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DEHYDRATION

Posted by SAMUEL ISABIRYE on February 18, 2013 at 8:10 AM

A condition brought about by the loss of significant

quantities of fluids and salts from the body

Cause

 Diarrhoea

Vomiting

Excessive sweating as in high fever Respiratory distress

Management in children HC2

Management with Plan A, B or C is based on an

assessment of the degree of dehydration according

to key clinical signs - see table below. Refer to

Management of Childhood Illness MoH 2000 for

further details.

 

Clinical features of dehydration in children

Signs

Degree of dehydration

None/Mild

Some Severe

General

condition

Well,

Alert

Restless,

irritable

Lethargic or

unconscious or very drowsy Eyes

Not sunken

Sunken Sunken

Fontanelle

Not sunken

Sunken Sunken

Ability to drink

Drinks normally

Drinks eagerly

thirsty

Drinks poorly or not able to drink

Skin pinch Goes back quickly

Goes back slowly

Goes back very slowly

Treatment Plan A Plan B Plan C

 

Plan A (No dehydration and for prevention):

Counsel the mother on the 3 rules of Home

Treatment

 - extra fluids, continue feeding, when to return

Give extra fluids - as much as the child will take Advise the mother to:

Continue/increase breastfeeding: -if child exclusively breastfed, give ORS or clean water in addition to milk

-if child not exclusively breastfed, give one or more of:

ORS, soup, rice-water, yoghurt drinks, clean water

In addition to the usual fluid intake, give ORS after each loose stool or episode of vomiting: <2yrs: 50-100mL; 2yrs and over: 100-200mL

- give the mother 2 packets to use at home

- giving ORS is especially important if the child has been treated with Plan B or Plan C during current visit

- give frequent small sips from a cup

-if child vomits, wait 10 minutes, then give more slowly

In a child with high fever or respiratory distress, give plenty of fluids to counter the increased fluid losses in these conditions

Continue giving extra fluid as well as ORS until the diarrhoea or other cause of dehydration stops

Counsel the mother on:

Correct breastfeeding and other feeding during sickness and health Increasing fluids during illness

How to maintain her own health

When to return to the health worker

Plan B (Some dehydration):

Give ORS in the following approximate amounts during the first 4 hours: Age (mths) < 4 4-12 13-24 25-60

Weight (kg) < 6 6-9.9 10-11.9 12-19

ORS (mL) 200-400 400-700 700-900 900-1400

.Only use child’s age when you don’t know the weight

.You can also calculate the approx. amount of

ORS to give a child in the first 4 hours as weight (kg) x 75mL

Show the mother how to give the ORS

- give frequent small sips from a cup

-if the child wants more than is shown in the table, give more as required

-if the child vomits, wait 10 minutes, then continue more slowly

For infants <6 months who are not breastfed, also give 100-200mL of clean water during this first 4 hours

Reassess patient frequently (every 30-60 minutes) for classification of dehydration and selection of Treatment Plan

After 4 hours:

Reassess the patient

Reclassify the degree of dehydration Select the appropriate Treatment Plan A, B or C

Begin feeding the child in the clinic

If the mother must leave before completing the child’s treatment:

Show her how to prepare ORS at home and how much ORS to give to finish the 4-hour treatment

Give her enough packets to complete this and 2 more to complete Plan A at home

Counsel the mother on the 3 rules of home treatment

- extra fluids, continue feeding, when to return

Plan C (Severe dehydration):

a) If you are able to give IV fluids:

Set up an IV fluids line immediately

-if the child can drink, give ORS while the drip is set up

Give 100ml/kg of compound sodium lactate infusion (Hartmann’s solution or Ringer’s Lactate solution) or half-strength [HS] Darrow’s solution in glucose 2.5% or sodium chloride infusion 0.9%

-divide the IV fluid as follows:

Age

First give 30mL/kg in:

Then give 70mL/kg in:

Infants (<12 months) 1 hour* 5 hours*

Children (12 mths-5yrs) 30 minutes* 2½ hours*

* Repeat once if radial pulse still very weak/undetectable

Reassess patient frequently (every 30-60 minutes) for classification of dehydration and selection of Treatment Plan If the patient is not improving:

Give the IV drip more rapidly

As soon as the patient can drink- usually after 3-4 hours in infants or 1-2 hours in children:

Also give ORS 5mL/kg/hour.

Continue to reassess the patient frequently, classify the degree of dehydration and select appropriate Plan A, B or C to continue treatment

b) If you are unable to give IV fluids but IV treatment is available nearby (i.e. within 30 minutes):

Refer urgently for IV treatment

If the child can drink:

Provide the mother with ORS and show her how to give frequent sips during the trip to the referral facility

c) If you are unable to give IV fluids and this therapy is not available nearby (i.e. not within 30 minutes ORS) but you can use a nasogastric tube (NGT) or the child can drink:

 

 

Start rehydration with ORS by NGT or by mouth: give 20mL/kg/hour for 6 hours (total = 120mL/kg)

Reassess the child every 1-2 hours:

-if there is repeated vomiting or increasing abdominal distension, give the more slowly

-if hydration status is not improving within 3 hours, refer the child urgently for IV therapy

 After 6 hours, reassess the child

Classify the degree of dehydration

Select appropriate Plan A, B or C to continue treatment

Note:

If possible, observe the child for at least 6 hours after rehydration to ensure that the mother can correctly use ORS to maintain hydration Management in Older Children & Adults HC3 & HC4

Assess the level of dehydration using the table below: linical features of dehydration older children and adults

Clinical feature

Degree of dehydration -Mild, Moderate, Severe

General appearance

Thirsty, alert

Thirsty, alert

Generally conscious, anxious, cold extremeties, clammy, cyanosis, wrinkly skin of fingers, muscle cramps, dizzy if standing

Pulse Normal Rapid

Rapid, thready, sometimes absent

Respiration Normal Deep, may be rapid

Deep and rapid Systolic BP Normal Normal Low, may be unmeasurable

Skin pinch

Returns rapidly

Returns slowly

Returns very slowly (>2 seconds)

Eyes Normal Sunken Very sunken

Clinical feature

Degree of dehydration

Mild Moderate Severe

Tears Present Absent Absent

Mucous membranes -Moist, Dry, Very dry

Urine output Normal

Reduced, dark urine

Anuria, empty bladder

•at least 2 of these signs must be present

Rehydrate the patient as follows

Degree of dehydration

Rehydration fluid

Route

Volume to give in first 4 h (1) Mild ORS (2) Oral 25mL/kg

Moderate ORS Oral 50mL/kg (3)

Severe SLC inf (4) IV 50mL/kg (5)

Notes on table

 1. Volumes shown are guidelines only – if necessary volumes can be increased or the initial high rate of administration maintained until clinical improvement occurs.

2. As well as ORS, other fluids such as soup, fruit juice and clean water may be given.

3. Initially adults can usually take up to 750mL ORS/hour.

4. If sodium lactate compound IV infusion (Ringer-Lactate) is not available:

use half-strength [HS] Darrow’s solution in glucose 2.5% or sodium chloride infusion 0.9%

-however, both of these are less effective

5. In severe dehydration, give IV fluids as rapidly as possible at first until radial pulse can be felt then slow down the rate of administration.

Volumes which may be given over the first 24 hours (60kg adult) are as follows:

Time period Volume of IV fluid

First hour                               1L

Next 3 hours                          2L

Next 20 hours                        3L

After 4 hours, evaluate rehydration in terms of clinical signs (and not in terms of volumes of fluid given).

As soon as signs of dehydration have gone (but not before) start fluid maintenance therapy with as much alternating ORS and water (to avoid hypernatraemia) as the patient wants

Continue this for as long as the cause of the original dehydration persists Note:

Continued nutrition is important – there is no physiological reason to discontinue food during treatment for dehydration

 

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