Documente Academic
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Laurence
of Dehydration
Finberg,
MD*
NORMAL
CHEMICAL
AND PHYSIOLOGY
ANATOMY
Before
discussing
dehydration
it
is worthwhile
to review
the normal
features
of an infant with respect
to
content
and distribution
of water and
mineral.
Approximately
70% of the
lean body mass is water. The distribution
of this water is shown in Fig
1 The plasma volume
owes its integ.
rity
to its protein
in Infancy
content,
which
is a
we have
assumed
tion
requires
that
enteral
severe
at least
dehydrainitial
par-
EDUCATIONAL
CLINICAL
EVALUATION
DEHYDRATION
66. Appropriate
knowledge
of the
immediate
management
of the infant with hypertonic
dehydration
(81/82).
OF
Dehydration
regardless
of the etiologic
factors
that produce
it is a
physiologic
disturbance
of clinical
importance.
lead
OBJECTIVES
repair.
Proper
to
assessment
appropriate
will
therapy
evaluation,
the tools are the clinical
history,
the examination
of the patient,
and a review
of laboratory
data.
Then
should
come
a systematic
analysis
of the problem
that
results
in a diagnosis
of the physio-
hospital
in the membrane
that
dium.
The compositional
logic
disturbance
and suggests
nature
of therapeutic
intervention,
stances
this symptom
ends the ability of the family to care for the baby.
are diagrammed
in Fig 2.
The second
consideration
necessary to handle any problem
is that of
obligatory
water requirements
to replace losses.
Table 1 gives the relationship
between
caloric
expenditure and water loss with the basal
state as the point of reference. For
ordinary
clinical
circumstances
requirements
are about
11/2
times
basal state. Electrolyte
requirements
have a wide range. Practical
considerations
make it necessary
to provide
ment
solute
in an
intravenous
solu-
and
bicarbonate
(or other
base)
brief
presentation
the
treat-
ment plans
are developed
around
parenteral
therapy.
In many situations,
eg, diarrheal
disease,
oral
fluid will be equally
satisfactory
if the
patient is able to drink.
The reader
should be able to adapt
the princi-
of
points
Hospital
York.
and
Medical
Center,
the
if
from
the
need
a number
special
dration,
stress.
history
a recent
weight
of
the patient,
this information
may
prove useful
as a benchmark.
The
presence
of fever, level and duration
if possible,
is clearly
description
important.
of the patients
in regard
humidity
mated.
environ-
to temperature
and
local
or systemic,
is also of importance
because
of the influence
of
infection
on catabolism
as well as
the implications
of an infection
for
physiologic
change.
Intensive
questioning
should
be
centered
on the site of fluid loss and
on
the
Since
type
most
and
fluid
amount
losses
of
are from
loss.
the
vomiting
in infancy
are of special
importance
because
a high oral intake
of liquid
is essential
to life processes,
especially
during
a catabolic
in an
usually
since
under
In examining
the history,
Clearly,
these
are the things
that
bear upon the intake
of fluid and
mineral
and on unusual
losses
of
these. When it is possible
to obtain
state.
#{149}
Montefiore
Bronx,
New
clinical
with
fluid
for
treatment
any.
In obtaining
In any
68. Appropriate
familiarity
management
of maintenance
and electrolyte
administration
the pediatric
patient (81/82).
relatively
impermeable
species
of
molecule.
The
extracellular
fluid
composition
differs
strikingly
from
the intracellular
fluid
despite
the
movement
of most ions across
cell
membranes
because
of an active
transport
system (N&, K, ATPase)
extrudes
sodifferences
is required.
when
67. Appropriate
knowledge
of the
immediate
management
of hyponatremic
dehydration
(81/82).
Indeed,
infant
pediatrics
in review
the
an
most
infant
most
circum-
for
important
dehy-
single
determination
is the patients
weight.
This measurement
should
always
be
obtained
with great
care and precision.
If the patient
is lethargic,
it is
important
also to determine
whether
irritability
is present
both
without
stimulus
and when
such
stimuli
as
sound,
light, and touch are applied.
Unusual
body movements
or convulsive twitchings
should be noted, and
one should
ascertain
whether
there
are tears.
The skin provides
many clues to
the state of hydration.
ularly
true in infancy
1 to 2 years.
In older
amination
of the skin
children,
exis less useful
in determining
the state of hydration.
Two signs of special
importance
are
changes
in elasticity and in turgor.
When
the abdominal
skin
in normal
infants is pinched,
it will snap back
promptly
on release.
When dehydration
has
progressed
to a serious
point,
pinched
skin
will
remain
standing
in folds
has been
seen,
however,
because
in serious
elasticity
may
also
be
under-nu-
trition
without
dehydration.
The nature
of the subcutaneous
tissue
is
different
in older children
and adults,
and this loss of elasticity
will not be
elicited
when
they
are dehydrated.
The presence
of turgor
is a sign of
circulatory
adequacy.
One
examvol.
3 no. 4 october
1981
PIR
113
Fluids
and
Electrolytes
ALIMENTARYTRACT
mOsm/Kg
ECF
TC*#{149}l%LBM
ICF
I
t:I3 PLASMA6%LBM
LUNGS-ECF----1----INTERSTITIALFLUID
19%LBM
HC03
IKIDNEY
28
SKI
11
+
47
ICE
45% LBM
No-
F-.--
Na-K
ATPase
CL
IT
TRANSCELLULAR*ATER I%LBM
-.-
kA)
NON-AQUEOUS
TISSUE
28% LBM
LEANBODYMASS(FAT FREE)OFINFANT
(54 PROTEIN
Fig
1.
Diagram
of normal
distribution
of
body water in lean body mass (LBM).
Adipose
tissue
is not associated
with significant
water.
Arrows
indicate
flows
of water
and
ions.
Transcellular
water
(TCW)
includes
water
within
intestines
(out of scale on diagram,
but
potentially
much
greater
than normal).
Other
Tcw is water sequestered
tightly
in tissues
and
not
rapidly
involved
in acute
body
changes.
ECF,
Extracellular
fluid;
ICF, intracellular
fluid.
TABLE
Basal Caloric
Weight
(kg)
A ge
Newborn
1 wk
to
Expenditure
2.5-4
6 mo
3-8
6tol2mo
8-12
Co
Mg
PLASMA
for Infants
and Children
Surface
(sq
Area
m)
Calories
(/kg)
0.2-0.23
50
0.2-0.35
65-70
50-60
45-50
45
6toloyr
20-35
0.7-1.1
40-45
11 to 15 yr
35-60
1.5-1.7
25-40
Adult
70
equals
1 .75
PIR 1 1 4
pediatrics
in
review
15-20
#{149}
INTRACELLULAR
FLUID
MUSCLE
-
these
routine
studies,
in a dehydrated
patient
blood
should
be
drawn
for analysis
(as a minimum)
of
the urea nitrogen
level and the electrolytes
(sodium,
potassium,
chloride, and bicarbonate).
If a more extensive
analysis
is desired,
blood
gases
plus
of dehydration.
The examination
of
the muscle
tone including
checking
for nuchal
rigidity
and testing
the
deep
tendon
reflexes
is a helpful
assessment
as will be discussed
below. Auscultation
of the heart
and
lungs
gives
information
on the quality of the heart sounds
and confirms
observations
with respect
to the rate
and depth
of breathing.
Routine
laboratory
studies
in dehydration
should
include
a hematocrit and a urinalysis.
In addition
to
calcium,
phosphorus,
magnesium,
glucose,
and
albumin
should
be measured.
Most
patients
do not require
such
an extensive
work-up.
For complicated
or unusual
cases,
1 mI/calorie.
__i__ R
Fig 2.
Ionic
profiles
of body
fluids.
Composition
of the three
physiologically
important
compartments
is shown
with
separating
barrier
indicated.
Concentrations
(mEq/liter)
are
shown
and left hand
scale
(mOsm/kg)
emphasizes
nonidentity
of these
measures
except
for
univalent
unbound
ions. Shaded
areas
indicate
low or absent
osmotic
activity
because
of large
molecule
size or because
of binding
of ion to large
molecule.
Protein
and amino
acids
have
important
osmolal
contribution,
even in low concentration
because
of relative
impermeability.
ECF, Extracellular
fluid;
ICF, intracellular
fluid.
0.45-0.55
0.6-0.7
Water expenditure
H2P04
S04
FLUID
0.35-0.45
INTERSTITIAL
10-15
1 5-20
12 to 24 mo
2 to 5 yr
._j_.
4
3
however,
such
studies
can
be quite valuable.
Having
obtained
the data
base
from history,
examination,
and preliminary
laboratory
data,
the next
step is a systematic
analysis
of five
cardinal
clinical
points.
Each
should
be reviewed
in assessing
the patients
status
although
in the most
severely
ill patients,
one may initially
have
to forgo
altogether
of
the
laboratory
because
patients
clinical
points
osmolality,
(3)
(4) intracellular
information
of
condition.
the
urgency
The
five
1981
DEHYDRATION
the
distortion
bution,
will be discussed
the physician
of dehydration,
of body
and
the
The
first
ment are
last three
distri-
metabolic
ances arising
from
drogen,
potassium,
ions.
water
to
extracellular
disturb-
above
effects
upon hyand
calcium
two
points
brachial
blood
pressure
maintained.
At this point
is in medical
shock
from
of assess-
more important
than the
if the patient
has poten-
tially adequate
renal and pulmonary
function.
The
homeostatic
mechanisms
of kidneys
and lungs
will correct
the metabolic
disturbances
if
fluid.
two
is usually
the patient
the loss of
Between
landmarks,
one
the
can
inter-
polate-but
not with precision-intermediate
degrees
of deficit.
When
the deficit over a short period of time
approaches
1 5% of the body weight,
blood
pressure
drops
and a moribund
state
The
ume
of
deficit
has
the
been
the
vol-
dehy-
the volume
and space disturbances
are quickly
and appropriately
corrected.
Patients
with impaired
renal
or
noring
the
duced
period,
by the patient
in each
an error in the opposite
pulmonary
function
careful
attention
assessment.
When
whether
require
to all five
going
sessments,
will
through
one
points
of
these
should
as-
determine
an emergency
state
exists.
The dehydration
may be classified
into hypernatremic,
isonatremic,
or
hyponatremic
states.
Finally,
the
metabolic
disturbances
those
of
evaluated.
including
hydrogen
ion
be
The
is
volume
deficit
should
The therapist
has three
considerations
with
respect
to volume.
The
first of these
is to assess
the degree
of deficit.
This,
of course,
is a
change
in composition
and can be
expressed
as in milliliters
gram
of
centage
this
body
weight
or
of weight
loss.
is often
10%
designated
per
kilo-
as a perIn jargon,
as 5%
or
dehydration,
by which
is
5% or 10% body weight
loss.
meant
The least objectively
icit is approximately
acute
weight
loss).
detectable
50 mI/kg
Elevated
rate
pulse
and
diminished
def(5%
pulse
pressure,
diminution
of output
of tears
and
urine,
may be the only manifestations.
When
a deficit
of approximately
100 mI/kg
exists,
a constellation of clinical
signs is usually present. These
include
depressed
fontanelle
in infants
and sunken
eyeballs in patients
at any age, loss of
elasticity
and of turgor
of the skin,
and other
evidences
of circulatory
deficit
which
acrocyanosis
of
the
tones,
include
coolness
or mottling
extremities,
feeble
and a weak,
and
of the skin
rapid
pulse.
heart
The
therday
be
thought
of as
of about
chloride
these
150
to
estimate
an ageor
expenditure
mines
water
from
the
these
ongoing
conditions
size-dependent
which
in
expenditure.
basal
temperature
changes,
and
lar movement.
state
there
is
caloric
turn
deterDeviations
include
body
changes,
ventilation
changes
from muscuAt average
clinical
and
with
normal
rather
the
On
precise
abnormalities
defined,
movement
in
an
servation
for
respect
to
continued
ab-
In a few diseases,
cholera,
these can
from
empirical
of the etiologies
on other
losses
data,
causing
problems,
will have
by continuing
to be
direct
ob-
of the patient.
experimental
increments
basis
for any of
described
can
in review
Osmolality
term
be
din-
as used
here
is a one-
word shorthand
way of saying
that
whats
being assessed
is a disturbance of the distribution
of water in
the body spaces.
The principal
emphasis
at this point in the analysis
is
to determine
whether
the patient
is:
hyponatnemic,
with
a relative
pre-
pondenance
of water in the cells at
the expense
of extracellular
fluid;
isonatnemic
with
a proportionate
constriction
of body fluids; on hypennatremic,
with relative
cellular
dessication,
conditions
of normal
body temperature ( 1 C) a slight increase
in ventilation
ascertained
1 gives
data
with
to
disease
abnormal
The
may be mod-
While
assessing
the deficit
it is
also appropriate
to consider
the volume needs of the patient
to replace
ongoing
obligatory
losses. This fluid
volume assessment
is sometimes
referred to as maintenance
fluid. One
assesses
the metabolic
state of the
At basal
diannheal
here
Table
concern
estimated
by the
estimates
expenditure
is related
2.
ified.
losses.
made
water
normal
losses.
such as Asiatic
the
a
hypen-
1 1 5-1 20 mEq/
estimates
patient
be readily
patients
when
time period-a
from
extracellular
it is a fluid with
of
double
be in-
fever,
of electrolyte.
A final
as
is, high
The
volume
points,
may
two
one
concentration
mEq/liter,
Volume
mates
clinician.
of these
cancel
estimated
safety
basal
energy
infants.
of fluid
primarily
deficit
fluid. Therefore,
that
time
di-
net result
that
they
of
to approximately
Should
all three
are free
oxidation
margin
ventilation
and continued
convulsive movements,
the effect
would
be
to triple the basal expenditure.
From
these
guideposts,
reasonable
esti-
be
The
10%
has proven
clinically
safe;
this makes meticulous
precision
unnecessary.
A marked
increase
in
any one of the three important
vanables will move the ongoing
obliga-
pro-
of
or two.
sodium
1.
water
another
for most
apy is for a short
the
should
rection.
omissions
calculation.
creased,
for estimating
tony losses
basal
state.
ensues.
basis
ically nor
advisable
the displaced
water
being
1981
PLR
115
Fluids
and
Electrolytes
TABLE
2.
Clinical
P rofiles
of Physiologic
Distu rbances
in Dehydration*
Osmolal
State
Characteristics
Isonatremic
Age
Hyponatremic
Hypernatremic
Any
Any
Any
Any,
Variable
Anorexia
Late in course
Minimal,
Marked
Time
of year
of ill-
ness
Often under
sible)
more
in summer
good
of wated
oral intake
early
in illness
maintained
Vomiting
Late
Diarrhea
Moderate
out
State of consciousness
Lethargy
Normal
May be obtunded
Variable
Common
Hypenirnitability
Unusual
Unusual
Marked
Normal
stimuli
Increased;
Muscle
Skin
tone
manifestation
Late
through-
Normal
elasticity
or absent
Early,
Long duration
days)
Poor
Very
(3 or more
may
be
coffee
ground
Variable
Disturbed
or weak
to tactile,
sound,
nuchal
and light
stiffness
some-
times present;
muscle twitchoccasionally
seen
Normal;
skin may have a velvety
or uncommonly
a doughy
feel
Good
Lroportionate
to fever
poor
Skin turgor
Pulse rate
Diminished
Increased
beyond
that caused by
fever
Poor
Markedly
increased
Blood
Maintained
Reduced,
borderline
pressure
or
slightly
Variable
Hyperpnea
low
of
Normal
circulatory
failure
Often, but variable
Variable,
sometimes
contributory
*
Associated
history
and signs
encountered
physiologic
disturbances
when
100 mI/kg
and
loss
rapid weight
lost
has occurred
secondary
to diarrheal
exceptions
may be seen though usually
sign is specific;
moreover,
the disease
disease.
These
cumulative
descriptions
are clinically
probable
stereotypes;
a cluster of these findings
will prove an accurate
predictor.
No one attribute
or
process
may change
the disturbance
from one part of the illness to another
as
may
listed
partial
therapy.
The
manifestations
dominate
and hypennatnemia
will nesuIt. The presence
of any factor
that
predisposes
to
insensible
water
loss, high ambient
temperature,
low
humidity,
fever-especially
high feyen, and hyperventilation
all predis-
pose
On
tion
with differing
marked
to water
to hypernatremia.
examination
points
to
deficient
circula-
loss
of
extracellular
are
system,
particucombination
of
is not severely
signs
refera-
lethargy
unstimulated
and hypenirnitability
to virtually
any stimulus,
a hypernatremic
state
should
be suspected.
Hypernatremic
patients,
in-
pediatrics
in review
#{149}
vol.
may
be either
the cause
of or the
Even
more
commonly
the skin will
have a somewhat
velvety
feel which
we have found
more
reliable
as an
indicator
of hypernatremia
than the
more traditionally
described
doughy
feeling.
In hypernatremic
states,
there
will be increased
muscle
tone
often
including
mild
nuchal
rigidity
which
is occasionally
mistaken
for
the nuchal
rigidity
of meningitis.
The
definitive
measurement
for
this
assessment
is the
level
of a sodium
3 no. 4 october
of the
physiologic
disturbance.
to the deficit
portion
of the repair
solution.
For most
patients,
those
with
isonatnemic
dehydration,
this
will be 1 40 to 1 55 mEq/Iiter.
More
sodium
should
be given if hyponatremia
is diagnosed
natremia
clinical
linked
to
ances,
result
and
less
if hyper-
is present.
Table
2 lists
associations
frequently
different
osmolan
disturb-
whether
or even
as
a cause,
or
both.
of so-
dium
in the serum.
This is a better
measurement
than
the
osmolality
per se because
some
substances
that affect
osmolality,
eg, urea,
do
not influence
body
water
distribution.
This assessment
point permits
as-
signment
result
concentration
3.
Hydrogen
Ion
Disturbance
The history
is helpful
in detecting
hydrogen
ion disturbance.
In infancy
unless
there
has been vomiting
with
high obstruction,
almost
all disturbances
produce
acidosis
and then
acidemia.
Diarrhea
is particularly
1981
DEHYDRATION
prone
to cause
ance.
The degree
this
type
of disturb-
of acidosis
or aci-
is not easily
gauged
laboratory
data.
Hyperpnea
dence
of a compensatory
without
is eviphenom-
demia
ena
and
presence
suggests
of ketones
similarly
helpful.
bered,
however,
oratory
infants
change
less than
from
either
tion,
or
less
than
sign
of
acidosis.
The
in the urine is
It should
that
be remem-
this
latter
lab-
does
not appear
in
the age of 5 months
starvation,
both.
or dehydra-
Ketonunia
5 months
old
metabolic
in
disease
is a
such
as
diabetes
or one of the aminoacidopathies.
Measurement
of the bicarbonate
ion or the complete
blood
gas
battery gives quantitative
dimensions
to
this
disturbance.
Although
therapy
could
and
sometimes
should
take
hydrogen
count,
ion
disturbance
it should
attention
correction
of maldistnibution
usually
that
to volume
enable
the
and
of water
kidney
and
fluid
fore,
is alkaline
some base
included
lution.
4.
even
not neutral;
thereis usually
properly
in maintenance
so
Intracellular
point
of
potassium
Ion
from
view
as well as absolute
terms so that the
experienced
clinician
is occasionally
given
a clue by what
seems
an inappropriate
ratio
of bicarbonate
to
chloride.
The electrocardiogram
unfortunately
reflects
only
the extracellular
value
of potassium
and so
no
quantitative
information.
Phosphate
and
magnesium
levels
are only occasionally
of clinical
importance
in states
of dehydration.
The important
clinical
principle
is
that potassium
must be provided
to
replace
tissue
losses
from
disease
and losses
produced
by the anticipated
high urine output
during
thenapy.
5.
Skeletal
Ions
Although
sium may
it is really
phosphate
be included
the calcium
importance.
Infants
in the first
mild
they
hypocalcemia;
may produce
week
have
imso that
may tip
Hypernaproduce
uncommonly
significant
hypo-
Losses
Whereas
intracellular
ion
include
potassium,
magnesium,
phosphate,
to rise even
potassium
is
ad-
be remembered
adequate
will
into
level
body
low. A high
bicarbonate
and a low
chloride
level in serum
suggest
potassium
deficit.
This is true in relative
adds
infants
usually
the potassium
when
the total
a clearly
it is usually
loss
that
is
are
losses
losses
and
clinical
only
the
important.
Whenever
there
of gas-
trointestinal
potassium
secretions,
significant
losses
are likely to occur.
calcemia.
Other
factors
that may do
this include
high
phosphate
levels
(often
because
of
renal
insufficiency)
and alkalemia,
which
is unusual.
Relative
alkalemia,
however,
can
be
produced
by
treatment
of
acidosis,
and rapid
hydration
may also produce
a dilutional
state.
Either
of these
may
predispose
to hypocalcemia
though
not
commonly.
In summary,
the neonatal
period
and hypernatremic
states
are
the factors
of most
importance
in
disturbances
of calcium
ion during
dehydration.
acidemia
or
IMPLEMENTATION
ISONATREMIC
HYPONATREMIC
The clinical
enables
one
tively
and
IN
AND
DEHYDRATION
analyses
to know
quantitatively
just reviewed
both
qualitathe
amount
of fluid
required
for repair
and for
other
needs
during
an ensuing
time
pediatrics
in review
which
will
arbitrarily
fore
implementation
must
be translated
be one
this
into
day.
a plan
rate of administration
Be-
information
for the
ing whether
each of the components
is to be spread
over
the day
or
whether
there
are times
for special
emphasis
for a given element
of thenapy. Therapy
in the first 24 hours
in
patients
with either
isotonic
constnic-
tion of body
fluids
(isonatremia)
or
those
requiring
slight
modification
because
of a hyponatremic
state will
be considered
here.
It is useful
to
divide
therapy
phases,
each with its own
ment within
the 24 hours.
into
may be divided
into three segments:
emergency,
repletion,
and early
recovery.
When
water
is lost from the
body
through
the
gastrointestinal
tract,
the loss ultimately
involves
all
of the body
compartments
to some
degree.
It follows
then
that
water
given
during
treatment
must wind up
in the various
body
compartments
as well.
The emergency
as its emphasis
plasma
then,
replacement
has
of
phase,
volume.
Most
of
the
water
loss
from
from
in isonatremic
dehydration
is
the extracellular
fluid.
Aside
the plasma,
the other compo-
nent
fluid
of this water
which
serves
medium
for
active
in bodily
needs
phase,
is the interstitial
as the transport
virtually
all
substances
functions.
This
early
repletion,
so that metabolic
space
the second
processes
may proceed
normally.
Finally,
waten and salts from cells,
intracellular
fluid,
will need
replacement
to en-
sure
three
proper
body
roughly
placed
phases
First,
function.
indicated
The
then
correspond
to the emphasis
during
each
of the
three
of therapy.
from the clinical
assessment
scheme,
the volume
to repair
as the
cellular
spaces
of fluid
the deficit
amount
may
required
obligatory
ongoing
data
indicated
needed
be estimated
to recover
Empirical
it is appropriate
to give this combined
volume
of fluid to the usual
dehydrated
patient within
the first 24 hours.
Thus
there
is a tentative
volume
to use in
have
planning
therapy
losses.
that
to which
added
any
continuing
losses.
From
the earlier
tion of the pathogenesis
vol. 3 no. 4 october
1981
may
be
abnormal
consideraof dehydnaPIR
117
Fluids
and Electrolytes
tion
it is also
dium
to give
known
during
how
the
much
first
so-
day
ing glucose
to Ringers
lactate
solution
though
both
have been
used
successfully.
In fact, even when
using albumin
solutions
I immediately
follow
administration
of that solution
with 10% glucose
in water,
20 ml/
kg, also very rapidly.
These
two infusions
together
can usually
be adcomplished
within
one hour,
a total
of 40 mI/kg,
a volume
which
is then
subtracted
from
the proposed
total
and
a qualitative
concept
of the amount
of base and of potassium
and calcium.
It remains
now to quantitate
specifically
each ofthe
elements
and
to divide
up the administration
in the
several
phases.
Emergency
days
An emergency
phase
is to be implemented
only if there
is significant
circulatory
deficit.
If such is not present, the emergency
phase
is repnesented
only by a more rapid
rate of
initial
infusion
during
the repletion
phase
on it may
even
be omitted
when
no circulatory
of any sort
tachycardia.
emergency
volume
to ascertain
how much
more is needed.
If an aqueous
solution alone
is to be given
initially,
a
1 0%
glucose
solution
to which
added
75 mEq/Iiter
of sodium,
55
mEq/Iiten
of chloride,
and 20 mEq/
liter of bicarbonate
(on other base) is
manifestations
are detectable;
eg, no
The emphasis
for the
phase
is restoration
of
interval.
consti-
lution
of
analogous
of water
for
appreciable
remain
plish
5% albumin
or any other
fluid is ideal.
The volume
in this infusion
an
intravascular
the
it was
infuse
20
albumin
without
goal.
long
mI/kg
ago
of plasma
accom-
and
can
tions
prove
the albumin
for the emeras for hypen-
during
to be equally
the emergency
solubut the
PIR 118
use
various
solutions.
of solutions
contain-
pediatrics
in review
#{149}
ion
urine
formation
rapidly.
the emergency
dium belongs
to the estimated
tenance
portion.
A solution
mEq/Iiten
of sodium
and half maintenance.
use Ringers
lactate
it should
fraction.
be
fluid,
mainwith 75
is half deficit
If one were to
on 0.9% saline
assigned
to
The
phase,
Recovery
phase
lasts
the
remaining
two
day or 1 6 hours.
The
fluid
is similar
to on
that of the preceding
who is presumed
of 1 00
mI/kg
to have a def(1 0%
of body
the
solution
may be substituted
point for any patient
who can
duration
of the
repletion
together
with the emergency
if any, should
be one third of
phase
a day on eight
hours.
The emphasis
for this phase
is restoration
of the
interstitial
fluid.
The
volume
to be
given
is such that 50% of the tentatively
assigned
days
volume
will be
at this
accept
it.
THERAPEUTIC
MANAGEMENT
FOR HYPERNATREMIC
DEHYDRATION
Because
the
hypennatnemia
separating
pathophysiology
has
this
distinct
form
of
features
of dehydration
casionally
perhaps
for
thirds
of the
composition
identical
with
weight)
with an isotonic
dehydration
and who
requires
an emergency
phase.
An oral glucose-electrolyte
Repletion
volume
given
must
be greater
to
achieve
a similar
effect
on plasma
volume-theoretically
four times as
much. When an aqueous
solution
is
to be used, different
authorities
have
recommended
prefer
the
provides
of starving
solutions
contain
sodium
and therefore should be assigned
to the deficit
fraction.
Glucose
water without
so-
all of
deficit
satisfactory
phase,
only
either
to the deficit
or maintenance
portion
of the allotment,
the task is
obvious.
Simple
plasma
on albumin
standard
way
to
implement
the
emergency
phase.
Subsequently,
it
was learned
that one may also use
aqueous
solutions
for this purpose
and avoid
the expense
and hazards
of protein
solutions,
yet accomplishing the desired
goal. In neonates
and
natremic
patients
in shock.
In other
patients
aqueous
initiates
In assigning
of the plasma
has become
one
malnourished
infants,
solutions
are preferred
gency
phase
as well
not
thus
bit more
on 5%
to a dehydrated
patient
risk of clinical
consequence
from overexpansion
volume.
This then
(so-called
cells
but also temporarily
pulls
additional
water
to the extracellulan
fluid,
even
into the vascular
fluid,
time,
one
substance
substrate
Empirically,
that
this
at least
of
and
intended
learned
will,
ieniod
chloride
physiologic
or
saline)
recommend
40 to 50 mI/kg again in
approximately
one hour. I prefer hypentonic glucose to be used because
on a so-
Chloride
The emphasis
in this phase
is replacement
of the intracellular
fluid.
The
rate
can
be slowed
and
the
the same
one-hour
of these
alternatives
0.9%
sodium
normal
on
plasma
mEq/Iiten.
mately
Either
contains
either
protein
on other substances
that will have the same
oncotic
properties
as plasma
albumin.
donor
is 20
Early
single
pletion
recommended.
This solution,
40 mI/
kg, is administered
over approxi-
the plasma
volume.
The simplest
way to do this is to infuse a fluid that
Thus,
is
administered
within
eight
hours.
During
this phase
there
is no point
in using
1 0% glucose,
but rather
5%
glucose
which
serves
well
as the
stock
solution.
The sodium
content
is adjusted
according
to the estimated
sodium
need
and can range
in concentration
from 40 to 80 mEq/
liter. Assuming
that urine
formation
has
become
clinically
visible
it is
time to add panenteral
potassium.
A
safe concentration
that will prevent
the clinical
effects
of potassium
de-
severe,
one third
plan of therapy
disturbances.
also occurs
in
of patients.
The
must
consider
these
Restoration
of hydration
follows
a
different
path when moderate
hypernatremia
is present.
treatment
to restore
connect
ances.
The
objective
is to replace
fluid
water distribution,
the
complicating
At first glance
therapy
1981
of
volume,
and to
disturbseems
DEHYDRATION
TABLE
3.
Scheme
of Rehydration
for Isotonic
Period
Phase
Emergency
Repletion
Duration
Emphasis
for restonation
Fluid composi-
#{189}-ihr
Plasma volume
6-7 hr
Extracellulan
A.
B.
Amount
Plasma
mm
tiont
(mI/kg
A.
of body
weight)f
or 5% albu-
+ 10%
cose
1 0% glucose
with
Na 75, C1 55,
HCO3
20 mEq/liten
20 mI/kg of each
solution
totaling
40
mI/kg
of an lnfant*
Period
Total
Early Recovery
5% glucose
glu-
Dehydration
16 to 18 hours
Intracellular
fluid
fluid
with
Na
5% glucose
24 hours
All compartments
with
Na
Na
9 mEq/kg,
40, K 20, C1 40
mEq/kg,
and base
mEq/liter
mEq/kg
20
60 mI/kg
1 00 mI/kg
additional
losses
plus any
abnormal
200
Cl
8.5
mI/kg
B. 40 mI/kg
*
Estimated
deficit
Use either
plan
1 0% of weight(i
A or B in period
00 mI/kg).
ongoing
losses
1 00 mI/kg.
1.
to be the simple
replacement
of waten. In fact,
careful
attention
to the
content
of solution
used and to the
rate of administration
reveal
that important
special
measures
must
be
taken.
Two other circumstances
also
require
comment:
the presence
of
oligunia
influences
decision
making,
and finally,
salt poisoning
should
be
considered
as a separate
entity.
Most
patients
with hypennatnemic
dehydration
are not severely
oligunic
owing
to the
relatively
expanded
plasma volume.
be considered
Estimated
150
mm H2O
140
130
#{149}120
infuse
plain
5% glucose
water
into
these
patients,
the
risk
would
be
cerebral
swelling-actually
water
intoxication.
This
results
from
the
presence
of endothelial
cell
tight
junctions
in the CNS.
Just as rapid
infusion
of hypertonic
salt results
in
brain
shrinkage,
so does rapid
infusion of isotonic
glucose
water
cause
brain
swelling.
Glucose
rapidly
crosses
the blood-CNS
barrier
by
active
transport
so that
unlike
the
red cell, the brain
does
not necognize glucose
as an osmol,
at least at
physiologic
levels
of glucose,
but
does
react
to sodium
and chloride
ions
as relatively
impermeable
because
of the tight junctions.
When
5% glucose
water
is infused
rapidly
intravenously
the CSF pressure
rises
(Fig 3). The increase
in
millimeters
of water
is the same
for
a given
infused
volume
and rate negardless
of the initial
pressure.
The
20 mI/kg
90
Ijb
2O
40
:1_g 3
Effect
kg. Same
symptomatic,
on CSFpressure
pressure
increase
is called
water
ofarapid
will occur
intoxication.
intravenous
at any
increase
in pressure
is from swelling
of the brain cells,
not an increase
in
interstitial
fluid, ie, not edema.
Brain
swelling
affects
a number
of nervous
system
functions
frequently
resulting
after
was
in convulsions.
For
hypernatremic
described
and
some
years
dehydration
recognized
din-
pediatrics
in review
base
infusion
line
60
80
TIME IN MINUTES
of
100
5% glucose
CSFpressure.
This
120
in water,
phenomenon,
20 ml!
when
ically,
convulsions
were
commonly
seen during
therapy,
because
rapid
water
replacement
was attempted.
This circumstance
led many
centens to suggest
adding
75 mEq/liter
or more
of sodium
salts
to initial
therapy.
This will reduce
risk of convulsions
but adds to the sodium
bunvol. 3 no. 4 october
1 981
PIR
119
Fluids
and
Electrolytes
volume
TABLE
4.
Regimen
for Therapy
of Hypernatremic
Considerations
(in Order)
1.
the
Dehydration
a Estimate
the patients
first (mI/kg)
tal sum.
deficit
and multiply
by clinical
by weight
2 days.
Use 2#{189}
(2%-3%)
content
to obviate
later
possible
Sodium
Allow
content
80-1
00 mEq/liter
for deficit
fraction
Potassium
tent
con-
If the
probof fluid
Generally,
maximum
safe amount for IV infusion
on about 40 mEq/Iiter.
Sodium
plus potassium
advised
equals 60-75
5. Anion content
mEq/liter
of cation.
Distribute
anions
between
chloride
and base in accordance
with clinical
judgment. Ifdesired, start with more base and
change to more chloride
after 6-12 hr. Do not
use HCO3
as base because
of calcium
to be
added. Use acetate on lactate along with chlo-
Salt
Calcium
content
7.
Rate of administration
be 275-350
ml/kg/48
hr or 6-7
mI/kg/hr.
trolyte,
den, frequently
sensible
water
while
losses
excessive
inare in prog-
suboptimal
dehydration,
anion
and
can
resolution
be
found,
to these
PIR 120
The repair
pediatrics
in review
distribution,
rate
for
48
glucose
content,
sopotassium
content,
calcium
of administration.
a method
additive,
Table
for analysis
Shock
enter
depleted
cells (mostly
muscle
cells)
carrying
water
into them.
At
the same
time water
is delivered
to
the patient
at a slow even rate. This
regimen
is appropriate
provided
the
patient
has no initial
serious
circu-
deficiency.
administered
of
by
considering
that a high potassium
intake would offset cerebral
swelling
and some of the potassium
would
latory
be
and of
content,
consideration
of each of these
points
for use in a
patient
with hypernatnemic
dehydration, but not in shock,
and who produces
visible
urine.
Shock,
oligunia,
and salt poisoning
are considered
separately.
with
in part,
to
with
demonstrates
outcome.
A compromise
problems
again
volume
hours
dium
ness, thus
aggravating
hypennatnemia.
Such
therapy
also
frequently
produces
visible
edema
in patients,
leading
to prolongation
of the recovery period.
An alternative
to increasing concentration
is to slow the rate
of infusion
which
will also avoid convulsions,
but at risk of being too slow
in repairing
is constructed
solution
#{149}
If the patient
has circulatory
impairment
(shock),
first infuse
20 mI/
kg of 5% albumin
solution
(single
donor
plasma,
plasma
without
immunoglobulin,
on whole
blood are all
satisfactory).
Sodium
content
in
these
fluids
up to 140 mEq/liten
is
not important
since
nearly
the whole
given
patient,
even
though
not in
event
of massive
salt
poi-
soning
(plasma
concentration
of sodium
>200
mEq/liten)
use penitoneal dialysis
to remove
excess
sodium
chloride.
For the dialyzing
solution
use 8% glucose
with no elec-
manner
Poisoning
In the
ride.
6.
pro-
hypotensive
shock,
has no apparent
urine,
try a rapid
infusion
of 5% albumin.
If urine then enters
the bladden, proceed
as before.
If no urine
enters
the bladder,
give furosemide,
1 mg/kg.
If urine
flow occurs,
proceed as above;
if not treat the patient
without
potassium
in the infusion.
Increase
the sodium
concentration
to 50 mEq/Iiten,
slow
the rate
by
reducing
the volume
to be administered,
subtracting
half the maintenance
allowance
from
the 48-hour
total.
general
If
urine,
Anuria
intravascular.
means
remain
is producing
ceed as in the
above.
Action
Volume
will
patient
1 00
mI/kg,
two
on
three
times
at approximately
one-hour
intervals.
Simultaneously
be sure
to
maintain
an intravenous
solution
to
deliver
a volume
of repair
and maintenance
solution
as above.
The hypenglycemia
induced
by this method
offsets
the
removal
of sodium
and
prevents
water
intoxication.
As the
glucose
is metabolized,
water slowly
enters
cells.
Insulin
is not advisable
for any hypennatnemic
patients
with hyperglycemia
because
rapid
removal
of glu-
cose
by metabolism
is the physiologic
equivalent
of rapid
water
infusion.
In summary,
the best
treatment
seems
to be a slow infusion
relatively
low in both glucose
and sodium
and
high in potassium
cium. For the past
with added
cal12 years this reg-
1981
and
con-
Reprints
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Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and
trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove
Village, Illinois, 60007. Copyright 1981 by the American Academy of Pediatrics. All rights reserved.
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