Emergency Medicine/Pediatric Rehydration

= Pediatric Rehydration =
 * Alex Flaxmanman==

= Clinical Eval of Dehydration = = Oral rehydration = = Oral Rehydration Solutions = = After Rehydration = = Parenteral Rehydration = = Bolus = = End Points = = Post-acute Treatment = = Monitoring- Give enough = = But not too much = = Calculations- Where to start = = Calculating Deficits = = Maintenance Fluids- Goals = = Maintenance Fluids- Calculations =
 * 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 ==
 * 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 ==
 * Resume breast feeding, or usual formula/milk ==
 * Resume feeding, if appropriate ==
 * (IVF) ==
 * 20 ml/kg, over 20 min ==
 * Use isotonic fluids- NS or LR ==
 * Blood, 5% albumin, plasma ==
 * “Adequate intravascular volume” ==
 * Clinical improvement ==
 * ↓ HR ===
 * Normal BP ===
 * Improved tissue perfusion (UO) ===
 * More alert affect ===
 * 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 ==
 * 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 ==
 * Edema ==
 * Pulmonary congestion ==
 * Mild		3–5%	→	 5% ==
 * Moderate	7–10%	→	10% ==
 * Severe		10–15%	→	15% ==
 * Water Deficit 	 = 	% dehydration × weight ==
 * Sodium Deficit	 = 	Water deficit × 80 mEq/L ==
 * Potassium Deficit = 	Water deficit × 30 mEq/L ==
 * Prevent dehydration ==
 * Prevent electrolyte disorders ==
 * Prevent ketoacidosis ==
 * Prevent protein degradation ==
 * “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 = = Special Cases = = Special Cases (cont’d) = = Special Cases- Lungs = = Special Cases (cont’d) = = Special Cases (cont’d) = = Hyponatremic dehydration =
 * NS ==
 * [Na]	154 mEq ===
 * [Cl]	154 mEq ===
 * LR ==
 * [Na]	130 mEq ===
 * [Cl]	109 mEq ===
 * [K]		   4 mEq ===
 * [Ca]	   3 mEq ===
 * [Lactate]	 28 mEq ===
 * 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 ==
 * Fever ==
 * Premature infants ==
 * Radiant warmers ===
 * Phototherapy ===
 * ↑ Fluids requirement ==
 * Tachypnea ==
 * Tracheostomy ==
 * ↓ Fluids requirement ==
 * Mist tent ==
 * Vent ==
 * NGT ==
 * Surgical drains ==
 * Diarrhea dehydration ==
 * Isotonic 60-70% ===
 * Hyponatremic 10-15% ===
 * Hypernatremic 10-20% ===

= Hypernatremic Dehydration = = IVF for Ongoing Losses = = Summary =
 * D5 1/4 NS + 15 mEq/L bicarbonate + 25 mEq/L KCl ==
 * Replace stool mL/mL every 1–6 hr ==
 * 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 ==