Pediatric Dehydration

Pediatric Dehydration
Marc Francis FRCPC Emergency R4 PEM Fellow year 1 Preceptor – Dr Phil Ukrainetz

Objectives Background to dehydration, diarrhea and vomiting
Approach to the dehydrated patient Case based review of the evidence for the above approach A sodium review (sorry!!!) Series of practical cases to enforce your new evidence based approach

Pediatric Dehydration
Questions, discussion and random humour to be inserted by Dr Ukrainetz

Why is this a peds problem?
Sick kids = decreased intake Higher percentage TBW Neonate 75% Child 65% Adult 60% Fever increases fluid needs Higher metabolic rate in kids less tolerance to fluid and electrolyte changes Poor renal concentration mechanisms at young age Inability to meet their own needs independently

Dehydration is not a disease
1) Decreased intake 2) Increased output Insensible losses Renal losses GI losses 3) Translocation Burns Ascites

Causes of Dehydration Diarrhea Vomiting Gastroenteritis
Stomatitis or pharyngitis Febrile illness DKA DI Burns

Diarrhea Leading cause of death worldwide in children < 4yo
Diarrhea in the United States 300 children < 5yo die per year 2-3 million office visits 200,000 hospitalizations In North America children < 5yo have on average 2 episodes of gastroenteritis per year Costs > 2 billion/year

Diarrhea DDx Gastroenteritis Malabsorption IBD IBS Drug side effects
Thyrotoxicosis Infections Endocrine disorders Addisons or CAH

Diarrhea Indications for stool studies Etiology Viral 60%
Toxic appearance Immunocompromised Bloody or invasive Duration > 5days Suspected parasites Travel Camping Poor Water Etiology Viral 60% Bacterial 20% Parasites 5% Parental illness 10% Unknown 10%

Vomiting “Vomiting without diarrhea should prompt a thorough search for another cause other than gastro”

Vomiting GI GU Toxic ID Endocrine Neuro Obstruction Pancreatitis Appy
Pyloric stenosis Volvulus Intussusseption GU UTI Pyelo RTA Toxic Drug ingestion Drug side effects ID Pneumonia Sepsis Endocrine Addisons CAH Neuro Meningitis/Encephalitis ↑ ICP

Case #1 5 mo Male HPI Exam Non-bloody profuse watery stool 7 days
10-15 stools per day – foul smelling Child eager to take water until this AM Now less interested in drinking and more lethargic Exam Quiet and tachypneic Sunken eyes and a dry mouth Tachycardic at 165 bpm Cap refill is 3 seconds Skin turgor prolonged

Case #1 How do you want to manage this patient?
What are some of the potential pitfalls in managing this patient? Do you have an approach to this patient? Would you like one?

Approach to Peds Dehydration
Initial Resuscitation Determine % dehydration Define the type of dehydration Determine the type and rate of rehydration fluids Final considerations The gospel according to Rob Hall

Initial Resuscitation Determine % dehydration Define the type of dehydration Determine the type and rate of rehydration fluids Final considerations

Initial Resuscitation
ABCs Initial fluid bolus 20cc/kg of NS or Ringers Appropriate in all types of dehydration Reassess q5mins and repeat x 3 Initial hypoglycemia 5cc/kg of D10W in infants 2cc/kg of D25W in children Think about Shock DDx if unresponsive to 3 attempts at NS bolus

Initial Resuscitation
Fluid Controversy… Theoretical risk of acidosis with NS “Dilutional acidosis” with addition of NaCl to the extracellular fluid Ringers lactate has some HCO3 Harder to find in our department Potential delay in fluid resuscitation No evidence to guide you

Case #2 20 mo F HPI Exam 2 days of vomiting and diarrhea
Not eating and will not drink 8 stools today but dad does not think there were any diapers with urine in them Afebrile Exam Appears mildly ill Tears + Vitals are normal including RR Mouth is Dry Cap Refill time is 2.0 seconds

Survey How dehydrated is this child? Who wants to do bloodwork?
3-5% 6-9% >10% Who wants to do bloodwork? Who wants to start an IV to rehydrate?

Determine % Dehydration
The CPS, AAP, CDC and WHO all have treatment guidelines for gastroenteritis These are based on the clinical assessment of dehydration Mild <5%, Moderate 6-9%, Severe >10% Gold standard is pre and post weight What are the markers that we use to assess this? Clinical Laboratory How reliable and precise are these markers?

Really we don’t care about kids <5% dehydrated. The ones that are >10% dehydrated are usually obviously unwell, so the challenge comes from trying to tease out those kids that fall within the mild-moderate range of dehydration

What are the best clinical markers?
Prolonged cap refill Sunken eyes Poor overall appearance Sunken fontanelle Absent tears Increased HR Weak Pulse Dry mucous membranes Abnormal resp pattern Abnormal skin turgor or tenting

Tenting

26 contained the original data required
Systematic review precision and accuracy of symptoms, signs and lab tests for evaluating pediatric dehydration ≥ 5% 1603 potential articles 26 contained the original data required 13 were eliminated due to lack of diagnostic standard or limited study design

Results Large variability in observations and elicited signs
Ranging from chance to good agreement

Conclusions Tests are imprecise with only fair to moderate agreement
The best 3 individual examination signs were: Prolonged Cap refill time Abnormal Skin turgor Abnormal resp pattern

Prospective cohort study Urban pediatric hospital ED N= 186 children
Validity and reliability of clinical signs in the diagnosis of dehydration in children Gorelick MH, et al. Pediatrics 1997;99:E6 Prospective cohort study Urban pediatric hospital ED N= 186 children Age range 1 month to 5 years With diarrhea, vomiting, or poor oral fluid intake admitted or followed as outpatients The diagnostic standard for dehydration was fluid deficit as determined from serial weight gain after treatment

Validity and reliability of clinical signs in the diagnosis of dehydration in children Gorelick MH, et al. Pediatrics 1997;99:E6 All children were evaluated for 10 clinical signs before treatment Decreased skin turgor Cap refill time >2 sec General appearance Absence of tears Abnormal respirations Dry MM Sunken eyes Abnormal radial pulse Tachycardia >150bpm Decreased urine output

Validity and reliability of clinical signs in the diagnosis of dehydration in children Gorelick MH, et al. Pediatrics 1997;99:E6 Results 63 children (34%) had dehydration defined as a deficit of 5% or more of body weight At this deficit, clinical signs were already apparent (median = 5) Individual findings had generally low sensitivity and high specificity parent report of decreased urine output was sensitive but not specific Meaning if they said that the u/o was good than that helped to r/o dehydration. If they said it was decreased it did not indicate a higher chance of dehydration

Validity and reliability of clinical signs in the diagnosis of dehydration in children Gorelick MH, et al. Pediatrics 1997;99:E6 Results: For detection of ≥ 5% dehydration Presence of 3 or more signs Sensitivity of 87% Specificity of 82% Positive LR of 4.9 ( ) Presence of 7 or more signs Positive LR 8.4 ( )

Validity and reliability of clinical signs in the diagnosis of dehydration in children Gorelick MH, et al. Pediatrics 1997;99:E6 Further logistic regression analysis showed most of the predictive power was in the following 4 signs Prolonged cap refill Dry MM Absence of tears Abnormal appearance 2/4 had positive LR of 6.1 ( ) Interesting that only 1 is shared with the more recent systematic review

Validity and reliability of clinical signs in the diagnosis of dehydration in children Gorelick MH, et al. Pediatrics 1997;99:E6 Conclusions Conventionally used clinical signs of dehydration are valid and reliable Individual findings lack sensitivity Diagnosis of clinically important dehydration should require at least three clinical findings

Case #3 You see a 17 month old child with a 3 day history of non-bloody D/V Your clinical assessment is that he is only mildly dehydrated You discover the CC has sent bloodwork prior to your arrival: ABG 7.34/33/84/17 Na 133 Cl 103 K 3.5 Cr 34 BUN 4.2 mmol/L Non-anion gap metabolic acidosis. Low K, low bicarb, BUN mildly increased

Does lab work help you in determining the degree of dehydration? What lab values do people use to assess severity of dehydration?

Results

Conclusions Tests such as BUN and bicarbonate are only helpful when results are markedly abnormal A normal bicarbonate concentration reduces the likelihood of dehydration No lab test should be considered definitive for dehydration

Case #4 6 day old Female HPI First child born at term
GBS negative mother Normal preg and delivery D/C’d within 24 hrs Exclusively breastfed HPI Mom says child is a “poor feeder” Not sure if her breastmilk has come in fully Child much more listless today Having to wake to feed No urine output or stools noted in the last 48hrs

Case #4 con’t Exam Vitals = HR 160, RR 38, T36.9°C, Sats 94%, BG4.1
Generally – difficult to rouse but irritable upon awakening CVS – normal pulse and cap refill Resp – clear Hydration – MM dry, no tears noted, skin is noted to be very soft and doughy

Case #4 con’t CBC Lytes Labs WBC 4.8 Hgb 179 Plt 433 Na 167 K 6.8
Bicarb 16 BUN = 7mmol/L Creatinine = 90umol/L What type of dehydration is this? What is the most likely cause? Hypernatremic dehydration likely secondary to unrecognized lactation failure

Define the type of dehydration
Three major classes of dehydration based on relative losses of Na and Water Isonatremic dehydration (80%) Hypernatremic dehydration (15%) Hyponatremic dehydration (5%) Thanks to Rob Hall for any details

Body Fluids ICF (mEq/L) ECF (mEq/L) Sodium 20 135-145
Potassium Chloride Bicarbonate Phosphate Protein Most of our physical signs are determined by the ECF compartment Most of the neurological changes come from changes in the ICF compartment

Isonatremic dehydration
By far the most common Equal losses of Na and Water Na = No significant change between fluid compartments No need to correct slowly

Hypernatremic Dehydration
Water loss > sodium loss Na >150mmol/L Water shifts from ICF to ECF Child appears relatively less ill More intravascular volume Less physical signs Alternating between lethargy and hyperirritability Or increased Na+ intake due to incorrect formula

Physical findings Dry doughy skin Increased muscle tone Correction Correct Na slowly If lowered to quickly causes massive cerebral edema intractable seizures

Hyponatremic Dehydration
Sodium loss > Water loss Na <130mmol/L Water shifts from ECF to ICF Child appears relatively more ill Less intravascular volume More clinical signs Cerebral edema Seizure and Coma with Na <120 Most common cause is sodium poor replacement of GI losses

Correction Must again be performed slowly unless actively seizing Rapid correction of chronic hyponatremia thought to contribute to…. Central Pontine Myelinolysis Fluctuating LOC Pseudobulbar palsy Quadraparesis

Case #4 18 mo M HPI previously heatlhy
Diarrhea and vomiting for 3 days Mom says stools are liquid and foul smelling with no mucous or blood 6 episodes of diarrhea and 4 episodes of vomiting per day not feeding well and activity level ↓ He seems weak and tired Decreased number of wet diapers

Case cont Exam VS = T 37.0, P 110, RR 25, BP 100/75, 11.3 kg
Generally: alert, crying, looks tired HEENT: minimal tears, lips dry, mucous membranes tacky CVS: mild tachycardia, no murmurs RESP: clear, no distress ABDO: flat, soft, and non-tender with hyperactive bowel sounds Hydration: capillary refill time is 2-3 seconds and his skin turgor is slightly diminished

Determine the type and rate of rehydration fluids
Oral Rehydration Therapy (ORT) vs Intravenous therapy (IVT) “ To poke or not to poke, that is the question”

ORT Oral rehydration therapy Fluid replacement should be over 3-4hrs
Appropriate for mild to moderate dehydration Safer Less costly Administered in various clinical settings Fluid replacement should be over 3-4hrs 50ml/kg for mild dehydration 100ml/kg for moderate dehydration 10ml/kg for each episode of vomiting or watery diarrhea Frequent and small is the way to go – preferably with a syringe CPS states 20cc/kg/hr 1st hour then 10cc/kg/hr over the next 6-8hrs if mild and 15-20cc/kg/hr over next 6-8hrs if moderate

ORT Contraindications to ORT Severe dehydration (≥10%)
Ileus or intestinal obstruction Unable to tolerate (Persistent vomiting) Signs of shock Decreased LOC or unconscious Unclear diagnosis Psychosocial situations

ORS Oral rehydration solutions contain Commercial preparations
45-90 mmol/L Na mmol/L glucose Commercial preparations Pedialyte Infalyte Rehydralyte WHO rehydration salts

Oral rehydration solutions (ORS)
Osmoles mOsm/L Glucose mmol/L Na mEq/L Cl HCO3 K WHO formulation 330 110 90 80 30 20 Pedialyte 270 140 45 35 AJ 730 690 5 x 32 Sports drink 255 x 3 D5W / 0.45% saline 454 300 77 Know this chart for any exam written by Dr. Bryan Young!!!

ORT “Show me the evidence!!!”

Objective RCT ED based study
To test the hypothesis that the failure rate of ORT would not be more than 5% greater than that of IVT RCT Non-inferiority study design N=73 pts ED based study Children 8 weeks to 3 years old Moderate dehydration on validated scale With viral gastroenteritis

Methods Patients were randomized to receive either ORT or IVT during the 4-hour study Treating physicians were blinded Patients were assessed before randomization and at 2 and 4 hours of therapy Successful rehydration at 4 hours was defined as resolution of moderate dehydration production of urine weight gain absence of severe emesis (>5 mL/kg).

Results: Half of both the ORT and IVF groups were rehydrated successfully at 4 hours with no statistical differences

The time required to initiate therapy was less in the ORT group
Results: The time required to initiate therapy was less in the ORT group Less than one third of the ORT group required hospitalization, whereas almost half of the IVF group was hospitalized No difference in parental preference of therapy CIs crossed 0 so no statistical differences in hospitalizations

17 trials of poor to moderate quality were included
Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children Hartling, L. et al. Cochrane Database of Systematic Reviews. 4, 2006 RCTs comparing IVT with ORT in children up to 18 yo with gastroenteritis 17 trials of poor to moderate quality were included N = 1811 pts Six deaths occurred in the IVT group and two in the ORT groups (4 trials)

Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children Hartling, L. et al. Cochrane Database of Systematic Reviews. 4, 2006 Results: No clinically important differences between ORT and IVT groups ORT group did have a higher risk of paralytic ileus The IVT group was exposed to risks of intravenous therapy For every 25 children (95% CI 14 to 100) treated with ORT one would fail and require IVT

Case Continued You institute a strict regiment of ORT therapy using Pedialyte Mom says every time he takes the fluids he vomits within a few minutes!!! What do you tell her? What are your options now? Studies using drug administration and immediate serum of IPECAC and only 50% recovery of the drug. ie: some is getting down always

NGT??? Is there a role for nasal gastric tube oral rehydration?
Recent UK evidence based guidelines indicate When caregivers are unwilling to perform ORT or when it is required overnight continuous nasogastric tube infusion is preferred over intravenous infusion Level V evidence Opinions of respected authorities only EBM review says that it is a viable and useful alternative

When to start feeding again?

Case #4 9 month old Male Previously healthy Weight 10kg 5 day hx of severe diarrhea with intermittent vomiting Mother says stool like liquid Has been aggressively rehydrating him with water at home Today is much more lethargic and difficult to rouse By ambulance to the ED

Case #4 Exam What do you want to do now? Investigations?
Vitals = HR 172, RR 41, BP 65/40, Temp 37.2, Child is minimally responsive to pain He is Tachycardic and Tachypneic Cap refill time is >3 seconds As you are examining him he begins to have a seizure What do you want to do now? Investigations? Cap gas comes back and the patients sodium is 115 Sodium on the cap gas is 121

Severe Dehydration Management of severe dehydration requires IV fluids
Fluid selection and rate should be dictated by The type of dehydration The serum Na Clinical findings Aggressive IV NS bolus remains the mainstay of early intervention in all subtypes

Isonatremic Dehydration
Calculate the fluid deficit Deficit (cc’s) = % dehydration x body wt D5½NS is fluid of choice (½ deficit – the bolus) over the first 8hrs Add maintenance and any ongoing losses to above Further ½ the deficit replaced over the next 16hrs Monitor electrolytes and U/O

Fluid deficit = (Current Na/Desired Na – 1) x 0.6 x body wt Replace with D50.2%NS Replace over 48hrs Reduce sodium by no more than 10mEq/L/24hrs (½ deficit – the bolus) over the first 24hrs Add maintenance and any ongoing losses to above Further ½ the deficit replaced over the next 24hrs

Hyponatremic dehydration
Na deficit = (Nadesired- Nacurrent) x 0.6 x Weight (kg) Divide above by Na in mEq/L within the replacement fluid 154 mEq in NS 77 mEq in D5½ NS 513 in 3% saline divide by deficit x 2 to determine rate at 0.5mEq/L/hr

If seizing Correct with 3% Saline bolus Target a Na of 120 Further correction beyond this with D5½ NS If not Seizing Correct with D5½ NS Target a Na of 130 Watch for Central Pontine Myelinolysis More likely in chronic hypo-Na with less Sx Correct slowly at rate of 0.5mEq/L/hr

Back to our case Exam What do you want to do now? Investigations?
Vitals = HR 172, RR 41, BP 65/40, Temp 37.2, Child is minimally responsive to pain He is Tachycardic and Tachypneic Cap refill time is 5 seconds Fontanelle and eyes are sunken As you are examining him he begins to have a seizure What do you want to do now? Investigations? Cap gas comes back and the patients sodium is 115!!!

Case cont Initial bolus Seizing Further correction after above
20cc/kg of NS Seizing Correct Na to 120 with 3% saline bolus (120 – 115) x 0.6 x 10kg = 30mEq 30mEq ÷ 513mEq/L = 58cc bolus Further correction after above Correct Na to 130 with D5½ NS ( ) x 0.6 x 10kg = 60mEq 60mEq ÷ 77mEq/L = 780cc 780 ÷ (10 x 2) = 39cc/hr to correct at 0.5mEq/L/hr

Want to make life easier?

Final considerations Does and Acid-Base Deficit exist?
Does a potassium disturbance exist? What is the patients renal function?

Does and Acid-Base Deficit exist?
Acidosis Lactate Ketones Loss of Bicarb in diarrhea Most will resolve with simple rehydration Consider HCO3 for pH<7.0 Controversial

Does a potassium disturbance exist?
K+ losses GI Renal Remember that K shifts with acidosis and certain therapies Always insure renal function prior to IV replacement

What is the patients renal function?
Asses for underlying renal dysfuction Pre-renal vs renal failure Renal dysfuction Fluid overload Hyperkalemia Need for Dialysis? Nephro consultation

Feel free to use the new approach
Rapid Fire Cases Feel free to use the new approach

Case 2yo F (14kg) 3 days of diarrhea and vomiting Exam
Decreased u/o as per mother Exam Generally appears well MM dry and no significant tears Skin turgor normal Tachycardic but not tachypneic Cap refill 2 seconds

Answers Initial resuscitation % dehydration Dehydration Type
deferred % dehydration 5-9% moderate Dehydration Type Likely Isonatremic Rehydration fluids ORT Pedialyte Rate and volumes Moderate dehydration 100cc/kg = 1400cc Replace over 3-4hrs Further 10cc/kg with ongoing losses Final considerations None

Case 8mo M (8kg) 4 day hx of severe diarrhea and vomiting Exam Labs
No further ongoing losses Exam Limp and cold Mottled with weak rapid pulse Sunken eyes and fontanelle Cap refill 5s Tenting of skin Labs Na = 170 K = 3.1 HCO3 = 18

160cc NS bolus % dehydration >10% Severe Dehydration Type Hypernatremic Rehydration fluids IV fluids D50.2NS Rate and volumes Volume deficit = 640cc Correct slowly over 48hrs 39cc/hr over first 24hrs 45cc/hr over next 24hrs Final considerations Add 20 mEq K to IV fluids (½ deficit – the bolus) over the first 24hrs Add maintenance and any ongoing losses to above Further ½ the deficit replaced over the next 24hrs

Case 16mo F 3 day Hx of vomiting and diarrhea Exam
Tolerating fluids not solids Good u/o Exam Appears well with normal vitals Tears + MM moist Cap refill <2s Skin turgor normal

Answers Send this kid home!!!

Case 2 yo M (16kg) 4 day Hx of vomiting and diarrhea Exam Labs
Appears drowsy but not lethargic Good tone Tachycardiac and tachypneic BP normal Very Dry MM Cap refill 3s Labs Na = 134 K = 3.1 HCO3 = 16

320cc of NS % dehydration >10% Severe Dehydration Type Isonatremic Rehydration fluids D5½ NS Rate and volumes Volume deficit = 10% x 16kg = 1600mls 110cc/hr over first 8hrs 100cc/hr over next 16hrs Final considerations Add 20 mEq K to IV fluids Watch for metabolic acidosis to resolve

Case 1yo F (10kg) 4 day Hx of severe diarrhea and vomiting Exam Labs
Lethargic and limp Weak rapid pulse Fontanelle sunken Cap refill 5s Cool and mottled Tenting of skin Labs Na = 114 K = 3.4 HCO3 = 18 During your exam the patient starts Seizing

200cc NS % dehydration >10% Severe Dehydration Type Hyponatremic Rehydration fluids IV Initially 3% saline D5½ NS after above Rate and volumes Initially correct to Na of 120 with 3% = 70cc bolus Then correct to Na of 130 with D5½ NS at rate of 0.5mEq/L/hr = 39cc/hr Final considerations Add 20 mEq K to IV fluids Na deficit = (Nadesired- Nacurrent) x 0.6 x Weight (kg) Divide above by Na in mEq/L within the replacement fluid 154 mEq in NS 77 mEq in D5½ NS 513 in 3% saline divide by deficit x 2 to determine rate at 0.5mEq/L/hr

Final Case You are working the overnight at the ACH with Dr. Hodsman
You scan REDIS looking for anything other than vomiting and diarrhea… You find nothing You note that all the kids you are treating are mild-moderate dehydration Some have failed ORT already tonight and or on IVs You start to wonder if there is anything that we could give these kids to help speed things up?

Ondansetron vs placebo
Double blind RCT Comparing ondansetron to placebo in children with gastroenteritis American centre N = 215 children Age 6m – 10y with gastro Mild-Moderate dehydration Ondansetron vs placebo 2mg for 8-15kg 4mg for 15-30kg 8mg for >30kg

Outcomes: Primary Secondary
Proportion of children who vomited while receiving ORT Secondary Number of vomiting episodes during ORT Rates of IV rehydration and hospitalization

NNT= 5 to prevent one episode of vomiting
Results: NNT= 5 to prevent one episode of vomiting (95% CI ) NNT=6 to prevent one episode of IV rehydration (95% CI ) Mean length of stay in the ED was reduced in the Ondansetron group 12% reduction (P=0.02) No statistical difference in hospitalization rates

Issues: Pharmaceutical sponsored
Used un-validated dehydration scoring system Lower threshold to treat with IV in their patient population than our setting? Side effects and cost

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Pediatric Dehydration

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