Pediatrics Book

Pediatric Dehydration Management

Aka: Pediatric Dehydration Management, Dehydration Management in Children, Intravenous Therapy Protocol in Pediatric Dehydration
  1. See Also
    1. Pediatric Dehydration
    2. Oral Rehydration Therapy Protocol in Pediatric Dehydration
  2. Indications
    1. Severe Pediatric Dehydration
  3. Labs
    1. Serum electrolytes
      1. Obtain in all cases of severe dehydration (not typically needed in mild to moderate dehydration)
      2. Correct serious electrolyte abnormalities prior to starting phase 2 (maintenance replacement)
    2. Serum Glucose
      1. Monitor in infants and toddlers with Diarrhea
  4. Management: Adjuncts
    1. Consider a single dose of Zofran to aid transition to Oral Rehydration Therapy
  5. Management: Initial Replacement (Phase 1 Acute Resuscitation)
    1. Give 20 ml/kg Normal Saline or Lactated Ringers over 10-15 minutes
    2. May repeat bolus until circulation stable
      1. May require up to 60 ml/kg within the first hour
      2. Stabilization criteria include
        1. Normal Heart Rate
        2. Capillary Refill <2 seconds
        3. Intact mental status
        4. Adequate urine output
    3. After fluid boluses until circulation stable
      1. Administer 100 ml/kg of fluid
        1. Option 1: Oral Rehydration Solution
          1. See Oral Rehydration Therapy Protocol in Pediatric Dehydration
        2. Option 2: Intravenous Normal Saline or Lactated Ringers
      2. Initiate maintenance fluids
        1. Option 1: Oral Rehydration Solution
          1. See Oral Rehydration Therapy Protocol in Pediatric Dehydration
        2. Option 2: Continue intravenous hydration as below
  6. Management: Maintenance Replacement with IV fluids (Phase 2 Resuscitation)
    1. See Oral Rehydration Therapy Protocol in Pediatric Dehydration (mild to moderate dehydration)
      1. Start the oral rehydration protocol (see above)
    2. Calculate 24 hour maintenance requirements
      1. See Maintenance Fluid Requirements in Children (Holliday-Segar Formula)
    3. Calculate Deficit (See Pediatric Dehydration)
      1. Mild Dehydration: 4% deficit (50 ml/kg deficit, 30 ml/kg if >10 kg)
      2. Moderate Dehydration: 8% deficit (100 ml/kg deficit, 60 ml/kg if >10 kg)
      3. Severe Dehydration: 12% deficit (120 ml/kg deficit)
    4. Calculate remaining deficit
      1. Subtract fluid resucitation given in Phase 1
      2. Some guidelines recommend replacement of deficit in 4 hours followed by oral maintenance
    5. Calculate Replacement over 24 hours
      1. First 8 hours: 50% Deficit + Maintenance
      2. Next 16 hours: 50% Deficit + Maintenance
    6. Determine Serum Sodium Concentration
      1. Pediatric Hypertonic Dehydration (Serum Sodium > 150)
      2. Pediatric Hypotonic Dehydration (Serum Sodium < 130)
      3. Pediatric Isotonic Dehydration
        1. Precautions
          1. Exercise caution with hypotonic solutions (Hyponatremia)
          2. Consider D5 NS as maintenance fluid instead of D5 1/2NS
          3. McNab (2015) Lancet [PubMed]
        2. Weight <28 kg: D5 1/2NS (prior recommendation D5 1/4NS)
        3. Weight >28 kg: D5 1/2NS
    7. Add Potassium to Intravenous Fluids after patient voids
      1. Potassium source
        1. Potassium Chloride
        2. Potassium Acetate for Metabolic Acidosis
      2. Potassium dosing
        1. Weight <10 kilograms: 10 meq/liter KCl
        2. Weight >10 Kilograms: 20 meq/liter KCl
    8. Correct for ongoing losses
      1. Reassess intakes and outputs every 4 hours
        1. Adjust fluids to maintain adequate urine output and Vital Signs
      2. Replace stool outputs
        1. Indicated if stool >30/ml/kg/day
        2. Replace equal volume of stool losses with 1/2NS with 20 kcl (in addition to maintenance volume)
      3. Replace ongoing fever-related losses
        1. Replace 1 ml/kg/hour per degree increase above normal (in celcius)

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