Dehydration pathophysiologic basis

for treatment.
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Dr Shankargouda .S. N.
MD Pediatrics.
Shankargouda child icu and hospital.
Near water tank , Madhav peth Miraj 416410.
Water makes about 60 percentage of body weight is water.
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 Na Cl 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.
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
aou 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.
1)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 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.
Do not use any glucose containing fluid at this stage(unless ofcourse if there is
associated hypoglycemia)
Glucose has a osmotic effect to start with but soon utilized- the associated water
causes hyponatremia.
Oral rehydration solution though must have glucose as this a driving force to absorb
electrolytes and water.
If the child is in a state to be able to drink than oral rehydration solution is the
treatment of choice.
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.
4)treat the cause.
Technical issues.
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.
The shock stage can compromise the peripheral circulation hence proper
monitoring of the intravenous catheter site is necessary .
Look for signs of swelling , redness , tightness of the splint and capillary filling distal
to the catheter.
Acess of the vein on the dorsum of hand is preferred, do not use the ante cubital
fossa acess .
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.
Do nots.
Do not use hypotonic solutions.
Does.
Safe venous acess is necessary.
Moniter the patient as well as the catheter site regularly.
Ask for help if necessary in time.

Dr Shankargouda S N MD PEDIATRICS

Mobile . 09422041034