Management of dehydration

Management of dehydration
Management of dehydration
	A person begins drinking oral rehydration solution (ORS) to prevent dehydration and electrolyte loss. This strategy adds modest amounts of sugar and salt to water. There are prepackaged ORS products available. A person can also use home products such as lightly salted soup or lightly salted water from the cooking of rice.
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Last updated September 28, 2024

Dehydration can occur as a result of diarrhea, vomiting, water scarcity, physical activity, and alcohol consumption. Management of dehydration (or rehydration) seeks to reverse dehydration by replenishing the lost water and electrolytes. Water and electrolytes can be given through a number of routes, including oral, intravenous, and rectal.

In diarrhea

When diarrhea occurs, hydration should increase to prevent dehydration.

The WHO recommends using the oral rehydration solution (ORS) if available, but homemade solutions such as salted rice water, salted yogurt drinks, vegetable and chicken soups with salt can also be given. The goal is to provide both water and salt: drinks can be mixed with half a teaspoon to full teaspoon of salt (from one-and-a-half to three grams) added per liter. Clean plain water can also be one of several fluids given.^[1]

ORS is mass-produced as commercial solutions such as Pedialyte, and relief agencies such as UNICEF widely distribute packets of pre-mixed salts and sugar. The World Health Organization (WHO) describes a homemade ORS with one liter water with one teaspoon salt (or 3 grams) and six teaspoons sugar (or 18 grams) added^[1] (approximately the "taste of tears").^[3] However, the WHO does not generally recommend homemade solutions as how to make them is easily forgotten.^[1] Rehydration Project recommends adding the same amount of sugar but only one-half a teaspoon of salt, stating that this more dilute approach is less risky with very little loss of effectiveness.^[4] Both agree that drinks with too much sugar or salt can make dehydration worse.^[1]^[4]

Medium dehydration

In what the World Health Organization (WHO) terms "some dehydration," the child or adult is restless and irritable, is thirsty, and will drink eagerly.^[1]

WHO recommends that if there is vomiting, don't stop, but do pause for 5–10 minutes and then restart at a slower pace. (Vomiting seldom prevents successful rehydration since most of the fluid is still absorbed. Plus, vomiting usually stops after the first one to four hours of rehydration.) With the older WHO solution, also give some clean water during rehydration. With the newer reduced-osmolarity, more dilute solution, this is not necessary.^[1]

Begin to offer food after the initial four-hour rehydration period with children and adults. With infants, continue to breastfeed even during rehydration as long as the infant will breastfeed. Begin zinc supplementation after initial four-hour rehydration to reduce severity and duration of episode. If available, zinc supplementation should be continued for 10 to 14 days. During the initial period of rehydration, the patient should be re-assessed at least every four hours.^[1]

The family should be provided with at least two days worth of ORS packets. WHO recommends, in addition to infants continued to be breastfed, that children older than six months be given some food before being sent home, which helps to emphasize to parents the importance of continuing to feed the child during diarrhea.^[1]

Severe dehydration

In severe dehydration, the person may be lethargic or unconscious, drinks poorly, or may not be able to drink.^[1]

In malnourished persons, rehydration should be performed relatively slowly by drinking or by nasogastric tube unless the person is also experiencing shock, in which case it should be performed quicker. Malnourished patients should receive a modified ORS which has less sodium, more potassium, and modestly more sugar. For patients not malnourished, rehydration should be performed relatively rapidly by means of intravenous (IV) solution. For infants under one year of age, WHO recommends giving, within the first hour, 30 milliliters of Ringer's Lactate Solution for each kilogram of body weight, and then, within the next five hours, 70 milliliters of Ringer's Lactate per kilogram of body weight. For children over one year and for adults, WHO recommends, within the first half hour, 30 milliliters of Ringer's Lactate per kilogram of body weight, and then, within the next two-and-a-half hours, 70 milliliters per kilogram. For example, if a child weighs fifteen kilograms (who is obviously over one year of age), he or she should receive 450 ml of Ringer's Lactate Solution within the first half hour, and then 1,050 ml of Ringer's Lactate within the next two-and-a-half hours. Patients who can drink, even poorly, should be given Oral Rehydration Solution (ORS) by mouth until the IV drip is running. In addition, all patients should start to receive some ORS when they are able to drink without difficulty, which is usually three to four hours for infants and one to two hours for older persons. ORS provides additional base and potassium which may not be adequately supplied by IV fluid. Ideally, patients should be reassessed every fifteen to thirty minutes until a strong radial pulse is present, and thereafter, assessed at least hourly to confirm that hydration is improving. Hopefully, patients will graduate to the medium dehydration or "some" dehydration category and receive continued treatment as above.^[1]

Inadequate replacement of potassium losses during diarrhea can lead to potassium depletion and hypokalaemia (low serum potassium) especially in children with malnutrition. This can potentially cause muscle weakness, impaired kidney function, and cardiac arrhythmia. Hypokalaemia is worsened when base is given to treat acidosis without simultaneously providing potassium, as happens in standard IVs including Ringer's Lactate Solution. ORS can help correct potassium deficit, as can giving foods rich in potassium during diarrhea and after it has stopped.^[1]

As in above sections, for all patients, supplemental zinc can help to reduce the severity and duration of diarrhea. In addition, supplemental vitamin A is often recommended, particular for children who have diarrhea during or shortly after measles, or in children who are already malnourished, although ideally for all patients.^[1]

In children

WHO recommends a child with diarrhea continue to be fed. Continued feeding speeds the recovery of normal intestinal function. In contrast, children whose food is restricted, have diarrhea of longer duration and recover intestinal function more slowly. A child should also continue to be breastfed.^[1] And in the example of the treatment of cholera, CDC also recommends that persons continue to eat and children continue to be breastfed.^[2]

If IV treatment is not available at the facility, WHO recommends sending the child to a nearby facility if it can be reached within 30 minutes and providing the mother with ORS to administer to the child during the trip. If another facility is not available, ORS can be given by mouth as the child can drink and/or by nasogastric tube.^[1]

WHO states that knowing the levels of serum electrolytes rarely changes the recommended treatment of children with diarrhea and dehydration, and furthermore, that these values are often misinterpreted. Most electrolyte imbalances are adequately treated by ORS. For example, a child who has been given an excess of sugar or salt like that which is in commercial soft drinks, sugared fruit drinks, or over-concentrated infant formula, may develop hypernatraemic dehydration. This occurs when these over-concentrated solutions sit in the gut and draw water from the rest of the body, and the reduced fluids in the body's tissues then have a higher proportion of salt to fluid. Children with serum sodium greater 150 mmol/liter have thirst out of proportion to other signs of dehydration. There is a danger of convulsions which usually occur when serum sodium concentrations are greater than 165 mmol/liter. Less commonly, convulsions can also occur when serum sodium is less than 130 mmol/liter. Treatment with ORS can usually bring serum sodium concentrations back to normal within twenty-four hours.^[1]

Children with diarrhea who drink mostly water or overly dilute drinks with too little salt may develop hyponatraemia (serum sodium less than 130 mmol/liter). This is especially common in children with shigellosis and in severely malnourished children with edema. ORS is safe and effective for nearly all children with hyponatraemia, an exception being children with edema for whom ORS provides too much sodium.^[1]

Contraindications

Drinks especially high in simple sugars, such as soft drinks and fruit juices, are not recommended as the main source of hydration, or for children under 5 years of age as they may increase diarrhea.^[5] Plain water may be used if more specific and effective ORT preparations of hydrational fluids are unavailable or are not palatable.^[5] A nasogastric tube can be used in young children to administer fluids if warranted.^[6]

Preparation

Appropriate amounts of supplemental zinc and potassium should be added if available. But the availability of these should not delay rehydration. As WHO points out, the most important thing is to begin preventing dehydration as early as possible.^[1] In another example of prompt ORS hopefully preventing dehydration, CDC recommends for the treatment of cholera continuing to give Oral Rehydration Solution during travel to medical treatment.^[2]

The approximate amount of oral rehydration solution (ORS)^[7] to be given over four hours can be obtained by multiplying 75 milliliters of solution by the child's weight in kilograms. For example, a child who weighs 15 kilograms should be given approximately 1,125 ml of ORS over four hours. Of course, the exact amount depends on how dehydrated the child is. And in general, let the person drink as much as they wish. The person can drink a little faster at first and then relatively slowly. For babies, a dropper or syringe without the needle may be used. Toddlers under two should be offered a teaspoonful every 1–2 minutes. Older children and adults may take frequent sips.^[1]

Procedure

Vomiting often occurs during the first hour or two of treatment with ORS, especially if a child drinks the solution too quickly, but this seldom prevents successful rehydration since most of the fluid is still absorbed. WHO recommends that if a child vomits, to wait five or ten minutes and then start to give the solution again more slowly.^[1]

Related Research Articles

Cholera is an infection of the small intestine by some strains of the bacterium Vibrio cholerae. Symptoms may range from none, to mild, to severe. The classic symptom is large amounts of watery diarrhea lasting a few days. Vomiting and muscle cramps may also occur. Diarrhea can be so severe that it leads within hours to severe dehydration and electrolyte imbalance. This may result in sunken eyes, cold skin, decreased skin elasticity, and wrinkling of the hands and feet. Dehydration can cause the skin to turn bluish. Symptoms start two hours to five days after exposure.

Diarrhea, also spelled diarrhoea or diarrhœa, is the condition of having at least three loose, liquid, or watery bowel movements in a day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin with loss of the normal stretchiness of the skin and irritable behaviour. This can progress to decreased urination, loss of skin color, a fast heart rate, and a decrease in responsiveness as it becomes more severe. Loose but non-watery stools in babies who are exclusively breastfed, however, are normal.

<span class="mw-page-title-main">Diabetic ketoacidosis</span> Medical condition

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. A person's breath may develop a specific "fruity" smell. The onset of symptoms is usually rapid. People without a previous diagnosis of diabetes may develop DKA as the first obvious symptom.

In physiology, dehydration is a lack of total body water, with an accompanying disruption of metabolic processes. It occurs when free water loss exceeds free water intake, usually due to exercise, disease, or high environmental temperature. Mild dehydration can also be caused by immersion diuresis, which may increase risk of decompression sickness in divers.

Hyponatremia or hyponatraemia is a low concentration of sodium in the blood. It is generally defined as a sodium concentration of less than 135 mmol/L (135 mEq/L), with severe hyponatremia being below 120 mEq/L. Symptoms can be absent, mild or severe. Mild symptoms include a decreased ability to think, headaches, nausea, and poor balance. Severe symptoms include confusion, seizures, and coma; death can ensue.

Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is a deficiency, excess, or imbalance of energy, protein and other nutrients which adversely affects the body's tissues and form.

Fluid replacement or fluid resuscitation is the medical practice of replenishing bodily fluid lost through sweating, bleeding, fluid shifts or other pathologic processes. Fluids can be replaced with oral rehydration therapy (drinking), intravenous therapy, rectally such as with a Murphy drip, or by hypodermoclysis, the direct injection of fluid into the subcutaneous tissue. Fluids administered by the oral and hypodermic routes are absorbed more slowly than those given intravenously.

Gastroenteritis, also known as infectious diarrhea, is an inflammation of the gastrointestinal tract including the stomach and intestine. Symptoms may include diarrhea, vomiting, and abdominal pain. Fever, lack of energy, and dehydration may also occur. This typically lasts less than two weeks. Although it is not related to influenza, in the U.S. and U.K., it is sometimes called the "stomach flu".

Electrolyte imbalance, or water-electrolyte imbalance, is an abnormality in the concentration of electrolytes in the body. Electrolytes play a vital role in maintaining homeostasis in the body. They help to regulate heart and neurological function, fluid balance, oxygen delivery, acid–base balance and much more. Electrolyte imbalances can develop by consuming too little or too much electrolyte as well as excreting too little or too much electrolyte. Examples of electrolytes include calcium, chloride, magnesium, phosphate, potassium, and sodium.

Hyperchloremia is an electrolyte disturbance in which there is an elevated level of chloride ions in the blood. The normal serum range for chloride is 96 to 106 mEq/L, therefore chloride levels at or above 110 mEq/L usually indicate kidney dysfunction as it is a regulator of chloride concentration. As of now there are no specific symptoms of hyperchloremia; however, it can be influenced by multiple abnormalities that cause a loss of electrolyte-free fluid, loss of hypotonic fluid, or increased administration of sodium chloride. These abnormalities are caused by diarrhea, vomiting, increased sodium chloride intake, renal dysfunction, diuretic use, and diabetes. Hyperchloremia should not be mistaken for hyperchloremic metabolic acidosis as hyperchloremic metabolic acidosis is characterized by two major changes: a decrease in blood pH and bicarbonate levels, as well as an increase in blood chloride levels. Instead those with hyperchloremic metabolic acidosis are usually predisposed to hyperchloremia.

Saline is a mixture of sodium chloride (salt) and water. It has a number of uses in medicine including cleaning wounds, removal and storage of contact lenses, and help with dry eyes. By injection into a vein, it is used to treat hypovolemia such as that from gastroenteritis and diabetic ketoacidosis. Large amounts may result in fluid overload, swelling, acidosis, and high blood sodium. In those with long-standing low blood sodium, excessive use may result in osmotic demyelination syndrome.

Oral rehydration therapy (ORT) is a type of fluid replacement used to prevent and treat dehydration, especially due to diarrhea. It involves drinking water with modest amounts of sugar and salts, specifically sodium and potassium. Oral rehydration therapy can also be given by a nasogastric tube. Therapy can include the use of zinc supplements to reduce the duration of diarrhea in infants and children under the age of 5. Use of oral rehydration therapy has been estimated to decrease the risk of death from diarrhea by up to 93%.

<span class="mw-page-title-main">Ringer's lactate solution</span> Fluid used for resuscitation after blood loss

Ringer's lactate solution (RL), also known as sodium lactate solution,Lactated Ringer's (LR), and Hartmann's solution, is a mixture of sodium chloride, sodium lactate, potassium chloride, and calcium chloride in water. It is used for replacing fluids and electrolytes in those who have low blood volume or low blood pressure. It may also be used to treat metabolic acidosis and to wash the eye following a chemical burn. It is given by intravenous infusion or applied to the affected area.

Fluid balance is an aspect of the homeostasis of organisms in which the amount of water in the organism needs to be controlled, via osmoregulation and behavior, such that the concentrations of electrolytes in the various body fluids are kept within healthy ranges. The core principle of fluid balance is that the amount of water lost from the body must equal the amount of water taken in; for example, in humans, the output must equal the input. Euvolemia is the state of normal body fluid volume, including blood volume, interstitial fluid volume, and intracellular fluid volume; hypovolemia and hypervolemia are imbalances. Water is necessary for all life on Earth. Humans can survive for 4 to 6 weeks without food but only for a few days without water.

The BRAT diet is a restrictive diet that was once recommended for people, particularly children, with gastrointestinal distress like vomiting, diarrhea, or gastroenteritis. Evidence, however, does not support a benefit. As of the 21st century, it is no longer recommended, as it is unnecessarily restrictive. The diet was first discussed in 1926.

Dilip Mahalanabis was an Indian paediatrician known for pioneering the use of oral rehydration therapy to treat diarrhoeal diseases. Mahalanabis had begun researching oral rehydration therapy in 1966 as a research investigator for the Johns Hopkins University International Center for Medical Research and Training in Calcutta, India. During the Bangladeshi war for independence, he led the effort by the Johns Hopkins Center that demonstrated the dramatic life-saving effectiveness of oral rehydration therapy when cholera broke out in 1971 among refugees from East Bengal who had sought asylum in West Bengal. The simple, inexpensive Oral Rehydration Solution (ORS) gained acceptance, and was later hailed as one of the most important medical advances of the 20th century.

Pedialyte is an oral electrolyte solution manufactured by Abbott Laboratories and marketed for use in children. It was invented by Dr. Gary Cohen of Swampscott, Massachusetts.

Hemendra Nath Chatterjee was an Indian scientist from West Bengal known for the earliest publication of a formula for Orally Rehydrated Saline (ORS) for diarrhea management in 1952. Although his results were published in The Lancet, they didn't receive much recognition from Western scientists until later. Some argue this was for cultural reasons as his treatment protocol included traditional medicine, and also because the scientific underpinnings of ORS weren't well understood. However, some argue he shouldn't be given credit for its invention at all, as some of his results contradict the results of modern studies, and argue his success was likely due to using only mildly ill patients.

David R. Nalin is an American physiologist, and Pollin Prize for Pediatric Research and Prince Mahidol Award, a.k.a. Mahidol Medal winner. Nalin had the key insight that oral rehydration therapy (ORT) would work if the volume of solution patients drank matched the volume of their fluid losses, and that this would drastically reduce or completely replace the only current treatment for cholera, intravenous therapy. Nalin led the trials that first demonstrated ORT works, both in cholera patients, and more significantly, also in other dehydrating diarrhea illnesses. Nalin's discoveries have been estimated to have saved over 50 million lives worldwide.

<span class="mw-page-title-main">Intravenous sodium bicarbonate</span> Pharmaceutical drug

Intravenous sodium bicarbonate, also known as sodium hydrogen carbonate, is a medication primarily used to treat severe metabolic acidosis. For this purpose it is generally only used when the pH is less than 7.1 and when the underlying cause is either diarrhea, vomiting, or the kidneys. Other uses include high blood potassium, tricyclic antidepressant overdose, and cocaine toxicity as well as a number of other poisonings. It is given by injection into a vein.

References

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 The Treatment Of Diarrhea, A manual for physicians and other senior health workers, World Health Organization, 2005. See "4.2 Treatment Plan A: home therapy to prevent dehydration and malnutrition," "4.3 Treatment Plan B: oral rehydration therapy for children with some dehydration," and "4.4 Treatment Plan C: for patients with severe dehydration" on pages 8 to 16 (12 -20 in PDF). See also "8. MANAGEMENT OF DIARRHOEA WITH SEVERE MALNUTRITION" on pages 22-24 (26-30 in PDF) and "ANNEX 2: ORAL AND INTRAVENOUS REHYDRATION SOLUTIONS" on pages 33-37 (37-41 in PDF).
1 2 3 Community Health Worker Training Materials for Cholera Prevention and Control Archived 2011-10-20 at the Wayback Machine , CDC, slides at back are dated 11/17/2010. Page 7 states " . . . Continue to breastfeed your baby if the baby has watery diarrhea, even when traveling to get treatment. Adults and older children should continue to eat frequently."
↑ A GUIDE ON SAFE FOOD FOR TRAVELLERS, WELCOME TO SOUTH AFRICA, HOST TO THE 2010 FIFA WORLD CUP (bottom left of page 1).
1 2 Rehydration Project, http://rehydrate.org/Homemade Oral Rehydration Solution Recipe.
1 2 "Management of acute diarrhoea and vomiting due to gastoenteritis in children under 5". National Institute of Clinical Excellence. April 2009.
↑ Webb, A; Starr, M (Apr 2005). "Acute gastroenteritis in children". Australian Family Physician. 34 (4): 227–31. PMID 15861741.
↑ Rosenfeldt, V.; Michaelsen, K. F.; Jakobsen, M.; Larsen, C. N.; Møller, P. L.; Pedersen, P.; Tvede, M.; Weyrehter, H.; Valerius, N. H.; Paerregaard, A. (2002). "Effect of probiotic Lactobacillus strains in young children hospitalized with acute diarrhea". The Pediatric Infectious Disease Journal. 21 (5): 411–416. doi:10.1097/00006454-200205000-00012. PMID 12150178. S2CID 24879134.

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[WHOtreatmentdiarrhoea2005-1] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 The Treatment Of Diarrhea, A manual for physicians and other senior health workers, World Health Organization, 2005. See "4.2 Treatment Plan A: home therapy to prevent dehydration and malnutrition," "4.3 Treatment Plan B: oral rehydration therapy for children with some dehydration," and "4.4 Treatment Plan C: for patients with severe dehydration" on pages 8 to 16 (12 -20 in PDF). See also "8. MANAGEMENT OF DIARRHOEA WITH SEVERE MALNUTRITION" on pages 22-24 (26-30 in PDF) and "ANNEX 2: ORAL AND INTRAVENOUS REHYDRATION SOLUTIONS" on pages 33-37 (37-41 in PDF).

[CDCmanualCholera-2] 1 2 3 Community Health Worker Training Materials for Cholera Prevention and Control Archived 2011-10-20 at the Wayback Machine , CDC, slides at back are dated 11/17/2010. Page 7 states " . . . Continue to breastfeed your baby if the baby has watery diarrhea, even when traveling to get treatment. Adults and older children should continue to eat frequently."

[2010WorldCupTravellersGuide-3] A GUIDE ON SAFE FOOD FOR TRAVELLERS, WELCOME TO SOUTH AFRICA, HOST TO THE 2010 FIFA WORLD CUP (bottom left of page 1).

[RehydrationProject-4] 1 2 Rehydration Project, http://rehydrate.org/Homemade Oral Rehydration Solution Recipe.

[NICE2009-5] 1 2 "Management of acute diarrhoea and vomiting due to gastoenteritis in children under 5". National Institute of Clinical Excellence. April 2009.

[Webb2005-6] Webb, A; Starr, M (Apr 2005). "Acute gastroenteritis in children". Australian Family Physician. 34 (4): 227–31. PMID 15861741.

[7] Rosenfeldt, V.; Michaelsen, K. F.; Jakobsen, M.; Larsen, C. N.; Møller, P. L.; Pedersen, P.; Tvede, M.; Weyrehter, H.; Valerius, N. H.; Paerregaard, A. (2002). "Effect of probiotic Lactobacillus strains in young children hospitalized with acute diarrhea". The Pediatric Infectious Disease Journal. 21 (5): 411–416. doi:10.1097/00006454-200205000-00012. PMID 12150178. S2CID 24879134.

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