Dehydration in Pediatrics Dr. Erin Killorn Pediatric Emergency physician February 19 th, 2015
Outline Assessing Dehydration PO vs IV rehydration Antiemetics Things to consider/not to miss
Assessing Hx & PE Colletti JE, et al. The management of children with gastroenteritis and dehydration in the Emergency department. J Emerg Med 2010;38:686-98.
Assessing - BW Urea and creat: not useful Urea rises but inconsistently/late Creat very rarely rises HCO3 may be more helpful Drops before urea or creat Does not correlate well with severity Additive utility with clinical impression BW only if req IV rehydration, concern for electrolyte imbalance/hypoglycemia Colletti JE, et al. The management of children with gastroenteritis and dehydration in the Emergency department. J Emerg Med 2010;38:686-98.
*PO* vs. IV (TREKK.ca) No/minimal dehydration Advice only, D/C home Some dehydration IV rehydration is rarely needed Begin deficit replacement with ORS Sm amt freq if V Aim for 50-100ml ORS/kg over 2-4 hr Wt in kg of ORS q5min (q10min ) Severe dehydration Immediate IV fluids (e.g. NS 20cc/kg) until CV stability restored may require as much as 60ml/kg over 1 st hr King CK, Glass, R, Bresee JS, Duggan C, Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: Oral rehydration, maintenance and nutritional therapy. MMWR Recomm Rep. 52 (RR-16): 1-16 (2003).
PO rehydration Pedialyte Use unflavoured only, add juice/crystals/sugar Tastes salty: need to cover that! Flavoured versions use aspartame G2/Gatorade Reasonable choice for children 9 mo 1 yr and up G2 has equivalent sugar to Pedialyte, and Na/K content is roughly half Avoid water alone, especially if sign V/D and/or very young
Antiemetics Use of Gravol not supported in clinical trials Ondansetron Enhances PO rehydration with mild-mod dehydration Saves IVs and admissions, decreases ED length of stay Single dose safe and cost effective In the right patients No evidence to support multiple doses (i.e. post D/C) Availability, cost, side effect and safety issues Freedman SB, Ali S, Oleszczuk M, Gouin S, Hartling L. Treatment of acute gastroenteritis in children: An overview of systematic reviews of interventions commonly used in developed countries. Evidence-based Child Health: A Cochrane Review Journal. 8 (4): 1123-1137 (2013).
Ondansetron ODT ideal Suspension or IV prep Dosing (IWK): 8-15kg 2mg 15-30kg 4mg >30kg 8mg
Admission Very rare Severe dehydration Worsening dehydration despite good PO intake or progressive symptoms Sign electrolyte imbalance/ongoing hypoglycemia Concern for other diagnosis young age* Social concerns
Counselling points No Gravol Fluid choice for home Slow progression of PO intake Encouragement if refusal Minimums for voids < 6 months = 4 6 to 12 month = 3 >12 months = 2 Illness duration: younger = longer
Things to consider/not to miss Vomiting Diff Dx in children = everything UTI Pneumonia More rarely: brain tumour, NAT Surgical presentations *Bilious V in a neonate Pyloric stenosis Intussusception Appy (*missed appy - D)
Things to consider/not to miss Hypoglycemia Lethargy out of keeping < 5 yrs: poor glycogen stores, poor mobilization Pathologic hypoglycemia (urine for ketones) FYI: not much sugar in Pedialyte! Hypo/hypernatremia Lethargy or irritability out of keeping Poor parental fluid choice water only in the young
Take Home Points Hx & PE most useful to assess PO is the way to go Ondansetron!...once and for the right ones Good D/C instructions go a long way (helping us help ourselves) Occasionally think of other things TREKK.ca
Questions?
Case 1 18 mo old F, wt 12kg 48 hr h/o V and D, last V yest eve, Dx1 today Drinking H2O, poor intake today, wet diaper x2 yest, x1 this am Fever x 24 hr initially, none today Brought to ED for lethargy O/E: HR 130, BP 80/50, RR 28, O2sat 99%, T 36.4 Alert, quiet, MMM, CR ~3s, abd soft, nil else focal Thoughts? Degree of dehydration? Approach?
Case 1 Bedside gluc 2.8 Assessment: mild dehydration and hypoglycemia Secondary to V/D, and? poor intake of H2O only Management? Further Hx?
Case 1 PO fluid challenge with 2mg ondansetron ODT Pedialyte with added dextrose, Gatorade, juice/popsicle Rpt bedside glucose in 30min (3.6) Further Hx from parents: 2 prior visits with dx of gastroenteritis with associated hypoglycemia Further concern? Management?
Case 2 11 mo old M, wt 10kg 48hr h/o V, ~10x today No fever, no D, no URTI sx Progressive lethargy today O/E: HR 175, BP 70/45, RR 32, O2sat 99%, T 36.4 Moaning, opens eyes and localizes to pain MM dry, CR 4-5s, cool ext, good pulses Moans with abd palpation, no guarding, nil else focal Diff Dx? Approach?
Case 2 ABCs IV/IO access 20cc/kg IV NS, rpt as needed (HR) Bedside glucose 6.8 Further Hx: intermittent crying episodes, worse today Diff Dx: Gastroenteritis with severe dehydration Intussusception Appendicitis Sepsis UTI DKA