Pediatrics Book

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Pediatric Hypertonic Dehydration

Aka: Pediatric Hypertonic Dehydration, Hypertonic Dehydration Management in Children
  1. See Also
    1. Pediatric Dehydration Management
    2. Hypernatremia
  2. Definitions
    1. Pediatric Hypertonic Dehydration
      1. Pediatric Dehydration AND Serum Sodium > 150
  3. Protocol: Example Case
    1. Weight: 35 kg Child
    2. Dehydration: 10%
    3. Serum Sodium: 158
  4. Protocol: Stabilization with Bolus Fluids (Phase I)
    1. See Pediatric Dehydration Management
    2. Give 20 ml/kg Normal Saline or Lactated Ringers over 10-15 minutes
    3. May repeat bolus until circulation stable
      1. May require up to 60 ml/kg within the first 1-2 hours
  5. Protocol: Calculate Replacement and Replace Phase 1 Fluids
    1. Approach as per Pediatric Dehydration Management
    2. See Maintenance Fluid Requirements in Children
    3. Deficit: 3500 ml - 700 ml (Replaced Phase 1)
    4. Example Replacement for the 35 kg child with 10% dehydration
      1. Replacement given over 48 hours
      2. Total = 2800 ml + 75 ml/h x 48 hours = 6400 ml/48 hours
      3. Hourly rate = 133 ml/hour for 48 hours
  6. Protocol: Choose Saline Solution
    1. Replace with Normal Saline (NS)
    2. Monitor Serum Sodium every 2-4 hours
      1. Decrease Serum Sodium 0.5 meq/L/hour (10 meq/L/day)
      2. Do not lower Serum Sodium by >15 meq/L/day
    3. Serum Sodium not correcting
      1. Switch to D5 1/2 Normal Saline but Exercise caution
    4. Serum Sodium still not correcting: Example 35 kg Patient as above
      1. Calculate Total Body Water Deficit (TBWD)
        1. TBWD = 4 ml/kg x (weight kg) x (Serum Sodium - 145)
        2. TBWD = (4 ml/kg x 35 kg) x (158 - 145) = 1820 ml
      2. Replace Total Body Water Deficit (TBWD)
        1. Replace TBWD with D5W over 48 hours
        2. Total: 1820 ml/48 hours
        3. Hourly: 38 ml/hour D5W
      3. Replace remainder with maintenance fluids
        1. Balance: 133 ml/hour - 38 ml/hour
        2. Hourly: 95 ml/hour D5 Normal Saline with KCL
  7. Protocol: Summary - 35 kg Child, hypertonic severe dehydration
    1. Monitor Serum Sodium every 2-4 hours
      1. Decrease Sodium at 0.5 meq/L/hour (10 meq/L/day)
    2. Start: D5 NS with 20 KCl at 133 cc/hour for 48 hours
    3. No Serum Sodium change:
      1. Switch: D5 1/2NS with 20 KCl at 133 ml/h for 48 hours
    4. Still no Serum Sodium change
      1. TBWD Replacement: D5W at 38 ml/h for 48 hours
      2. Maintenance: D5 1/2NS with 20 KCl at 95 ml/h for 48 hours
  8. Resources
    1. Vega and Bhimji (2017) Pediatric Dehydration in Stat Pearls
      1. https://www.ncbi.nlm.nih.gov/books/NBK436022/
  9. References
    1. Walton (2020) Crit Dec Emerg Med 34(6): 3-9
    2. Canavan (2009) Am Fam Physician 80(7):692-6 [PubMed]

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