Transcript Gastroenteritis, types of dehydration

Types of dehydration and their
treatment
Prof. Molnár Dénes
Causes of dehydration
• Decreased intake
Anorexia
Coma
Fluid deprivation
Causes of dehydration
• Increased loss
Gastrointestinal
Vomiting
Diarroea
Enterocutan fistules
Causes of dehydration
Increased loss
Renal
Osmotic diuresis
Diuretic administration
Mineralocorticoid deficiency
renal diseases
Central and nephrogenic diabetes
insipidus
Causes of dehydration
• Increased loss
Skin and airways
High environmental temperature
Cystic fibrosis
Burn
Inflammatory skin diseaeses
Body fluid compartments by age
Newborn
1 yr
3 yr
9 yr
Adult
Weight (kg)
3
10
15
30
70
Body surf. (m2)
0.2
0.5
0.6
1
1.7
TBW (%)
78
65
-
-
60
ECF (%)
45
25
-
-
20
ICF (%)
33
40
-
-
40
Fluid electrolytes (mE/l)
ECF
ICF
Sodium
140
10
Potassium
4
150
Calcium
5
3
Magnesium
3
30
Chloride
100
4
Bicarbonate
25
10
Daily amount and electrolite composition of
gastrointestinal juice in infants
Secretum
Volumeség(ml)
Na+
mEq/l
Ka+
mEq/l
ClmEq/l
HCO3
mEq/l
Saliva
200
50
20
30
40
Ventricular fluid
1440
35
10
180
-
Bile
400
150
10
90
40
Pancreatic secr.
450
150
10
50
110
Smal bowel secr. 800
140
5
70
75
Large bowel
secr.
40
90
15
30
100
Maintenance fluid and electrolyte requirement
Subject/ cation
Weight
Requirement
Fluid/Children
10 kg
100ml/kg/day (4 ml/kg/hour)
Fluid/Children
11-20 kg
1,000 ml + 50 ml/kg/day for each kg over 10 kg
(2 ml/kg/hour)
Fluid/Children
> 20 kg
1,500 ml + 20 ml/kg/day for each kg over 20 kg
(1 ml/kg/hour)
Sodium
2-4 mmol/kg/day (ECF)
Potassium
1-3 mmol/kg/day (ICF)
Calcium
1-2.5 mmol/kg/day
Chloride
2-3 mmol/kg/day
Glucose
5g/100 ml water
Factors influencing maintenance fluid requirement
Cause of fluid loss
Fluid requirement
Fever$
10-12% incr./1 °C
Hyperventilation
10-60 ml/100 kcal
Sweating
10-25 ml/100 kcal
Diarrhoea
Loss from the gi
trackt and renal
disease*
mild
10-25 ml/kg/day
Moderate
25-50ml/kg/day
Severe
50-75 ml/kg/day
Monitor the loss and adjust
fluid accordingly
*in case of anuria insensible water loss = 400 ml/m2, $above 38°C is to be corrected
Types of dehydrations
1. Hypotonic
Se Na < 130 mmol/l
2. Isotonic
Se Na 130-150 mmol/l
3. Hypertonic
Se Na > 150 mmol/l
Diferences in clinical signs
Isotonic
Hypotonic
Hypertonic
Se Na (mmol/l)
130-150
<130
>150
Mucous
membr.
dry
dry
parched
Mental st.
lethargic
coma/seizure
irritable/seizur
e
Incr. pulse
++
++
+
Decr. BP
++
+++
+
A dehydratio súlyossági fokozatai
Signs
Mild
Moderate
Severe
General status and
behavour
Normal, slightly thirsty
Irritable, thirsty
Lethargic , comatic,
shock
Pulzus
Normal, filled pulse
rapid
Very rapid, easily
suppressible
Breathing
Normal
Deep, rapid
Rapid, deep or
periodical
Turgour of the skin
Normal
Slightly decreased
decreased
Eyes
Normal
sunken
Deeply sunken
Lacrimation
Normal
limited
Abscent
Mucous membranes
wet
dry
Very dry
Urine
Normal (> 1ml/kg/hr)
small, dark (0,5 – 1,0
ml/kg/hr
Very small or abscent
(0,5 ml/kg/óra)
Weight loss %
4-5
6-9
 10
Fluid loss ml/kg
40-50
60-90
100-150
Fluid loss wt%
4-5
6-9
10-15
Calculation of losses
Fluid loss = aactual TBW – normal TBW
Aktual TBW = 0.6 × bwt(kg) × plasma osm.(mOsm/l)/ norm.
plasma osm (290)
Calculated plasma osmolarity (mOsmol/l) = 1.86 × Na+ +
glucose/18 + urea/2.8
Normal TBW = 0.6 × body weight (kg) – age dependent
Na deficit = Norm. Se Na - actual Se Na × Bwt × 0.6
Potassium defficiency
20 - 40 % of the fluid loss is intracellular
K loss = 150 mmol/l × 0.2-0.4 × ffluid loss (l)
The calculation of the exact K loss is possible if the intracellular K
concentration is known.
WHO által javasolt rehidráló folyadékok összetétele
mmol/l
Modified
WHO
WHO
Na+
90
90
60
K+
20
20
20
Cl-
80
110
50
HCO-
30
–
30
Citrate-
–
–
–
20
20
20
Glukcose mmol/l
111
111
111
Osm
mosm/l
331
331
271
Glucose:Na
1,2:1
1.2:1
1,8:1
Glucose g/l
The composition of oral rehydration
solutions in Hungary
Sal ad
rehydratione
m
(Fono)
Sal ad
rehydr.
pro
parvulo
(Fono)
Sal ad rehydr. c.
natr.
hydrogencarb.
(Fono)
Sal ad rehydr.
c.
natr.
hydregencarb.
pro parvulo
(Fono)
Na+
90,5
46
90
45
55
57,4
K+
20
25
20
25
34
21,8
Cl-
80
40
80
40
50
44,8
–
–
30
30
–
–
Citrate-
11,5
11,5
–
–
11,5
9,4
glucose
g/l
20
25
20
25
17,4
14
mmol/l
111
139
111
139
97
78
Osm
mosm/l
317
265
331
279
215
235
glucose
:Na
1,2:1
3:1
1,2:1
3:1
1,8:1
1,4:1
mmol/l
HCO-
Milupa
RES 55
With
carotta
Hipp
ORS
200
A Hipp ORS 200; further components:
Protein: 4 g/l; fat: 1 g/l; carbohydrate: 42 g/l – from this
glucose: 14 g/l, fructose: 4 g/l, sacharose: 4 g/l, starch: 20 g/l
A Milupa RES 55 with carrot; further constituents:
Protein: 5,7 g/l, fat: 0,6 g/l; carbohydrate: 75,2 g/l – from this
glucose: 17,4 g, fructose: 0,9 g, sacharine: 0,9 g,
polysacharide: 55,8 g; fiber: 3 g/l
Therapy
• In mild dehydration the oral rehydration can be
tried.
• Within 6 hrs 50 ml/kg glucose-electrolite solution
(Hipp ORS, RES 55) is given
• If the condition of the child improves, sucking
infant can get brest milk, formula feed infant can
receive the formula.
• In moderate or severe dehydration refer the child
into hospital – i.v. rehydration
Oral rehydration is limited by few
conditions:
• Extreme fluid loss, depressed
consciousness
• Persistent vomiting
• Glucose intolerance (probability:< 2
% secondary monosaccharide
malabsorption, diabetes mellitus)
• Acute abdomen
• Low complience of the parents
Therapy
• In the presence of shock (independent
of the type of dehydration) 20 ml/kg bwt
physiologic saline or vagy Ringer lactate
is to be given in bolus or rapid infusion.
Therapy
• 1. Hypotonic
A/ Symptomatic:
The Sodium concentration should be increased
urgently by 5 mmol/l (within 1 hr). 5 mmol ×
0.6 bwt kg Na should be administered. Total
correction is not necessary. 1.2 ml/kg bwt 3%
(0.5 mmol/ml) increases the Se Na
concentration by 1 mmol/l.
B/ Asymptomatic:
Slow correction (24-36 h)
Na requirement: loss + daily requirement is
added to the calculated fluid requirement.
Therapy
• 2. Isotonic
Replacement of the losses - physiologic NaCl
solution (Na conc. =150 mmol/l) is to be
given.
Maintenance requirement: 25-50 mmolNa/l
Total fluid requirement: maintenance
requirement + loss – the half of the latter is to
be givenm within the first 8 hrs, the next half
in the next 16 hrs.
Therapy
• 3. Hypertonic
• Slow correction – danger of brain edema!!
• Decrease of Se Na = 10 mmol/l/24 h is the
goal.
• If the Se Na >180 mmol/l - dialysis
• Usually we administer physiologic saline or
Ringer lactate in nthe first hours of the
treatment.
• The frequent monitoring of the Se Na
concentration is required.
• The fluid requirement: loss + maintenace
Example
30 kg bwt
Fluid loss: 10% (moderate, severe)
Fluid requirement:
Maintenance req.: 1000ml + 10 × 50 + 10×20 =1700 ml/24h
Loss: 30000/100 × 10= 3000 ml
The half of the lost volume is administered within the first 8 hrs, the
remaining in the next 16 hrs.
The maintenace req. is distributed evenly in thje 24 hrs.
Electrolyte composition of the fluid is dependent on the type of
dehydrition.
The composition of the maintenace fluid generaly:
In 1000 ml fluid 25 –50 mEq Na, 25mEq K, 50 mEq Cl és 50 g glukóz
During the first day of the treatment of dehydration the administration of
K is not required if there is no increased potassium loss (eg: diabetic
ketoacidosis). Certainly not until normal diuresis is achieved!!
Hyprkalaemia
• Se K > 5 mmol/l
• 0,5-1,0 ml/kg 10%-os Ca-gluconicum
• 0,5-1,0 g/kg glucose solution with insulin (1 E
insulin/3 g glucose)
• 1-2 mEq/kg NaHCO3
• ß2 mimeticum
• 1 g/kg Na-polistirol-sulfate per os v enema
• Peritoneal v haemodialysis
Hypokalaemia
• Se K < 3,5 mmol/l
• Treat the cause
• Oral K supplementation in mild or chronic
situations
• Iv K supplementation in severe cases
IV K supplementation
• Stabilize the peripheral circulation, renal
function
• Correct the acidosis
• The K concentration of the Iv solution
cannot be more than 40 mmol/l and its rate
should not succeed 0,5-1,0 mmol/kg/h
Acid-base disbalance
• Necessary Na HCO3= required HCO3 – act.
HCO3 x f x bwt (kg)
F= 0,3 in older children, 0,4 in infants, 0,5 in
neonates