Treatment

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-

tion, when one is needed,

to prevent
hemolysis.
All conditions
may be met
by allowing
2 to 3 mEq/kg/day
of
both sodium
and potassium.
Chloride

and

bicarbonate

(or other

base)

ions for the healthy

infant awaiting
surgery,
for example,
should
be divided
about
3:1. In disease
states
appropriate
modification
may
be
made.
In this

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-

ples to an oral route of administration whenever

it is appropriate.
Here

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

should be at least approxiAny evidence

of infection,

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

tract, this is usually

the focus
but it should
be pointed
out that fluid
loss can occur
into a
tissue or through the urine as well.
The
symptoms
of anorexia
and
gastrointestinal

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,

the advent of vomiting

with diarrhea
is what
precipitates
admission
to the

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

This is particup to the ages

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

lost. This sign

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

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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

vol. 3 no. 4 october

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.

ines for it by pinching

the skin and
squeezing
out the blood
from
the
pinched
area and thereby
causing
a
color change.
In the healthy
patient,
the color
returns
almost
instantaneously
upon release.
Slowness
in the
return
of color
denotes
a loss
of
turgor.
Very
slow
return
in the absence
of a local
skin
problem
(or
edema)
indicates
shock.
Pulse
rate and pressure
are most
important
determinations
since
tachycardia
is the first manifestation

__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

are: (1) volume,

(2)
hydrogen
ion status,
ions, and (5) skeletal

1981

Downloaded from http://pedsinreview.aappublications.org/ by Desiree 'Desi' Rivera-Nieves on March 22, 2015

DEHYDRATION

ions. Each of these

in detail
enabling
define
the degree

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

drated weight rather than calculating

the hydrated
weight
and using
it.
This
error
is compensated
for in
the clinical
calculations
by also ig-

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

bed, the caloric

ture are about
amount.

rather
the

On

precise
abnormalities

defined,

movement

in

and water expendi1#{189}

times the basal

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

but this is not practical

pediatrics

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

but for most

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

liter, and bicarbonate

or other
base
of 25 to 30 mEq/liter.
After considering
the
next
several
analysis

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

does it prove to be even

to attempt
such detailed

tony losses
basal
state.

ensues.

basis

ically nor
advisable

the displaced

water

being

found in the extracellular

space.
The history
is helpful
in making
these
distinctions.
If purging
has
progressed
for a number
of days,
sodium
losses will be high, particularly if no sodium
intake
has occurred
during
this period.
In fact, if
relatively
mineral-free
water
has
been offered
by any route, a hyponatnemic
state will result.
If the patient has maifltained
regular food intake followed
by an abrupt cessation
of intake
with on without
vomiting,
then water
losses
will tend to prevol. 3 no. 4 october

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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,

Fever and other

evidences of infectious etiology

Variable

Variable, minimal nespinatory involvement

usual

High grade fever common; respiratory symptoms common with

increased ventilatory
rate

Anorexia

Late in course

Minimal,

Marked

Time

of year

of ill-

ness

Often under
sible)
more

in summer

good

of wated

1 yr of age (any pos-

Most in winter months,

especially
when humidity
is very low inside

oral intake

early

in illness

maintained

Vomiting

Late

Diarrhea

Moderate
out

State of consciousness
Lethargy

Normal

May be obtunded

Variable

Common

Usual and marked

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

fluid. If the circulation

impaired
but there

are

ble to the nervous

larly the identifiable

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-

stead of losing dermal

elasticity
in
the usual
fashion,
often
have
a
doughy
feel to their abdominal
skin.
PIR 1 1 6

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

Downloaded from http://pedsinreview.aappublications.org/ by Desiree 'Desi' Rivera-Nieves on March 22, 2015

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

lung to do this task quite satisfactorily. During

therapy
the ions selected
should
either
be chosen
to be slowly
corrective
or at least
not to worsen
the disturbance.
Remember
the normal pH of plasma
and extracellular

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

and magnehere as well,

ion that is of

in the first

or two of life frequently

paired
calcium
homeostasis
superimposed
dehydration
them
to hypocalcemia.
tremic
states
frequently

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.

The extent of these losses is known

from empirical
data rather than from
any easy method of either estimating
or measuring
with the current
clinical laboratory.
When the patient has
had longstanding
diarrhea
or vomiting, the potassium
losses
will be
large. If there has been polyunia,
potassium
losses
will
be predictably
large as well. Measurement
of potassium level in the serum
may be deceptive
because
any diminution
in
the glomerular
filtration
will cause

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

and for decid-

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

time segThe day

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

Downloaded from http://pedsinreview.aappublications.org/ by Desiree 'Desi' Rivera-Nieves on March 22, 2015

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

phase. Table 3 shows the foregoing

therapeutic
implementation
for a patient
icit

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

from the more common

varieties,
the
principles
of therapy
must
accommodate
the differences.
Mild hypocalcemia
occurs
in approximately
20% of patients.
Hyperglycemia,
oc-

casionally
perhaps

vol. 3 no. 4 october

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

for the nutrition

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

tutes the emergency

phase.
Those who use Ringers
lactate

single

pletion

and base may be distributed

according to the clinical
assessment
of the
hydrogen
ion status
of the patient.

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

Downloaded from http://pedsinreview.aappublications.org/ by Desiree 'Desi' Rivera-Nieves on March 22, 2015

of

volume,
and to
disturbseems

DEHYDRATION

TABLE

3.

Scheme

for First 24 Hours

Period

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,

40, K 20, C1 40

mEq/kg,

and base
mEq/liter

to 45, and base

1 5 to 20 mEq/Iiter

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

This group may then

first. If one were to

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

Downloaded from http://pedsinreview.aappublications.org/ by Desiree 'Desi' Rivera-Nieves on March 22, 2015

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

vol. 3 no. 4 october

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-

One amplue of 10% calcium

gluconate
for every
500 ml of infusate.
1/48 of volume/hr
for 48 hr. In infant, usual volume
will

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.

and none for maintenance

portion.
Resultant
concentration
is usually 20-35 mEq/Iiter.
Use
this concentration
of sodium or simply estimate
at 25 mEq/Iiten.
4.

general

If

urine,

Anuria

lems with hyperglycemia.

3.

intravascular.

means

(kg) for to-

b. Estimate 48 hr worth of maintenance

water
following usual clinical rules.
c. Add a + b for tentative volume of solution for
2. Glucose

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-

imen has been highly

successful
has not produced
complicating
vulsions.

1981

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and
con-

Treatment of Dehydration in Infancy

Laurence Finberg
Pediatrics in Review 1981;3;113
DOI: 10.1542/pir.3-4-113

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Downloaded from http://pedsinreview.aappublications.org/ by Desiree 'Desi' Rivera-Nieves on March 22, 2015

Treatment of Dehydration in Infancy

Laurence Finberg
Pediatrics in Review 1981;3;113
DOI: 10.1542/pir.3-4-113

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pedsinreview.aappublications.org/content/3/4/113

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.
Print ISSN: 0191-9601.

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