Hypertonic dehydration.

Dehydration

This name is given to those clinical situations in which fluid and electrolyte losses exceed current spending.

The most common state of dehydration in children is due to acute gastroenteritis.

The determination of the degree of dehydration is mainly based on the clinic. The clinical estimate indicates the percentage of decrease in body weight loss due to acute water. Example: A 5% dehydration indicates that it has lost 5% of body weight, acute loss of fluid.

Depending on the degree of dehydration are divided into:

1. Mild Dehydration: Lack of 5%.

- Clinical signs: Characterized by the loss of interstitial fluid.

* Poor skin temperature.

* Sunken fontanelles.

* Sunken eyes.

* Dryness of mucous membranes.

These changes reflect important hemodynamic compromise, however, when there is significant ongoing losses and inability to take adequate fluid by mouth, these signs indicate a progressive deficit fluid therapy is necessary.

2. Deficit of 5% to 10%.

There are clinical signs of interstitial deficit but clinical signs of intravascular fluid deficits:

* Lethargy.

* Tachycardia.

* Low blood pressure.

* Decreased urine output.

All this reflects a significant hemodynamic compromise.

3. Deficit of 10% to 15%.

They are present all the signs of depletion of interstitial and intravascular spaces, plus signs as: pale, flabby, weak and rapid pulse, hypotension and oliguria, indicating intravascular collapse and shock.

CLASSIFICATION.

The type of dehydration is determined by the serum sodium concentration, which indirectly reflects the osmolarity.

1. Isotonic dehydration (most common).

Occurs when the acute loss of fluid intercellular fluid concentration (LIC) is proportional to the concentration of extracellular fluid (ECF).

The serum sodium is 130 to 150 mEq / l.

Because no osmolar gradients are created between the ICF and ECF will be minimal displacement of fluid and therefore the low incidence of shock, unless the degree of dehydration is very important.

In this case the estimated fluid deficit can be replaced within 24 hours of treatment.

2. Hypotonic dehydration.

The serum sodium is less than 130 meq / l.

There is loss of fluids and electrolytes, as in gastroenteritis and only replaces the water.

It also appears when sodium losses are greater than the water pudiéndiendose also develop in children with other chronic disorders of salt losers (cystic fibrosis, salt losing adrenogenital syndrome and renal disease are loss of salt).

Besides the loss of fluid in the extracellular space or hypoosmolar the ECF hypotonicity as a result of excessive loss of electrolytes, promotes water movement from the ECF to the ICF. Resulting in even higher concentration of the ECF and thus a higher incidence of shock.

In this case the shock will be discussed first and then replace the deficit in the first 24 hours of treatment.

3. Hypertonic dehydration.

Defined by a serum sodium exceeds 150 mEq / l.

Occurs when body water losses exceed the losses of salt.

Occurs most frequently in children with gastroenteritis for which administered oral solutions with high salt concentration.

The ECF hypertonicity and hyperosmolarity leads to a movement of water from the ICF to the ECF.

The subsequent intracellular dehydration produces a typical pasty texture of the skin.

In severe cases of this dehydration, intracellular dehydration and metabolic acidosis associated, can cause significant brain injury as a sequel.

Diabetes insipidus and diabetes insipidus may occur as hypertonic dehydration.

We must avoid rapid correction of hypernatremia.

The rapid filling of liquids can force a rapid re-expansion of the cells and produce convulsions during corrective fluid.

If there is shock will be treated first. After restoring the circulation phase begins replacement of the deficit, that must be changed slowly, even in 48 hours or 72 hours.

In the first 24 hours should be given maintenance fluids plus half of shortfall.

In this type of dehydration is frequently believed to hypocalcemia is associated with loss of potassium and total body potassium deficit. If the total serum calcium of 7 mg / dl or lower can add 1 vial of 10% calcium gluconate for every 500 ml of fluid IV tubing. Not taking baking because it could precipitate.

In these cases the fluid should have a base venoclisis lactate. With a base liquid bicarbonate will have to use another route for calcium.

For severe acidosis is necessary with bicarbonate therapy, but may add the sodium bicarbonate replacement therapy.

Administered as sodium as sodium bicarbonate (NaHCO3) must be included in the calculations of replacement of sodium.

TREATMENT.

a) First stage:

* Treatment of shock, if any:

- Restore the plasma volume to achieve an adequate cardiac output and a good organ perfusion.

And stabilize the movement:

b) Second stage:

* Correction of the deficit with the provision of maintenance fluids.

1. Blood drawn for determination of electrolytes, BUN (urea nitrogen), complete blood count, blood and other studies indicated clinically indicated.

Start with the administration of intravenous fluids.

2. If this is clinical shock or impending start venoclysis of isotonic saline or Ringer lactate at 20 ml / g for 1 hour. If not corrected within an hour, repeat the same volume infusion.

3. Estimating the need for maintenance of fluid and the estimated deficit, based on clinical assessment and determination of electrolytes. The amount of maintenance and the deficit is the amount of fluid infused in the first 24 hours, except in hypertonic dehydration, which maintain more than half of the deficit is the amount to be given within 24 hours.

4. Give half in all liquids calculated during the first 8 hours, during the second quarter and another 8 hours during the third quarter.

5. Add potassium chloride infusion has been identified on renal function is normal.

6. If acidosis is severe (plasma bicarbonate below 10 mEq / l) add sodium bicarbonate to the solution at a rate of 1 meq / kg, will increase serum bicarbonate 2 meq / l.