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Reg. No. GR/RNP/KLP 136/12-14 Posted in Kolhapur RMS

Pathophysiologic basis for Treatment
Dr. Shankargouda S. N.
M.D. Pediatrics

Shankargouda Child ICU and Hospital

Near Water Tank , Madhav Peth,
Miraj 416410.

Mobile . 09422041034
Water makes about 60 percentage of body weight.
What characteristics of water make it such a ideal medium for body functions ?
) Water is a good conductor of heat.
) Water has a high surface tension hence it allows it to function as a good solute.
) Water has a high dielectric constant hence it allows conduction of current.
Water molecule has a net charge on it hence the molecules like NaCl dissociate into ions do not
tend to reassociate again. These ions are essential for the proper electrogenicity of the cell and
form a major basis for cell function, cell life and life as whole. Hence water is able to perform
all the essential functions for life.
Plasma is 5 % of body weight. Interstitial fluid is 15 % of body weight. Intracellular fluid is
40 % body weight.
Water as a constituent of this body fluids helps in either dissolving the solvents, heat transfer
or as a base for electric activity. In plasma and interstitial fluid it helps to maintain a proper
viscosity of the blood.



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As a major bulk of blood it helps to fill the veins and helps the blood fill the heart properly so
that the heart can effectively contract on the blood volume and generate pressure for the blood
to flow ahead. This blood flow has characteristic pattern in the large and small vessels.
The blood with high hematocrit causes increase in viscosity.But in smaller vessels the
increase in the hematocrit has little effect on the viscosity due to the pattern of flow in the
small vessels. Hence a small change in hematocrit caused by dehydration does not cause the
blood to be thick I the small vessels. This is a major mechanism to protect the flow of blood in
the small vessels and hence the function of endothelium and the organs.
Extracellular fluid has sodium as the major cation and chloride as the anion. While in the
intracellular fluid potassium is a major cation and phosphates/others are the mahor anions.
The proper distribution of these electrolytes across the cell membrane is essential for forming
the resting membrane potential and the generation of action potential a activity essential for
execution of its function in the organ.
So not only the proper amount of water and the electrolytes but the proper distribution in
various compartments is essential for survival.
Having understood the essence of the proper fluid electrolyte balance let us turn attention to
the pathologic states.
Dehydration is caused usually by loss of total body water and electrolytess.The effect
depends on the the percent loss of water and electrolytes and the speed with which it occurs.
Thee effect also depends on the compartment (intravascular , interstitial, intracellular )of the
loss. The comparative loss of sodium and water decides the concentration of sodium and
hence the osmotic effects are added on top of the fluid water deficit.
Serum sodium is usually 135-145 meq/liter. The sodium in the interstitial fluid is practically
equal to the plama concentration. The intracellular sodium concentration is about 15 meq/l
Amount of sodium in the intravascular fluid by its osmotic effect holds water along with it and
determines the total blood volume- the total blood volume compared to the volume of the
vascular compartment determines the fullness of the vascular system and hence determines
the amount of blood pumped by the heart.

Understanding the effect of fluid loss :

Acute gastroenteritis- vomiting and loose stools causes the loss of electrolytes and water.
With vomiting of gastric contents there is loss of acidic content (causing alkalosis), and
vomiting of the intestinal contents causes loss of alkali(causing acidosis).
The loss of sodium and electrolytes reduces bold volume hence the necessary fullness of the
vascular system is reduced and the effective pumping of the heart does not occur. Reduced

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blood flow reduces the hydrostatic pressure at the capillaries and force necessary to push the
intravascular resource rich fluid from the intravascular to interstitial fluid is reduced. Reneval
of the interstitial fluid with necessary elements is hampered. Build up of cellular waste is
increased. Hence the cell function suffers. The reduced blood flow causes reduced oxygen
flow to the cells and the cells undergo a anaerobic metabolism causing production of lactic
acids causing acidosis.
Reduction in the intravascular volume causes signs like- tachycardia, reduced warmth of
limbs, reduced urine output- later drop in blood pressure. Acidosis and shock cause the
consciousness to drop. Reduced turgor of the interstial compartment due to loss of interstiatial
water and electrolytes cause sings as- reduced skin elasticity , sunken eyeballs and sunken
anterior fontanalle. The sunken fontanalle is due to reduced interstitial volume of the brain and
skin, and reduced venous filling.
Treatment is directed at all the above issues.

Step 1 : Evaluation of the degree of dehydration.

Actually the major intention is to see that the circulatory disturbances are in proportion to the
degree of dehydration by comparing the interstitial signs with the circulatory signs.
Also if the there is reduced consciousness than see if it is in proportion to the degree of
dehydration. If there is a discrepancy in the above, than we have to evaluate and treat
associated issues like hypoglycemia, water imbalance(hyponatremia, hypernatremia

Step 2 : Building the intravascular volume.


If there are signs of circulatory insufficiency 10-20 ml. of normal saline or ringer lactate
pushed over 5 to 20 minutes depending on severity.
B Do not use any glucose containing fluid at this stage(unless ofcourse if there is associated
B Glucose has a osmotic effect to start with but soon utilized- the associated water causes
B Oral rehydration solution though must have glucose as this a driving force to absorb
electrolytes and water.
B If the child is in a state to be able to drink than oral rehydration solution is the treatment of
As there is loss of both fluid and electrolytes oral ly given fluid should contain electrolytes in
proper proportion.

Step 3 : Correcting the deficit of water and electrolytes, until the signs of interstitial fluid loss
are resolved.
The amount and duration depend on the degree of loss and ongoing losses through vomiting
and stools.
The deficit can be corrected over 24-48 hrs.
Monitoring of the circulatory signs and the interstitial signs regularly is essential.

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Step 4 : Treat the cause. Technical issues.

B It may be difficult to obtain a intravenous access in cases of shock go in for bone marrow
acess in such cases. Try and get venous acess as soon as possible and remove the bone
marrow needle.
B The shock stage can compromise the peripheral circulation hence proper monitoring of
the intravenous catheter site is necessary.
B Look for signs of swelling , redness , tightness of the splint and capillary filling distal to
the catheter.
B Acess of the vein on the dorsum of hand is preferred, do not use the ante cubital fossa
B Using the saphenous acess is mor safe than the ante cubitol fossa if required(as there are
no neurovascular structures around).
The disturbances of water balance are not covered in this discussion.
I have tried to cover the elements to understand the scientific approach to the de hydrated
child. I realize that this may not be sufficient considering the spectrum of the problem. Will be
happy to answer any questions arising or suggestion for correction.

Donts.... Do not use hypotonic solutions.


Safe venous acess is necessary.

Moniter the patient as well as the catheter site regularly.
Ask for help if necessary in time.