Dehydration in children Homola L, Musil V Department of Pediatric Infectious Diseases Faculty of Medicine, University Hospital Masaryk University, Brno •Symptoms •Differential diagnoses, Anamnesis, Physical examination •Dehydration •Lab tests •Treatment • Physical examination nbehavior: apatia or excitation, thirst nskin: colour, turgor nhead: fontanella maior, eyes, mucosa, lips nheart: tachycardia nabdomen: pain, resistance, peristalsis, hepatosplenomegaly nlimbs: pulsation Dehydration degree •Mild •home treatment • •Medium •hospitalization? •Severe •ICU!!! • Mild dehydration nweight loss <5% nNeonates with 4 kg, weight loss < 200g nadult with 60kg, weight loss < 3kg n nthirst noliguria n nealko_baby Medium dehydration nweight loss 5-10% n+ visible sign nbehavioral changes- apatia/irritability ndry or sticky mucous membrane ntears missing nsunken eyes (endophtalmus) nlower fontanelle nlower skin turgor (loss of skin elasticity) ntachycardia n Dehydratace_VFvkleslá n n n n n n n n n C:\Users\26131.EKO\Desktop\dehydration_skin_turgor.jpg Severe dehydration nweight loss >10% nsigns of hypovolemic shock ncold acral parts ncyanosis nthready pulse ndifficult breathing nrapid breathing nlethargy ncoma perioralcyanosis1 Why laboratory tests? nASTRUP nESR nComplete blood count nBlood chemistry nUrine nCoagulation n ASTRUP vomiting ↓Hydrochlorid acid diarrhea ↓Bicarbonate ? pH Alkalosis Acidosis ASTRUP ([Na+] + [K+]) − ([Cl−] + [HCO−3]) Metabolic acidosis Normal anion gap High anion gap ↓ HCO−3 →↑ Cl− •Lactate (tissue hypoperfusion, liver dysfunction) •Keto acids (starving, DM) •Paraprotein (malignancies) •Toxins (ethanol, methanol, ethylene glycol) •Renal failure – decreased excretion of acids + decreased HCO−3 reabsorption C:\Users\26131\Desktop\image040.jpg Erythrocyte sedimentation rate nnon-specific measure of inflammation nindirectly measures the degree of inflammation n n FW n n Blood Count nDegree of inflammation nLeukocytosis nType of inflammation n>Neutrophils – drum sticks or immature forms, toxic granulations n>Lymphocytes – viral nEosinophils (normal to 5%), more – allergy, parasites (tissue helminths), cleaning after disease nMonocytes (normal to 10%), more – EBV ? nNeutrophil to lymphocyte count ratio - NLCR üearly parameter of systemic inflammation and stress in critically ill ü˃10 systemic bacterial infection (condition: neutrophilia and lymfocytopeny) n n Blood Count ndehydration n↑hemoglobin and hematocrit nanemia, bleeding n↓hemoglobin, hematocrit ndegree of inflammation n↓ PLT Blood chemistry n n n n nCRP n nX n nPCT § n • n Blood chemistry nCRP •protein of acute phase, norm <8 mg/ml •hepatic origin (NO in liver failure!) •inflammatory condition, malignancy → ↑IL-6 → synthesis of CRP n→ marker of inflammation, not only infection •binds to phosphocholine expressed §on the dead or dying cells → ↑ necrosis (heart attack, multiple trauma) §some bacteria → ↑ bacterial infection •dynamics §first level: 4 – 6 h §peak: 36 – 48 h §elimination half-life time: 18 hours •diagnostic use: §determining disease progress or the effectiveness of treatments § § n • n Blood chemistry nPCT •production §normal: parafollicular cells of the thyroid (precursor of the calcitonin) §inflammation: somatic cells (protein of acute phase, norm < 0,05 ng/l) •dynamics §first level: 2 - 3h §peak: 6 – 12 h §elimination half-time: 24 - 30 hours •diagnostic use §differential diagnosis of infectious and non-infectious process §greatest sensitivity and specificity for the differential diagnosis of infectious and non-infectious SIRS §2x negative in first 12 h → exclusion of sepsis n→ marker of infection (bacterial) § • n • n nplasma osmolality (275 – 295 mmol/kg) nelectrolyte-water balance nNa (ECF volume regulation), gluc, urea… nhyper-,izo- , hypo- nIons § Na, K, Cl, Ca §+ Mg, P - seizures nurea, creatinine – kidneys function nglycaemia §↑Glc - stress, DM screening §↓Glc – apatia, acetonemic vomiting, seizures nLactate ntissue hypoperfusion, liver dysfunction →MAC with high anion gap nprognostic tool (dynamic changes) n n Blood chemistry Urine nUrinary infection nleu, erc, proeinuria nDisorder of kidney function nproteinuria, glycosuria nStarvation nketones nDehydration: n↑urine osmolality n Coagulation nBleeding n nLiver function (short elimination half-time of coagulation parameters) n nSevere conditions (sepsis) Therapy Rehydration – step by step • •Dehydration degree •Calculation of overall volume •Fluid management Calculation of overall volume §Basal intake of fluid: §Less than 10 kg = 100 ml/kg §10-20 kg = 1000 + 50 ml/kg for each kg over 10 kg §Greater than 20 kg = 1500 + 20 ml/kg for each kg over 20 kg § • Estimated loss of fluids n <1 year: severe 100ml/kg, medium and mild: 50 ml/kg n >1 year: severe 50ml/kg, medium and mild 20 ml/kg n §Ongoing pathological losses + ions, glucose and acidobasic correction n+ 12% of basal intake for every 1°C of body temperature n+ 50 - 150 ml for every vomiting or stool • § IV rehydration Calculate: e.g. Boy, 20 kg, 5-year-old, estimated weight loss to 10 % (medium dehydration) basal intake: ? estimated loss: ? (ongoing losses) Calculation of overall volume §Basal intake of fluid: §Less than 10 kg = 100 ml/kg §10-20 kg = 1000 + 50 ml/kg for each kg over 10 kg §Greater than 20 kg = 1500 + 20 ml/kg for each kg over 20 kg § • Estimated loss of fluids n <1 year: severe 100ml/kg, medium and mild: 50 ml/kg n >1 year: severe 50ml/kg, medium and mild 20 ml/kg n §Ongoing pathological losses + ions, glucose and acidobasic correction n+ 12% of basal intake for every 1°C of body temperature n+ 50 - 150 ml for every vomiting or stool • § Calculate: e.g. Boy, 20 kg, estimated weigh loss 5 - 10 % (medium dehydration) basal intake: 1000 + (50 x 10) = 1500 ml estimated loss: 20 x 20 = 400 ml (ongoing losses) •1500 ml + 400 ml…= 1900 ml • Calculation of overall volume Fluid management Calculated volume in next 24 hours (boy, 20 kg): 1900 ml •1/2 in first 8 h: 950 ml (first hour 10 – 20 ml/kg) •1. hour: speed 200 ml/h •next 7 hours: 750 ml …speed of infusion 107 ml/h •2/2 in next 16 h: 950 ml + add ongoing pathol. losses (in next hours) + ongoing ions and acidobasic correction (blood test results…in first 2 hours) Monitor for signs and symptoms •state of consciousness •urine output •skin turgor •tachycardia IV rehydration II - fluid management Oral rehydration nmild dehydration nperoral rehydration fluid (water, Na, K, Glc) – WHO defined nrice water, mineral still water IV solutions •Crystalloids – small molecules •about 25 % remain in vascular space •Isotonic – 0.9 % NaCl, Ringer fundin, Ringer lactate, Plasmalyte •Hypotonic - 5 % Gluc, 0,45 % NaCl •Hypertonic – 10 % Gluc, Plasmalyte + 5 % Gluc… • •Colloids - large molecules • →severe dehydration? •remain in vascular space •E.g. Hydroxyethyl starch (HES) – max. safety dose – 25 ml/kg/day •↑ price •AE: anaphylactoid reactions, coagulopathy •(Blood products) – NO: for volume expansion! Isotonic solutions •concertation of electrolytes is similar to that of plasma •inicial treatment of dehydration (if we don't know parameters of ions and acid-base balance) •0.9 % NaCl • I: MAC high anion gap (lactate, ketoacids), renal impairment (absence of K+) •Plasmalyte: electrolyte concentrations, osmolality and pH mimic plasma • • • • Hypotonic solutions •Lower concetration of electrolytes or tonicity compared to plasma •<250 mmol/l → shift to cells •NO •hypernatremic dehydration (>150 mmol/l) •pacient at risk for increased ICP •liver disease, trauma, burns (depletion of intravascular volume) → cerebral edema •hyponatremic dehydration (<130 mmol/l) → deeper hyponatremia → cerebral edema •YES •ongoing pathological losses (e.g. hypoglycemia) Hypertonic solutions •Higher concentration of electrolytes or tonicity compared to plasma •≥375 mmol/l → ECF – volume expander •E.g. Plasmalyte + 5 % gluc (572 Osmol/l), 10 % Gluc (556 mmol/l), 3% NaCl, 10 % NaCl, 7.5 % KCl… • •NO •replacement of volume (↑Osmol) •high speed ! - phlebitis, fluid volume overload → pulmonary edema •YES •glucose and ion correction (e.g. 3% NaCl in symptom. hyponatremic. dehydration) •Correction of MAL (NaCl) • • • pH C:\Users\26131\Desktop\370_12_KB-Acid-base.jpg •Plasmalyte (pH 7.4) •Ringer fundin (pH 5.1 – 5.4) •correction of MAC <7,1 •4,2 %/8,4 % NaHCO3 •Add 1/3 -1/2 of calculated amount •correction of MAL >7,45 •↓CL: NaCl, KCl, NH4Cl… •Ringer lactate (pH 6.5) voda Thank you for your patience