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Pediatric hydration therapy: Historical review
and a new approach

Kidney International, Vol. 67 (2005), pp. 380–388

CASE PRESENTATION
A4-year-old boy weighing 15 kg presented with a 3-day
history of vomiting, decreased appetite, and 2 days of nonbloody
diarrhea. He was “warm to the touch” according
to the parents, but no direct measurement of temperature
was taken.Anolder sibling had had a similar illness 5 days
prior to the onset of vomiting by the patient.
For the previous 2 days, the patient had ingested only
water, apple juice, and non-cola soft drinks. The parents
believed that his urine output had dropped but only in
the previous 12 hours. The patient’s past medical history
and review of systems were unremarkable. He took no
medications on a chronic basis, although acetaminophen
in appropriate doses was used by the family “when the
child felt warm” (2–3 times/day).
On physical examination, he was mildly irritable and
appeared somewhat uncomfortable while sitting quietly
on his parent’s lap. The oral temperature was 38.2◦C;
blood pressure, 90/64 mm Hg while seated; heart rate,
120 beats/min; and respiratory rate, 24 breaths/min. His
skin was warm without rashes or edema. The head, ears,
eyes, nose, and throat revealed a somewhat dry oral mucosa
but no other abnormal findings. His neck was supple
without significant lymphadenopathy or thyromegaly.
Chest examination revealed normal lung sounds with no
murmur. The abdomen was slightly distended and tympanic
with active bowel sounds and no organomegaly or
masses. There was no costovertebral angle tenderness.
The patient had very slight peri-anal redness; the rest of
the genitourinary exam was normal. His joints were not
red, full, or tender, and he had full range of motion of his
arms and legs.
Urinalysis revealed a specific gravity of 1.020; 1+ protein,
and negative for blood, bilirubin, glucose, leukocyte
esterase, and nitrate; trace ketones; 1 to 2 white blood
cells/high-power field, and 1 granular cast. Blood studies
disclosed: sodium, 128 mEq/L; potassium, 3.6 mEq/L;
chloride, 98 mEq/L; bicarbonate, 18 mmol/L; serum creatinine,
0.7 mg/dL; and blood urea nitrogen, 26 mg/dL.
The parents were concerned because the child continued
to vomit.

Indications for the prescription of intravenous fluids

I. Highest priority

• a) Defend haemodynamics

• 1. Re-expand a severely contracted ECF volume

•

• 2. Prevent a fall in blood pressure when venous tone is low (e.g., anaesthesia)

• b) Return the ICF volume towards normal

• 1. Acute hyponatraemia that is symptomatic

• Infuse hypertonic saline to raise the PNa by 5 mM in 1–2 h

•

• 2. Chronic hyponatraemia with a seizure

• Infuse hypertonic saline to raise the PNa by 5 mM, but maximum is 8 mM/day; a lower target should be set if the patient is malnourished or K-depleted

•?

• 3. Chronic asymptomatic hyponatraemia

• Raise the PNa by up to 8 mM/day, slower rate if the PK is low in a malnourished patient

•?

•II. Moderate priority

• a) Re-expand a modestly contracted ECF volume

• Replace ongoing losses

• Avoid oliguria

• Match estimated electrolyte-free water loss in sweat and in the GI tract

Q J Med 2003; 96:601–610

•

Recommendations

How to Select Optimal Maintenance Intravenous Fluid Therapy

•Establish normal blood pressure

•Repair deficit; replace ongoing losses•

IF Na<138, DO NOT infuse hypotonic fluid•

Do not infuse NS in absence of indication•

Examine [Na] before infusing >1-2 L hypotonic fluids•

Be aware of occult oral water intake (ice, pop)•

Be ever more cautious if pt is young or has small muscle mass (50% of body H20 in muscle)•

Hypotonic fluid rate should match daily loss of electrolyte-free water in sweat in pt with Na>138•‘

One-size fits all - normal saline’ is NOT the answer…•

Q J Med 2003; 96:601–610