Pediatric emergency medicine trisk 0527 0527
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Notable exceptions include patients with extremely voluminous watery diarrhea,
major burn patients who continue to require isotonic fluids, children with diabetic
ketoacidosis who do not require dextrose initially, and children with severe
metabolic derangements where rapid correction will lead to severe complications.
The fluid rate is determined by the estimated fluid deficit, ongoing losses, and
maintenance fluid requirements ( Fig. 22.3 ). Usually, 50% of the child’s fluid
deficit is given over the first 8 hours in addition to one-third of the daily
maintenance fluid requirements. In hypertonic states, after initial stabilization
with isotonic fluids, the replacement solution is given more slowly to allow
equilibration across the blood–brain barrier (see Chapter 100 Renal and
Electrolyte Emergencies ).
Parenteral rehydration via an IV catheter has been used extensively. The
advantages of IV rehydration are numerous including familiarity with the
procedure, widespread acceptance, and direct vascular access to rehydrate a
patient. There are disadvantages associated with IV catheter use, primarily
difficulty in obtaining access in dehydrated children, particularly those younger
than 3 years, pain associated with placement, and the time and resources required
for placement. Subcutaneous rehydration is a method to deliver fluids
parenterally that was common prior to the widespread use of IV catheters. There
is evidence that using human recombinate hyaluronidase (Hylenex) with a
subcutaneous catheter may be an alternative for mild and moderately dehydrated
children who have failed ORT. It is a method that can also be used as a bridge to
getting IV access in severely dehydrated patients however intraosseous access
should also be considered in the severely ill. Hyaluronidase temporarily dissolves
hyaluronic acid and allows fluid to be administered subcutaneously, which is
subsequently absorbed into the vascular system. Advantages of subcutaneous
fluid administration include ease of placement and decreased pain with insertion.
More research in this new modality is required.
