Diagnostic Dilemma

Dehydration correction

A 1-year-old girl presented with fever, vomiting, and diarrhea for one day. She is on bottle feeds for 6 months, is immunized to date. On examination, she was dehydrated, had dry mucosa, delayed skin turgor, tachycardia (pulse = 140/min), hypotension (BP = 70/40 mm of Hg) with poor perfusion. Other systems were normal. She was treated as viral diarrhea with moderate dehydration and received fluids as maintenance + 10% dehydration correction. She was also advised replacement fluids as 50cc ORS for every loose stool passed. After 16 hours, the child had gallop rhythm and puffiness of eyes. The total fluids that she had received were 750cc of 1/3rd Dextrose Normal Saline (DNS) and 1000cc of ORS. The motions that the child had passed in the 16 hours were 11 semi-loose stools. The weight of the child was 5 kg. The child was passing urine every 10 minutes.

Is oral ORS or intravenous fluids, the cause of fluid overload in the child?
Expert Opinion :
The child has received excess fluids almost 4 times the maintenance. Since the child was moderately dehydrated at the time of admission, the child would require fluids of 500cc as maintenance + 500cc of deficit which should be 1000cc over 24 hours of which 500cc would be in 1st 8 hours and the next 500cc would be in the next 16 hours. Thus the IV fluids that the child has received seem to be fine. Regarding the oral fluids, it has been given as a replacement, one has to judge the number of stools a child has been passing and then give fluids accordingly. For semi-loose stools, the amount of fluids lost in stools would be 15-30 ml/stool. For watery stools like cholera amount of fluids lost in stools would be 25-50cc/stool in an infant. Thus, in this child stool fluid loss would be around 15-20 ml/stool as the child has semi-loose stools. This child has 11 semi-loose stools in 16 hours and would require 160-200 ml of fluids for ongoing losses. Instead, the child has received 1000 ml of ORS. Thus fluid replacement for ongoing losses has been excessive.
Thus, in a child with diarrhea, it is necessary to correctly balance fluid and electrolytes, or else one may lead the child from dehydration to congestive cardiac failure.
Answer Discussion :
arun kumar chatterjee
both iv fluid as well as ors. iv fluid 150/kg ;ors 200ml/kg inappropriately large.
4 months ago
Alvin Bowyah
4 months ago

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