A Nurse Is Reviewing Lab Reports The Nurse Recalls Blood Plasma Is Located

Continuing Education Activity

The World Health Arrangement defines aridity as a condition that results from excessive loss of trunk water. The almost common causes of dehydration in children are vomiting and diarrhea. This activity describes the causes and pathophysiology of pediatric dehydration and highlights the role of the interprofessional team in its direction.

Objectives:

Identify the etiology pediatric dehydration.
Recollect the presentation of pediatric drhydration.
List the treatment and management options bachelor for pediatric dehydration.
Explain interprofessional team strategies for improving intendance coordination and communication to advance the management of pediatric dehydration and improve outcomes.

Access gratuitous multiple choice questions on this topic.

Introduction

The Globe Health Organization defines dehydration every bit a status that results from excessive loss of trunk water. The most common causes of dehydration in children are vomiting and diarrhea.

Etiology

Infants and young children are specially susceptible to diarrheal disease and dehydration. Reason include college metabolic rate, inability to communicate their needs or hydrate themselves, and increased insensible losses. Other causes of dehydration may exist the result of other disease processes resulting in fluid loss which includes: diabetic ketoacidosis (DKA), diabetes insipidus, burns, excessive sweating, and third spacing. Dehydration may also exist the result of decreased intake along with ongoing losses. In addition to total trunk water losses, electrolyte abnormalities may be. Infants and children have higher metabolic needs and that make them more susceptible to aridity.[1]

Epidemiology

Dehydration is a major cause of morbidity and mortality in infants and young children worldwide. Each year approximately 760,000 children of diarrheal affliction worldwide. Most cases of dehydration in children are the consequence of acute gastroenteritis.

Acute gastroenteritis in the United States is usually infectious in etiology. Viral infections, including rotavirus, norovirus, and enteroviruses cause 75 to 90 pct of infectious diarrhea cases. Bacterial pathogens cause less than 20 percent of cases. Common bacterial causes include Salmonella, Shigella, and Escherichia coli. Approximately x percent of bacterial disease occurs secondary to diarrheagenic Escherichia coli. Parasites such as Giardia and Cryptosporidium account for less than 5 per centum of cases.

Pathophysiology

[1]Aridity causes a subtract in total trunk water in both the intracellular and extracellular fluid volumes. Volume depletion closely correlates with the signs and symptoms of dehydration. The total body h2o (TBW) in humans is distributed in two major compartments. 2/third the of TBW is in the intracellular compartment and the other i/3rd is distributed between interstitial space (75%) and plasma (25%). The full body water is higher in infants and children equally compared to the adults. In infants, it is 70% of the total weight, whereas it is 65% and sixty% respectively in children and adults. As indicated before dehydration is full water depletion with respect to the sodium and volume depletion is the decrease in the circulation volume. Book depletion is seen in acute claret loss and burns, whereas distributive book depletion is seen in sepsis and anaphylaxis. In much of the literature, the stardom betwixt dehydration and volume depletion is a blur.

Metabolic acidosis is seen in infants and children with aridity, the pathophysiology of which is multifactorial.

1. excess bicarbonate loss in the diarrhea stool or in the Urine is certain types of renal tubular acidosis

ii. Ketosis secondary to the glycogen depletion seen in starvation which sets in infants and children much earlier when compared to adults.

iii. Lactic acid production secondary to poor tissue perfusion

four. Hydrogen ion retention by the kidney from decreased renal perfusion and decreased glomerular filtration rate.

In children with pyloric stenosis have very unique electrolyte abnormalities from the excessive emesis of gastric contents. This is seen mostly in the older children. They loose chloride, sodium, potassium in add-on to volume resulting in hypochloremic, hypokalemic metabolic alkalosis. Kidney excretes base in the grade of Hco3 ion to maintain acid-base residue of loss of Hydrogen ion in the emesis in the class of hydrogen chloride. It is interesting to note that kidney also excretes hydrogen ion to save sodium and water, which could be the reason for aciduria. Recently published commodity has shown that many children with pyloric stenosis may not take metabolic alkalosis.

History and Concrete

Diverse sign and symptoms tin can exist present depending on the patient's caste of dehydration. Dehydration is categorized as mild (3% to 5%), moderate (6% to ten%), and severe ( more than than x%). The table below tin assist with categorizing the patient's caste of dehydration. The degree of dehydration between an older kid and infant are slightly dissimilar every bit the baby could have total trunk water (TBW) content of 70%-80% of the body weight and older children have TBW of lx% of the body weight. An babe has to lose more body weight than the older child to get to the aforementioned level of aridity.[2]

Dehydration% Mild 3% to 5% Moderate 6% to x% Severe >10%

Mental status Normal Listless, irritable Altered mental

Heart rate Normal Increased Increased

Pulses Normal Decreased Thready

Capillary refill Normal Prolonged Prolonged

Claret pressure Normal Normal Decreased

Respirations Normal Tachypnea Tachypnea

Eyes Normal Slightly sunken Fewer tears

Fontanelle Normal Sunken Sunken

Urine output Normal Decreased Oliguric

(see image below)

Evaluation

Dehydration could exist associated with hypo or hyper or isonatremia. About cases of dehydration are hyponatremic. In selected cases, electrolyte abnormalities may exist. This includes derangements in sodium levels, acidosis characterized by low bicarbonate levels or elevated lactate levels. For patients with vomiting, who have not been able to tolerate oral fluids hypoglycemia may exist present. Evaluation of urine specific gravity and the presence of ketones tin can assist in the evaluation of dehydration.[3]

Children who were given free water when they have ongoing diarrhea disease can present with hyponatremic dehydration, the excess of costless water concurrent to excess sodium and bicarbonate loss in diarrhea. This is also seen in the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). In these cases, the children appear to be more than dehydrated and could also present with hyponatremic seizure action.

Similarly, infants who are fed oral rehydration solution prepared from excess salt or who lost excess free water as in diabetes incipidus could have hypernatraemic aridity

End-tidal carbon dioxide measurements take been studied in an attempt to assess degrees of dehydration greater than 5 per centum in children. This non-invasive approach has hope, simply as of now has not proven to be an effective tool in determining the degree of aridity in children. [4]

Treatment / Management

Priorities in the direction of aridity include early recognition of symptoms, identifying the caste of dehydration, stabilization, and rehydration strategies. [two][5][three]

Symptoms include vomiting, diarrhea, fever, decreased oral intake, inability to keep upwardly with ongoing losses, decreased urine output, progressing to languor, and hypovolemic shock.

Mild Dehydration

The American Academy of Pediatrics recommends oral rehydration for patients with mild aridity. Breastfed infants should keep to nurse. Fluids with high saccharide content may worsen diarrhea and should be avoided. Children tin can exist fed age-appropriate foods oftentimes but in pocket-sized amounts.

Moderate Aridity

The Morbidity and Mortality Weekly Report recommends administering 50 mL to 100 mL of oral rehydration solutions per kilogram per body weight during two to four hours to supercede the estimated fluid deficit, with additional oral rehydration solution, administered to replace ongoing losses.

Astringent Dehydration

For patients who are severely dehydrated, rapid restorations of fluids are required.

Patients who are severely dehydrated can present with contradistinct mental condition, lethargy, tachycardia, hypotension, signs of poor perfusion, weak thread pulses, and delayed capillary refill.

Intravenous fluids, starting with 20 ml/kg boluses of normal saline are required. Multiple boluses may be needed for children in hypovolemic shock. Additional priorities include obtaining a point of care glucose test, electrolytes, and urinalysis assessing for elevated specific gravity and ketones. [6]

Hypoglycemia should be assessed at the point of intendance testing via glucometer, and venous blood gas with electrolytes or serum chemistries. It should exist treated with intravenous glucose. The dose is 0.5 gm/km to 1 gm/km. This translates to 5 ml/kg to 10 ml/kg of D10, 2ml/kg to four ml/kg of D25, or 1 ml/kg to- ii ml/kg of D50. The use of D50 is ordinarily reserved for an adolescent or adult-sized patients using a large bore intravenous line.[7]

Replacement of Fluids

An cess of the degree of dehydration will determine the fluid replacement. Using tables that can predict the degree of dehydration is helpful. If a previous "well weight" is available, that tin can be subtracted from the patient'due south "sick weight" to calculate full weight loss. One kilogram weight loss equates to ane liter of fluid lost.

The rate of replacement is based on the severity of the dehydration. Patients with hypovolemic shock need rapid boluses of isotonic fluid either normal saline or ringer lactate at 20ml/kg trunk weight. This could be repeated 3 times with reassessment in-between the boluses. Ringer lactate is superior to normal saline in hemorrhagic shock requiring rapid resuscitation with isotonic fluids.[8] This difference is not constitute in the children with severe dehydration from acute diarrheal affliction. In these children, the replacement with normal saline and ringer lactate did prove similar clinical improvement.[9]

Rapid infusion tin can cause cardiac insufficiency, congestive heart failure, and pulmonary edema. Rapid correction in patients with diabetic ketoacidosis can cause cerebral edema in adolescent and children.

The charge per unit of replacement fluids is calculated later taking into account for the maintenance, replacement and deficit requirement of the patient. Sodium requirements of the children in the hospital are higher than that of the adults. The children have high metabolic needs, has higher insensible lose as they have a higher trunk surface area. They likewise have college respiratory and heart rates, requiring the employ of an intravenous solution containing high sodium like D5NS. The deficit is determined by the caste of dehydration equally outlined before. The second stage of fluid replacement therapy lasts for viii hours, during which the child requires 1/2 of the remaining deficit in addition 1/3rd of the maintenance fluid. The remaining half of the deficit and the 2/tertiary of the daily maintenance therapy is given during the tertiary phase of the therapy which spans the following 16 hours.

Holliday-Segar calculation is used for calculation of maintenance fluid in children, which is 100ml/kg/day for first 10 kg torso weight (BW), then 50 ml/kg/day for the next 10 kg BW and and so twenty ml/kg /day for whatsoever BW over and above.[10]

For patients where intravenous access can non exist accomplished or maintained, other methods tin can exist employed. They include continuous nasogastric hydration and subcutaneous hydration.[11]]

Hypodermoclysis refers to hydrating the subcutaneous space with fluid which tin be captivated systemically. Hypodermoclysis is best reserved for the stable child or babe with mild to moderate dehydration who either fails a trial of fluids past oral cavity or who needs some caste of rehydration to facilitate gaining intravenous admission afterwards a slow subcutaneous fluid bolus has been given.

The process begins with:

The placement of topical anesthetic cream, such as EMLA, cover with an occlusive dressing, expect for xv to 20 minutes."Pinch an inch" of peel anywhere, only the well-nigh practical site for immature children is between the scapulae.Insert a 25-gauge butterfly needle or 24-gauge angiocatheterInject 150 units hyaluronidase SC (if available).Infuse 20 mL/kg isotonic solution over one hour, repeat as needed or use this technique as a bridge to intravenous admission.

Differential Diagnosis

Hypernatremia in emergency medicine

Hyperosmolar Hyperglycemic Nonketoic blackout

Hypokalemia in emergency medicine

Hyponatremia in emergency medicine

Hypovolemic daze

Metabolic acidosis in emergency medicine

Pediatric gastroenteritis in emergency medicine

Pediatric pyloric stenosis

Pearls and Other Bug

Once the patient's condition has stabilized, hydration therapy continues to supercede existing and ongoing losses. Fluid therapy should include maintenance fluids plus replacement of the existing fluid deficit.

Deficit calculation tin can exist determined in several means. If the patient's weight before the illness is known, it can exist subtracted from the electric current weight. Each kilogram lost would be equivalent to i liter of fluid lost. If the prior weight is non known, multiply the weight in kilograms past the dehydration percent.

For a 10 kg patient who is 10% dehydrated, 0.i represents 10%

(10 kg) ten (.ten) = 1 kilogram

Maintenance fluids can exist calculated as follows:

For a patient weighing less than 10 kg, they should receive 100 mL/kg/24-hour interval.

If the patient weighs less than 20 kg, fluids will include the 1000 mL/day plus 50 mL/kg/day for each kilogram betwixt 10 kg and 20 kg.

For patients weighing more twenty kg, give 1500 mL/solar day, plus xx mL/kg/twenty-four hour period for each kilogram over 20 kg. Split the total by 24 to decide the hourly rate.

In hyponatremic dehydration, half of the deficit can exist replaced over eight hours with the remaining half the post-obit xvi hours. Severe hyponatremia (< 130 mEq/L) or hypernatremic dehydration (> 150 mEq/L) is corrected over 24 to 48 hours. Symptomatic hyponatremia (seizures, lethargy) tin be acutely managed with hypertonic saline (3% sodium chloride). The deficit may be calculated to restore the sodium to 130 mEq/L and administered over 48 hours, every bit follows:

Sodium deficit = (sodium desired - sodium actual) x volume of distribution ten weight (kg))

Example: Sodium = 123, weight = 10 kg, assumed volume of distribution of 0.vi; Sodium deficit = (130-123) X 0.6 X 10 kg = 42 mEq sodium. Hypertonic saline (3%) which contains 0.v mEq/mL may be used for rapid fractional correction of symptomatic hyponatremia. A bolus dose of 4 mL/kg raises the serum sodium by 3 mEq/L to 4 mEq/L.

Rapid correction of hypernatremia may issue in cerebral edema, as a effect of intracellular swelling occurs. Osmotic demyelination syndrome, also known equally key pontine myelinolytic, can occur every bit a result of rapid correction of hyponatremia. Symptoms include a headache, confusion, contradistinct consciousness, gait disturbance, and may lead to respiratory arrest.

Enhancing Healthcare Team Outcomes

Diarrheal diseases and resulting severe dehydration are the leading cause of babe bloodshed worldwide especially in children < 5years of historic period.[12]. This burden is fifty-fifty higher among children in developing countries. To improve the outcome and decrease the morbidity and mortality from the diarrhea diseases especially Rotaviral affliction which is the leading cause of death in children we need cooperation betwixt various different agencies and countries.

World health organization while working with member countries and other agencies promotes national policies and investments to take admission to safety drinking h2o, to improve sanitation, to research in diarrhea prevention like vaccination, to implement preventive measures like source h2o treatments, safe storage and to assist train the health care workers who could go into communities to bring the change at local level.

Review Questions

Figure

Dehydration Calibration. Contributed by Roy One thousand. Vega Md

References

one.: Tutay GJ, Capraro G, Spirko B, Garb J, Smithline H. Electrolyte profile of pediatric patients with hypertrophic pyloric stenosis. Pediatr Emerg Intendance. 2013 Apr;29(iv):465-8. [PubMed: 23528507]
2.: Falszewska A, Szajewska H, Dziechciarz P. Diagnostic accuracy of three clinical dehydration scales: a systematic review. Curvation Dis Child. 2018 Apr;103(4):383-388. [PubMed: 29089317]
3.: Vega RM, Avner JR. A prospective study of the usefulness of clinical and laboratory parameters for predicting per centum of dehydration in children. Pediatr Emerg Care. 1997 Jun;thirteen(3):179-82. [PubMed: 9220501]
4.: Freedman SB, Johnson DW, Nettel-Aguirre A, Mikrogianakis A, Williamson-Urquhart South, Monfries N, Cheng A. Assessing Dehydration Employing End-Tidal Carbon Dioxide in Children With Vomiting and Diarrhea. Pediatr Emerg Care. 2018 Aug;34(eight):564-569. [PubMed: 28538608]
5.: Yang HW, Jeon Westward, Min YG, Lee JS. Usefulness of end-tidal carbon dioxide as an indicator of dehydration in pediatric emergency departments: A retrospective observational study. Medicine (Baltimore). 2017 Sep;96(35):e7881. [PMC free article: PMC5585495] [PubMed: 28858101]
half dozen.: Geurts D, Steyerberg EW, Moll H, Oostenbrink R. How to Predict Oral Rehydration Failure in Children With Gastroenteritis. J Pediatr Gastroenterol Nutr. 2017 Nov;65(5):503-508. [PubMed: 28248796]
7.: Sendarrubias One thousand, Carrón M, Molina JC, Pérez MÁ, Marañón R, Mora A. Clinical Impact of Rapid Intravenous Rehydration With Dextrose Serum in Children With Acute Gastroenteritis. Pediatr Emerg Care. 2018 December;34(12):832-836. [PubMed: 28463940]
viii.: Martini WZ, Cortez DS, Dubick MA. Comparisons of normal saline and lactated Ringer's resuscitation on hemodynamics, metabolic responses, and coagulation in pigs after severe hemorrhagic shock. Scand J Trauma Resusc Emerg Med. 2013 December xi;21:86. [PMC costless article: PMC4029282] [PubMed: 24330733]
nine.: Kartha GB, Rameshkumar R, Mahadevan S. Randomized Double-blind Trial of Ringer Lactate Versus Normal Saline in Pediatric Acute Severe Diarrheal Dehydration. J Pediatr Gastroenterol Nutr. 2017 Dec;65(6):621-626. [PubMed: 28422812]
10.: Meyers RS. Pediatric fluid and electrolyte therapy. J Pediatr Pharmacol Ther. 2009 October;14(4):204-eleven. [PMC free article: PMC3460795] [PubMed: 23055905]
11.: Rébeillé-Borgella B, Barbier C, Moussaoui R, Faisant A, Michard-Lenoir AP, Rubio A. [Nasogastric rehydration for treating children with gastroenteritis]. Arch Pediatr. 2017 Jun;24(six):527-533. [PubMed: 28416428]
12.: GBD Diarrhoeal Diseases Collaborators. Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Affliction Study 2015. Lancet Infect Dis. 2017 Sep;17(9):909-948. [PMC free article: PMC5589208] [PubMed: 28579426]

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Source: https://www.ncbi.nlm.nih.gov/books/NBK436022/