Pediatric emergency medicine trisk 0524 0524
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for the patient’s response to treatment. Careful reevaluation must be undertaken
as rapid infusion of IV fluids in a patient who is actually in heart failure will be
detrimental causing worsening of the condition. When blood pressure is restored,
heart rate returns to normal, distal pulses strengthen, and skin perfusion improves,
isotonic fluids may be safely discontinued. Careful attention should be paid to
ongoing losses. Urine output is the most important indicator of restored
intravascular volume in patients with intact renal and adrenal function, and
without diabetes mellitus or insipidus, and should be a minimum of 1 mL/kg/hr.
Hypoglycemia can often coexist in severe dehydration. Dextrose can be given via
IV. An initial bolus of 5 mL/kg of D10 can be given via peripheral IV or, if a
central line is present, 2 mL/kg of D25.
Oral Rehydration Therapy
If the child is determined to be mildly or moderately dehydrated, then oral
rehydration therapy (ORT) is the therapeutic option of choice. ORT is the
frequent administration of small volumes of an appropriate rehydration solution,
typically with an oral syringe. The use of ondansetron, a serotonin 5HT3 selective
receptor antagonist, has clearly been shown to improve the success of rehydration
with ORT in patients greater than 6 months of age ( Table 22.4 ). A one-time
dose has been shown to be sufficient and prescribing for home use has not been
shown to reduce return rates to the ED. Once given, ORT should be initiated in 15
to 30 minutes. An appropriate rehydration solution has the correct balance of
glucose and sodium, which enables the body to absorb the water passively via the
sodium glucose cotransport mechanism in the small intestine. The glucose-tosodium ratio is an important determinant in the acceptability of these solutions.
Optimal solutions have a 1:1 or a 2:1 glucose:sodium ratio. When additional
sweetener is added to the rehydration solution, the ratio of glucose to sodium is
distorted and may result in osmotic diarrhea or inappropriate absorption of
electrolytes. There are two categories of rehydration solutions: initial rehydration
solutions that contain 60 to 90 mEq/L of sodium (e.g., Rehydralyte, World Health
Organization oral rehydration solutions) and maintenance solutions that contain
40 to 60 mEq/L of sodium (e.g., Pedialyte). If the etiology of the dehydration is
presumed to be due to cholera, then the higher sodium concentration is
appropriate because there is a large sodium loss in the diarrhea stools of cholera
patients. However, if the etiology of the dehydration is presumed to be viral
gastroenteritis, then the lower sodium concentration solutions would be
appropriate and are more readily available. Both rehydration and maintenance
solutions have approximately 20 mEq/L of potassium and a low glucose
