Pediatric Dehydration
                           =====================

þ Dehydration Assessment
  (basic)

                Mild            Moderate        Severe
                <5%             5-10%           >10%
------------------------------------------------------------------------
Mental Status   alert, active   quiet, tired    lethargic
HR              +/-             ++              ++++
Mucous Membs.   nl.             dry             parched
------------------------------------------------------------------------

þ Isotonic dehydration:
 losses found to be about 80 mEq/L of Na+ and 80 mEq/L of K+ [###].

þ Criteria for IV rehydration
 - per Children's (conservative):  pH <7.13 on venous gas, or ketones in urine
 - per Bruce Rosenthal, _lots_ of kids have ketones in urine from starvation
   but don't necessarily need IV rehydration

þ IV rehydration protocols:
 - aggressive protocol:  Ringer's 100cc/kg over 4 hours [###].
 - LR bolus then D5/.6NS at 10cc/kg/hr.
 - D5LR + 15 mEq/L KCl:  20cc/kg over 1 hr, then 10cc/kg/hr for 3 hrs [###].
 - LR or NS 20cc/kg bolus, then check dextrostick, then D5-1/2NS + 20 mEq
   KCl/L @ 10cc/kg/hr for 3 hours [###].

þ Criteria for admission for dehydration:
 - severe dehydration
 - moderate dehydration:
  + Na+ < 125 or > 150
  + CO2 =< 10, or pH < 7.25
  + failed outpatient Rx

þ Na+:
 - need to pay attention if <130 or > 150.  In U.S., 95% will be isotonic.

þ Multifactorial acidosis from dehydration:
 - direct loss from diarrhea
 - decreased GFR with decreased acid excretion
 - also from fermentation by bacteria in the gut.

þ Glucose in dehydration:
 - 15% of those selected for IV rehydration will have low glucose, mostly
   patients < 24 months [###].
 - glucose is needed regardless of initial glucose value because a small
   percentage of patients with an initially normal glucose will become
   hypoglycemic during rehydration [###].
 - how much?  0.5 g/kg/hr will increase glucose in a few patients, but
   doesn't cause a significant osmotic diuresis [###].

þ Oral fluids and feeding after diarrhea:
 - Current recommendation is to continue breast milk or formula; lactase
   deficiency does occur but isn't clinically signficant.  No need for clear
   fluids.  Lactose-free fluids only needed for severe dehydration.  [###]