para>A systematic approach in assessing risk factors is necessary for early prevention and management of dehydration in the elderly, especially those in long-term care facilities.
COMMONLY ASSOCIATED CONDITIONS
- Hypo-/hypernatremia
- Hypokalemia
- Hypovolemic shock
- Renal failure
DIAGNOSIS
Calculate % dehydration = (pre-illness weight - illness weight)/pre-illness weight — 100. Supplement this along with the ongoing fluid loss.
View LargeClinical Finding (2)MildModerateSevereDehydration: children5-10%10-15%>15%Dehydration: adults3-5%5-10%>10%General condition: infantsThirsty, alert, restlessLethargic/drowsyLimp, cold, cyanotic extremities, may be comatoseGeneral condition: older childrenThirsty, alert, restlessAlert, postural dizzinessApprehensive, cold, cyanotic extremities, muscle crampsQuality of radial pulseNormalThready/weakFeeble or impalpableQuality of respirationNormalDeepDeep and rapid/tachypneaBPNormalNormal to lowLow (shock)Skin turgorNormal skin turgorReduced skin turgor, cool skinSkin tenting, cool, mottled, acrocyanotic skinEyesNormalSunkenVery SunkenTearsPresentAbsentAbsentMucous membranesMoistDryVery dryUrine outputNormalReducedNone passed in many hoursAnterior fontanelleNormalSunkenMarkedly sunken
HISTORY
- Fever
- Intake (including description and amount)
- Diarrhea (including duration, frequency, consistency, ± mucus/blood)
- Vomiting (including duration, frequency, consistency, ± bilious/nonbilious)
- Urination pattern
- Sick contacts
- Medication history (e.g., diuretics, laxatives)
PHYSICAL EXAM
- The most useful individual signs for identifying dehydration in children are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern (3).
- Vitals: pulse, BP, temperature
- Orthostatic vital signs: Take BP and heart rate (HR) while supine, sitting, and standing.
- Systolic BP decrease by 20, diastolic BP decrease by 10, or HR increase by 20 highly suggestive of hypovolemia (4)
- Weight loss: <5%, 10%, or >15%
- Mental status
- Head: sunken anterior fontanelle (for infants)
- Eyes: sunken, ± tear production
- Mucous membranes: tacky, dry, or parched
- Capillary refill: ranges from brisk to >3 seconds
DIFFERENTIAL DIAGNOSIS
- Decreased intake: ineffective breastfeeding, inadequate thirst response, anorexia, malabsorption, metabolic disorder, obtunded state
- Excessive losses: gastroenteritis, diarrhea, febrile illness, diabetic ketoacidosis, hyperglycemia, hyperosmolar hyperglycemic state, diabetes insipidus, intestinal obstruction, sepsis
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- For mild dehydration: generally not necessary
- For moderate to severe dehydration
- Blood work, including electrolytes, BUN, creatinine, and glucose
- Urinalysis (specific gravity, hematuria, glucosuria)
- Imaging does not play a role in the diagnosis of dehydration, unless diagnosis of the specific medical condition causing the dehydration requires imaging.
- In adults, there is evidence to support the use of inferior vena cava collapsibility as a surrogate marker for volume status.
Pediatric Considerations
Infants and the elderly may not concentrate urine maximally, so a nonelevated specific gravity should not be reassuring.
TREATMENT
MEDICATION
First Line
- Oral rehydration is the first-line treatment in dehydrated children. If this is unsuccessful, use IV rehydration. If IV unobtainable, nasogastric (NG) rehydration can be considered (5).
- Oral rehydration is the first-line treatment in dehydrated adults as long as they can tolerate fluids. Have a lower threshold for IV rehydration if needed.
- If the patient is experiencing excessive vomiting, consider using an antiemetic.
- Ondansetron (PO/IV) may be effective in decreasing the rate of vomiting, improving the success rate of oral hydration, preventing the need for IV hydration, and preventing the need for hospital admission (6,7).
- Other antiemetics can be used.
Second Line
- Loperamide may reduce the duration of diarrhea compared with placebo in children with mild to moderate dehydration (two randomized controlled trials [RCTs] yes, one RCT no).
- In children ages 3 to 12 years with mild diarrhea and minimal dehydration, loperamide decreases diarrhea duration and frequency when used with oral rehydration.
Pediatric Considerations
Given a higher risk for serious adverse events, loperamide is not indicated for children <3 years of age with acute diarrhea.
ISSUES FOR REFERRAL
- For severe dehydration, critical care referral and ICU-level care may be warranted.
- Surgical consultation for acute abdominal issues
SURGERY/OTHER PROCEDURES
For specific underlying causes of dehydration, such as intestinal obstruction or appendicitis
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Intractable vomiting/diarrhea
- Electrolyte abnormalities
- Hemodynamic instability
- Inability to tolerate oral rehydration therapy (ORT)
- Stabilize ABCs.
- If mild dehydration, try ORT.
- If excessive vomiting/severe dehydration with shock, start IV access and IV fluids immediately.
IV Fluids
- Stage I
- For moderate to severe dehydration in children: isotonic saline or Ringer lactate solution bolus of 10 to 20 mL/kg; may repeat up to 60 mL/kg; if still hemodynamically unstable, consider colloid replacement (blood, albumin, fresh frozen plasma) and address other causes for shock.
- For moderate to severe hypovolemia in adults: isotonic saline or Ringer lactate 20 mL/kg/hr until normal state of consciousness returns/vital signs stabilize. Also consider colloid replacement if continued fluids required beyond 3 L.
- Stage II: Replace fluid deficit along with maintenance over 48 hours. Fluid deficit = preillness weight - illness weight.
- An alternative IV treatment option for moderate (10%) dehydration in children
- Bolus with NS/LR at 20 mL/kg for 1 hour
- Replete fluid deficit with D5 1/2 NS + 20 mEq KCl/L at 10 mL/kg for 8 hours (hours 2 to 9).
- Replete 1.5 for maintenance fluids with D5 1/4 NS + 20 mEq/L of KCl for 16 hours (hours 10 to 24).
- An alternative to IV fluids is hypodermoclysis, the SC infusion of fluids into the body.
- Indications: hydration of patients with mild to moderate dehydration who do not tolerate oral intake because of cognitive impairment, severe dysphagia, advanced terminal illness, or intractable vomiting. It is also indicated to prevent dehydration, especially in frail elderly residents living in long-term care settings who reject the oral route for any reason; useful technique for patients with difficult IV access
- Contraindications: severe dehydration or shock, patients with coagulopathy or receiving full anticoagulation, patients with severe generalized edema (anasarca) or congestive heart failure, and those with fluid overload (8)
Nursing
Strict inputs and outputs: oral and IV input and output of urine and stool, which may include weighing wet diapers
Discharge Criteria
- Input > output
- Underlying etiology treated and improving
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Activity as tolerated
- If mild to moderate dehydration, the patient may be mobile without restrictions, although watch for orthostasis/falls.
- If moderate to severe dehydration, bed rest.
Patient Monitoring
Ongoing surveillance for recurrence
DIET
- Bland food such as bananas, rice, apples, toast (BRAT) diet
- If diarrhea, avoid dairy for 48 hours after symptoms resolve. One review of weak RCTs and three of five subsequent RCTs found that lactose-free feeds reduced the duration of diarrhea in children with mild to severe dehydration, compared with lactose-containing feeds. However, two subsequent RCTs found no difference between lactose-free and lactose-containing feeds in duration of diarrhea.
- Small frequent sips of room temperature liquids
- For children, Pedialyte (liquid or popsicles)
- Continue breastfeeding ad lib.
PATIENT EDUCATION
- Patients should go to the nearest emergency facility or call 911 if they or their child feels faint or dizzy when rising from a sitting or lying position, becomes lethargic and/or confused, or complains of a rapid heart rate.
- Patients should call their physician if they are unable to keep down any fluids, vomiting has been going on >24 hours in an adult or >12 hours in a child, diarrhea has lasted >2 days in an adult/child, or an infant/child is much less active than usual or is very irritable.
- Patient information on dehydration: http://www.mayoclinic.org/diseases-conditions/dehydration/basics/definition/con-20030056
PROGNOSIS
Self-limited if treated early; potentially fatal
COMPLICATIONS
- Seizures
- Renal failure
- Cardiovascular arrest
REFERENCES
11 Thomas DR, Cote TR, Lawhorne L, et al. Understanding clinical dehydration and its treatment. J Am Med Dir Assoc. 2008;9(5):292-301.22 Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics. 1997;99(5):E6.33 Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA. 2004;291(22):2746-2754.44 Lanier JB, Mote MB, Clay EC. Evaluation and management of orthostatic hypotension. Am Fam Physician. 2011;84(5):527-536.55 Rouhani S, Meloney L, Ahn R, et al. Alternative rehydration methods: a systematic review and lessons for resource-limited care. Pediatrics. 2011;127(3):e748-e757.66 Colletti JE, Brown KM, Sharieff GQ, et al. The management of children with gastroenteritis and dehydration in the emergency department. J Emerg Med. 2010;38(5):686-698.77 Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework. BMJ Open. 2012;2(4):e000622.88 Lopez JH, Reyes-Ortiz CA. Subcutaneous hydration by hypodermoclysis. Rev Clin Gerontol. 2010;20(2):105-113.
SEE ALSO
Oral Rehydration
CODES
ICD10
- E86.0 Dehydration
- E87.1 Hypo-osmolality and hyponatremia
- E86.1 Hypovolemia
ICD9
- 276.51 Dehydration
- 276.1 Hyposmolality and/or hyponatremia
- 276.52 Hypovolemia
SNOMED
- 34095006 dehydration (disorder)
- 89627008 Hyponatremia (disorder)
- 85648000 Hypoosmolarity (finding)
- 28560003 Hypovolemia (disorder)
CLINICAL PEARLS
- Dehydration is the result of a negative fluid balance and is a common cause of hospitalization in both children and the elderly.
- Begin by assessing the level of dehydration and determining the underlying cause.
- Treatment is directed at restoring fluid balance via oral rehydration (first-line) therapy or IV fluids and treating underlying causes.