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Pediatric Dehydration. Katharine Smart, MD, DTM&H, FRCPC Pediatric Emergency Medicine Alberta Children’s Hospital (special thanks to Marc Francis). Objectives. Review the epidemiology and impact of gastroenteritis in children Approach to the dehydrated patient - PowerPoint PPT Presentation

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  • Pediatric DehydrationKatharine Smart, MD, DTM&H, FRCPCPediatric Emergency MedicineAlberta Childrens Hospital(special thanks to Marc Francis)

  • ObjectivesReview the epidemiology and impact of gastroenteritis in childrenApproach to the dehydrated patientReview the evidence for clinical and laboratory determination of dehydrationReview Oral Rehydration Therapy and its indicationsDiscuss the concept of fluid challenge and the need for a paradigm shift

  • Case 1A 20-month-old girl is brought to the emergency department (ED) after 2 days of vomiting and diarrhea.Father reports no solid intake since the illness began and now child will not drinkToday- 8 stools and no diapers with urine in themThe child appears mildly ill but makes tears while cryingHer respiratory rate and quality are normal, VSSHer mouth is somewhat dryCRT is 1.5 secondsSkin turgor is normalBUN is 4.3 mmol/L; Bicarb 19 mmol/L

  • Who Cares?Dehydration is one of the leading causes of morbidity and mortality in children throughout the worldCauses 30% of worldwide deaths among infants and toddlersPre-ORT gastro was the number one killer of children in developing countries- it now falls behind LRTIs

    8000 children younger than 5 years die each day due to gastroenteritis and dehydrationAlmost 3 million/year!!

  • Who cares?In the US and Canada, children < 5 average 2 episodes of gastroenteritis/yearGastro leads to 2 to 3 million office visits and 10% of all pediatric hospital admissions (US data)The direct costs of outpatient and hospital visits are more than $2 billion per year (US data)

  • Dehydration is not a disease1) Decreased intake2) Increased outputInsensible lossesRenal lossesGI losses3) TranslocationBurnsAscites

  • Why is this a peds problem?Sick kids = decreased intakeHigher percentage TBWNeonate 75%Child 65%Adult 60%Fever increases fluid needsHigher metabolic rate in kidsless tolerance to fluid and electrolyte changesPoor renal concentration mechanisms at young age

  • Causes of DehydrationDiarrheaVomitingGastroenteritisStomatitis or pharyngitisFebrile illnessDKADIBurns

  • Causes

  • DiarrheaDDxGastroenteritisMalabsorptionIBDIBSDrug side effectsThyrotoxicosisInfectionsEndocrine disorders

  • DiarrheaIndications for stool studiesToxic appearanceImmunocompromisedBloody or invasiveDuration > 7 daysSuspected parasitesTravelCampingPoor Water

  • Vomiting

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

  • VomitingGIObstructionPancreatitisAppyPyloric stenosisVolvulusIntussusseption

    GUUTIPyeloRTAToxicDrug ingestionDrug side effects IDPneumoniaSepsisEndocrineAddisonsCAHNeuroMeningitis/Encephalitis ICP

  • Case #15 mo MaleHPINon-bloody profuse watery stool 7 days10-15 stools per day foul smellingChild eager to take water until this AMNow less interested in drinking and more lethargicExamQuiet and tachypneicSunken eyes and a dry mouthTachycardic at 165 bpmCap refill is 3 secondsSkin turgor prolonged

  • Case #1How 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?

  • Approach to Peds DehydrationInitial ResuscitationDetermine % dehydrationDefine the type of dehydrationDetermine the type and rate of rehydration fluidsFinal considerations

  • Approach to Peds DehydrationInitial ResuscitationDetermine % dehydrationDefine the type of dehydrationDetermine the type and rate of rehydration fluidsFinal considerations

  • Initial ResuscitationABCsInitial fluid bolus20cc/kg of NS or RingersAppropriate in all types of dehydrationReassess q5mins and repeat x 3Initial hypoglycemia5cc/kg of D10W in infants2cc/kg of D25W in childrenThink about Shock DDx if unresponsive to 3 attempts at NS bolus

  • Approach to Peds DehydrationInitial ResuscitationDetermine % dehydrationDefine the type of dehydrationDetermine the type and rate of rehydration fluidsFinal considerations

  • Case #220 mo FHPI2 days of vomiting and diarrheaNot eating and will not drink8 stools today but dad does not think there were any diapers with urine in themAfebrileExamAppears mildly illTears +Vitals are normal including RRMouth is DryCap Refill time is 2.0 seconds

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

  • AAP GuidelineThe AAP guideline states that the treatment of a child with diarrhea is directed primarily by the degree of dehydration presentMild (3%-5%)Moderate (6%-9%)Severe (>9%) Mild to Moderate- ORTSevere- IV fluidsCDC uses a similar assessment and scale

  • WHO ClassificationNone (3-5%)Some (5-10%)Severe (>10%)

    Treatment recommendations are the sameNone- maintain hydrationNone-Some- ORTSevere- IV fluids

  • So whats up??Despite recommendations for oral rehydration in mild or moderate dehydration, ORT is used in < 30% of the cases of gastro for which it is indicatedClinicians tend to overestimate the degree of dehydrationMay result in more invasive intravenous rehydrationWhat do you think?

  • Determine % DehydrationGold standard is pre and post weightWhat are the markers that we use to assess this?ClinicalLaboratoryHow reliable and precise are these markers?

  • Is this Child Dehydrated?Michael J. Steiner; Darren A. DeWalt; Julie S. Byerley, JAMA. 2004;291(22):2746-2754

    Quantifying dehydration is important and commonUtility of the clinical history, physical examination, and laboratory tests had not previously been systematically reviewedTeaching the assessment of dehydration often based on clinical experience and medical traditionSteiner et al, conducted a systematic review of the literature on the precision and accuracy of history, physical examination, and laboratory tests in identifying dehydration in children between 1 month and 5 years old

  • Clinical Signs

  • Capillary Refill Time- what is normal?Although many practitioners use other sites to measure capillary refill time, most studies of this sign use the palmar surface of the distal fingertipUsing this approach, values for non-dehydrated children are less than 1.5 to 2 secondsGorelick et al, found that fever did not affect the test characteristics in children with vomiting, diarrhea, or poor oral intake

  • Laboratory SignsBUN >8= >2.9 mmol/L>18= >6.4 mmol/L>27= >9.6 mmol/L>45= >16 mmol/L

  • Validity and Reliability of Clinical Signs in the Diagnosis of Dehydration in Children, Marc H. Gorelick, Kathy N. Shaw and Kathleen O. Murphy, Pediatrics 1997;99;e6

    Scale gave equal weight to 10 commonly elicited signs:Decreased skin elasticityCRT > 2 secondsGeneral appearanceAbsence of tearsAbnormal respirationsDry mucous membranesSunken eyesAbnormal radial pulseTachycardia (heart rate150/min)Decreased urine output3 of the 10 signs 87% sensitive and 82% specific in detecting 5% dehydrationLR positive, 4.9

    7 of 10 signs 82% sensitive and 90% specific in detecting 10% dehydrationLR positive of 8.4

  • Gorelick, contdLogistic regression analysis showed 4 signs contained most of the predictive power:Capillary refill timeDry mucous membranesAbsence of tearsAbnormal overall appearance

    2 of 4 signs was 79% sensitive and 87% specific for diagnosing 5% dehydrationLR positive of 6.13 of 4 signs was 82% sensitive and 83% specific for diagnosing 10% dehydrationLR positive of 5.1

    * Not statistically different than 10 sign model

  • History- they havent peed all day!Steiner pooled 3 studies to evaluate the accuracy of history taking in assessing dehydrationAll 3 of these studies evaluated history of low urine output as a test for dehydrationLow urine output did not increase the likelihood of 5% dehydration (LR, 1.3; 95% CI, 0.9-1.9)Also NOT predictive of dehydration:A history of vomiting, diarrhea, decreased oral intake, reported low urine output, a previous trial of clear liquids, and having seen another clinician during the illness prior to presenting to the ED

  • Development of a Clinical Dehydration Scale for use in Children between 1 and 36 months of age. J. Friedman, et al. J Peds, Aug 2004 pp.201-207Developed a clinical score to assess severity and response to treatment in children aged 1-36 monthsScore not intended to be diagnosticFound 4 of 9 items to be the most valid and reliableGeneral appearanceMucous membranesSunken eyesAbsent tearsOf 137 patients only 1 had severe dehydration (>10% weight loss) but 94 (69%) received IV fluids; 9 patients had moderate dehydration (6-9% weight loss)

  • Steiner conclusionsData suggest that signs of dehydration can be imprecise and inaccurateDifficult for clinicians to predict the exact degree of dehydrationCombination of clinical symptoms better than individual signs or lab findingsSteiner et al agrees with WHO and other groups that recommend using the physical examination to classify dehydration as none, some, or severeThis general assessment can then be used to guide clinical management

  • What does it mean for us?We can classify children as:Not dehydrated- need advice on how to maintain hydrationSome dehydration- need ORT and if successful advice on how to maintain hydrationSevere dehydration- need fluid resuscitation followed by rehydration

  • Approach to Peds DehydrationInitial ResuscitationDetermine % dehydrationDefine the type of dehydrationDetermine the type and rate of rehydration fluidsFinal considerations

  • Case #46 day old FemaleFirst child born at termGBS negative motherNormal preg and delivery D/Cd within 24 hrsExclusively breastfedHPIMom says child is a poor f