#### II. Definitions

1. Pediatric Hypertonic Dehydration
1. Pediatric Dehydration AND Serum Sodium > 150

#### III. Protocol: Example Case

1. Weight: 35 kg Child
2. Dehydration: 10%
3. Serum Sodium: 158

#### IV. 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

#### V. 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

#### VI. 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

#### VII. 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

#### IX. References

1. Walton (2020) Crit Dec Emerg Med 34(6): 3-9
2. Canavan (2009) Am Fam Physician 80(7):692-6 [PubMed]