a dehydrated child or for any length of time in a child who is not dehydrated.
    • There is no need to dilute formula because > 80% of children with acute diarrhea can tolerate full-strength mild safely.
  3. Antidiarrheal and antimotility agents such as loperamind, are not recommended in children and contraindicated in young childen.
  4. All infants & children who appear toxic or have high-risk social situations, significant dehydration, significant ongoing fluid losses, altered mental status, inability to drink, or laboratory evidence of hemolytic anemia, thrombocytopenia, azotemia, or a significant dysnatremia should be admitted.
  5. Children who respond to oral or IV hydration can be discharged.
    • Instructions should be given to return to the ED or seek care with PCP if the child becomes unable to tolerate PO hydration, develop bilious vomiting, become less alert, or exhibit signs of dehydration (no wet diapers).
    • Dietary recommendations include a diet high in complex carbohydrates, lean meats, vegetables, fruits, & yogurt.
    • Fatty foods & foods high in simple sugars should be avoided.
    • The BRAT diet is discouraged because it does not provide adequate energy source.

Admit Orders: Acute Gastroenteritis

1. Admit to:

2. Diagnosis: Acute Gastroenteritis.

3. Condition:

4. Vital Signs: Call MD if:

5. Activity:

6. Nursing: Inputs and outputs, daily weights, urine specific gravity.

7. Diet: Rehydralyte, Pedialyte or soy formula (Isomil DF), bland diet.

8. IV Fluids: See Dehydration, page 107.

9. Special Medications:

Severe Gastroenteritis with Fever, Gross Blood and Neutrophils in Stool (E coli, Shigella, Salmonella):

-Ceftriaxone (Rocephin) 50-75 mg/kg/day IV/IM q 12-24h, max 4 gm/day OR

-Cefixime (Suprax) 8 mg/kg/day PO bid-qd, max 400 mg/day [susp: 100 mg/5 mL; tabs: 200, 400 mg] OR

-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 10 mg of TMP component/kg/day PO bid x 5-7d, max 320 mg TMP/day [susp per 5 mL: TMP 40 mg/SMX 200 mg; tab DS: TMP 160 mg/SMX 800 mg; tab SS: TMP 80mg/SMX 400 mg]

Salmonella (treat infants and patients with septicemia):

-Ceftriaxone (Rocephin) 50-75 mg/kg/day IV/IM q12-24h, max 4 gm/day OR

-Cefixime (Suprax) 8 mg/kg/day PO bid-qd, max 400 mg/day [susp: 100 mg/5 mL; tabs: 200, 400 mg] OR

-Ampicillin 100-200 mg/kg/day IV q6h, max 12 gm/day or 50-100 mg/kg/day PO qid x 5-7d, max 4 gm/day [caps: 250, 500 mg; drops: 100 mg/mL; susp: 125 mg/5 mL, 250 mg/5 mL, 500 mg/5 mL] OR

-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 10 mg TMP/kg/day PO bid x 5-7d, max 320 mg TMP/day [susp per 5 mL: TMP 40 mg/SMX 200 mg; tab DS: TMP 160 mg/SMX 800 mg; tab SS: TMP 80mg/SMX 400 mg]OR

-If >18 years: Ciprofloxacin (Cipro) 250-750 mg PO q12h or 200-400 mg IV q12h [inj: 200, 400 mg; susp: 100 mg/mL; tabs: 100, 250, 500, 750 mg]

Antibiotic Associated Diarrhea and Pseudomembranous Colitis (Clostridium difficile):

-Treat for 7-10 days.

-Metronidazole (Flagyl) 30 mg/kg/day PO/IV (PO preferred) q8h x 7 days, max 4 gm/day. [inj: 500 mg; tabs: 250, 500 mg; suspension] OR

-Vancomycin (Vancocin) 40 mg/kg/day PO qid x 7 days, max 2 gm/day

[caps: 125, 250 mg; oral soln: 250 mg/5 mL, 500 mg/6 mL]. Vancomycin therapy is reserved for patients who are allergic to metronidazole or who have not responded to metronidazole therapy.

10. Extras and X-rays: Upright abdomen.

11. Labs: SMA7, CBC; stool Wright stain for leukocytes, Rotazyme. Stool culture and sensitivity for enteric pathogens; C difficile toxin and culture, ova and parasites; occult blood. Urine specific gravity, UA, blood culture and sensitivity.


 

Shigella Sonnei

-Treat x 5 days. Oral therapy is acceptable except for seriously ill patients. Ciprofloxacin should be considered for resistant strains but is not recommended for use for persons younger than 18 years of age.

-Ampicillin (preferred over amoxicillin) 50-100 mg/kg/day PO q6h, max 3 gm/day [caps: 250, 500 mg; drops: 100 mg/mL; susp: 125 mg/5 mL, 250 mg/5 mL; 500 mg/5 mL] OR

-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 10 mg TMP/kg/day PO/IV q12h x 5 days [inj per mL: TMP 16mg/SMX 80mg; susp per 5 mL: TMP 40 mg/SMX 200 mg; tab DS: TMP 160 mg/SMX 800 mg; tab SS: TMP 80mg/SMX 400 mg] OR

-Ampicillin 50-80 mg/kg/day PO q6h, max 4 gm/day; or 100 mg/kg/day IV/IM q6h for 5-7 days, max 12 gm/day [caps: 250, 500 mg; susp: 125 mg/5 mL, 250 mg/5 mL]OR

-Ceftriaxone (Rocephin) 50-75 mg/kg/day IV/IM q 12-24h, max 4 gm/day OR

-Cefixime (Suprax) 8 mg/kg/day PO bid-qd, max 400 mg/day [susp: 100 mg/5 mL; tabs: 200, 400 mg].

Yersinia (sepsis):

-Most isolates are resistant to first-generation cephalosporins and penicillins.

-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 10 mg/kg/day TMP PO q12h x 5-7days [susp per 5 mL: TMP 40 mg/SMX 200 mg; tab DS: TMP 160 mg/SMX 800 mg; tab SS: TMP 80mg/SMX 400 mg].

Campylobacter jejuni:

-Erythromycin 40 mg/kg/day PO q6h x 5-7 days, max 2 gm/day

Erythromycin ethylsuccinate (EryPed, EES)

[susp: 200 mg/5 mL, 400 mg/5 mL; tab: 400 mg; tab, chew: 200 mg]

Erythromycin base (E-Mycin, Ery-Tab, Eryc)

[cap, DR: 250 mg; tabs: 250, 333, 500 mg] OR

-Azithromycin (Zithromax)

10 mg/kg PO x 1 on day 1 (max 500 mg), followed by 5 mg/kg/day PO qd on days 2-5 (max 250 mg)

[cap: 250 mg; susp: 100 mg/5mL, 200 mg/5mL; tabs: 250, 600 mg]

Enteropathogenic E coli (Travelers Diarrhea):

-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 10 mg/kg/day TMP PO/IV bid [inj per mL: TMP 16 mg/SMX 80 mg; susp per 5 mL: TMP 40 mg/SMX 200 mg; tab DS: TMP 160 mg/SMX 800 mg; tab SS: TMP 80mg/SMX 400 mg].

-Patients older than 8 years old: Doxycycline (Vibramycin) 2-4 mg/kg/day PO q12-24h, max 200 mg/day [caps: 50, 100 mg; susp: 25 mg/5mL; syrup: 50 mg/5mL; tabs 50, 100 mg].

Enteroinvasive E coli:

-Antibiotic selection should be based on susceptibility testing of the isolate. If systemic infection is suspected, parenteral antimicrobial therapy should be given.

Giardia Lamblia:

-Metronidazole is the drug of choice. A 5-7 day course of therapy has a cure rate of 80-95%. Furazolidone is 72-100% effective when given for 7-10 days. Albendazole is also an acceptable alternative when given for 5 days.

-Metronidazole (Flagyl) 15 mg/kg/day PO q8h x 5-7 days (max 4 gm/day)

[tabs: 250, 500 mg; suspension] OR

-Furazolidone (Furoxone) 5-8.8 mg/kg/day PO qid for 7-10 days, max 400 mg/day [susp: 50 mg/15 mL; tab: 100 mg] OR

-Albendazole (Albenza): if > 2 years, 400 mg PO qd x 5 days [tab: 200mg; suspension]

Entamoeba Histolytica:

Asymptomatic cyst carriers:

-Iodoquinol (Yodoxin) 30-40 mg/kg/day PO q8h (max 1.95 gm/day) x 20 days [tabs: 210, 650 mg; powder for reconstitution] OR

-Paromomycin (Humatin) 25-35 mg/kg/day PO q8h x 7 days [cap: 250 mg] OR

-Diloxanide: 20 mg/kg/day PO q8h x 10 days, max 1500 mg/day. (Available only through CDC).

Mild-to-moderate intestinal symptoms with no dysentery:

-Metronidazole (Flagyl): 35-50 mg/kg/day PO q8h x 10 days, max 2250 mg/day [tabs: 250, 500 mg; suspension] followed by:

-Iodoquinol (Yodoxin) 30-40 mg/kg/day PO q8h (max 1.95 gm/day) x 20 days [tabs: 210, 650 mg; powder for reconstitution] OR

-Paromomycin (Humatin) 25-35 mg/kg/day PO q8h x 7 days [cap: 250 mg] OR

-Diloxanide: 20 mg/kg/day PO q8h x 10 days, max 1500 mg/day. (Available only through CDC).

Dysentery or extraintestinal disease (including liver abscess):

-Metronidazole (Flagyl): 35-50 mg/kg/day PO q8h x 10 days, max 2250 mg/day [tabs: 250, 500 mg; suspension] followed by:

-Iodoquinol (Yodoxin) 30-40 mg/kg/day PO q8h (max 1.95 gm/day) x 20 days [tabs: 210, 650 mg; powder for reconstitution] OR

-Paromomycin (Humatin) 25-35 mg/kg/day PO q8h x 7 days [cap: 250 mg] OR

-Diloxanide: 20 mg/kg/day PO q8h x 10 days, max 1500 mg/day. (Available only through CDC).

 

Admit Orders: Dehydration

1. Admit to:

2. Diagnosis: Dehydration

3. Condition:

4. Vital Signs: Call MD if:

5. Activity:

6. Nursing: Inputs and outputs, daily weights. Urine specific gravity q void.

7. Diet: Renal diet of high biologic value protein of 0.6-0.8 g/kg, sodium 2 g, potassium 1 mEq/kg, and at least 35 kcal/kg of nonprotein calories.

8. IV Fluids:

Maintenance Fluids:

<10 kg 100 mL/kg/24h

10-20 kg 1000 mL plus 50 mL/kg/24h for each kg >10 kg

>20 kg 1500 mL plus 20 mL/kg/24h for each kg >20 kg

Electrolyte Requirements:

Sodium: 3-5 mEq/kg/day

Potassium: 2-3 mEq/kg/day

Chloride: 3 mEq/kg/day

Glucose: 5-10 gm/100 mL water required (D5W - D10W)

Estimation of Dehydration

Degree of Dehydration

Mild

Moderate

Severe

Weight Loss - Infants

5%

10%

15%

Weight Loss - Children

3%-4%

6%-8%

10%

Pulse

Normal

Slightly increased

Very increased

Blood Pressure

Normal

Normal to orthostatic, >10 mm Hg change

Orthostatic to shock

Behavior

Normal

Irritable

Hyperirritable to lethargic

Thirst

Slight

Moderate

Intense

Mucous Membranes

Normal

Dry

Parched

Tears

Present

Decreased

Absent, sunken eyes

Anterior Fontanelle

Normal

Normal to sunken

Sunken

External Jugular Vein

Visible when supine

Not visible except with supraclavicular pressure

Not visible even with supraclavicular pressure

Skin

Capillary refill <2 sec

Delayed capillary refill, 2-4 sec (decreased turgor)

Very delayed capillary refill (>4 sec), tenting; cool skin, acrocyanotic, or mottled

Urine Specific Gravity (SG)

>1.020

>1.020; oliguria

Oliguria or anuria

Approximate Fluid Deficit

<50 mL/kg

50-100 mL/kg

> 100 mL/kg

Electrolyte Deficit Calculation:

Na+ deficit = (desired Na - measured Na in mEq/L) x 0.6 x weight in kg

K+ deficit = (desired K - measured K in mEq/L) x 0.25 x weight in kg

Cl− deficit= (desired Cl - measured Cl in mEq/L) x 0.45 x weight in kg

Free H2O deficit in hypernatremic dehydration = 4 mL/kg for every mEq that serum Na >145 mEq/L.

Phase 1, Acute Fluid Resuscitation (Symptomatic Dehydration):

-Give NS 20-30 mL/kg IV at maximum rate; repeat fluid boluses of NS 20-30 mL/kg until blood pressure and pulse are normal.

Phase 2, Deficit and Maintenance Therapy (Asymptomatic dehydration):

Hypotonic Dehydration (Na+ <125 mEq/L):<125>

-Calculate total maintenance and deficit fluids and sodium deficit for 24h (minus fluids and electrolytes given in phase 1). If isotonic or hyponatremic dehydration, replace 50% over 8h and 50% over next 16h

-Estimate and replace ongoing losses q6-8h.

-Add potassium to IV solution after first void.

-Usually D5 1/2 NS or D5 1/4 NS saline with 10-40 mEq KCL/liter 60 mL/kg over 2 hours. Then infuse at 6-8 mL/kg/h for 12h.

-See hyponatremia, page 111.

Isotonic Dehydration (Na+ 130-150 mEq/L):

-Calculate total maintenance and replacement fluids for 24h (minus fluids and electrolytes given in phase 1) and give half over first 8h, then remaining half over next 16 hours.

-Add potassium to IV solution after first void.

-Estimate and replace ongoing losses.

-Usually D5 1/2 NS or D5 1/4 NS with 10-40 mEq KCL/L.

Hypertonic Dehydration (Na+ >150 mEq/L):

-Calculate and correct free water deficit and correct slowly. Reduce serum sodium by 10 mEq/L/day; do not reduce sodium by more than 15 mEq/L/24h or by >0.5 mEq/L/hr.

-If volume depleted, give NS 20-40 mL/kg IV until adequate circulation, then give 1/2-1/4 NS in 5% dextrose to replace half of free water deficit over first 24h. Follow serial serum sodium levels and correct deficit over 48-72h.

-Free water deficit: 4 mL/kg x (serum Na+ -145)

-Also see “hypernatremia” page 111.

-Add potassium to IV solution after first void as KCL.

-Usually D5 1/4 NS or D5W with 10-40 mEq/L KCL. Estimate and replace ongoing losses and maintenance.

Replacement of ongoing losses (usual fluids):

-Nasogastric suction: D5 1/2 NS with 20 mEq KCL/L or 1/2 NS with KCL 20 mEq/L.

-Diarrhea: D5 1/4 NS with 40 mEq KCl/L

Oral Rehydration Therapy (mild-moderate dehydration <10%):

-Oral rehydration electrolyte solution (Rehydralyte, Pedialyte, Ricelyte, Revital Ice) deficit replacement of 60-80 mL/kg PO or via NG tube over 2h. Provide additional fluid requirement over remaining 18-20 hours; add anticipated fluid losses from stools of 10 mL/kg for each diarrheal stool.

Oral Electrolyte Solutions

Product

Na (mEq/L)

K (mEq/L)

Cl (mEq/L)

Rehydralyte

75

20

65

Ricelyte

50

25

45

Pedialyte

45

20

35