Neobook — clinical reference

Methods of rehydration
Deciding on appropriate fluid regimen
Severe (10%) dehydration - initial rehydration
Some (5%) dehydration - initial rehydration

Fluid therapy is the mainstay of the management of acute gastroenteritis

Methods of rehydration

Whilst being assessed/triaged in the emergency centre (EC) the child should be given 10ml of ORS (by syringe, teaspoon or cup) every 5‐10 minutes and gradually increase the amount as tolerated, in the ORT corner.

Children should only be admitted if they have failed an adequate observed trial of oral rehydration therapy (ORT) in the ORT corner and are ≥5% dehydrated i.e. have “some/moderate” dehydration.

Oral rehydration (“ad lib” ORS) can continue to be given throughout the subsequent admission unless they have shock, depressed level of consciousness or paralytic ileus.

Breast feeding infants should continue to breastfeed.

NASOGASTRIC RE-HYDRATION is the method of choice of initial rehydration in all children with moderate dehydration (5%) and some children with severe dehydration (10%) i.e. those without associated shock (e.g. with malnutrition, not vomiting). A decision will then be made on the rate of rehydration, i.e. whether the rehydration is rapid or slow.

INTRAVENOUS RE-HYDRATION is indicated in the following situations:

circulatory shock
paralytic ileus (abdominal distension, no bowel sounds, severe vomiting)
severe/10% dehydration with profuse diarrhoea and vomiting fluids (an alert thirsty child with severe dehydration does not necessarily need a drip)
depressed level of consciousness or severe hypotonia
vomiting/not tolerating continuous nasogastric ORS
child <3 months with severe dehydration and/or suspected sepsis
Failed nasogastric rehydration (vomiting or not improving)

Deciding on appropriate fluid regimen

Take into account

Degree of dehydration (NB – remember that this is ALWAYS an estimate)
Age
Co‐morbid disease (especially severe acute malnutrition)

in working out:

WHAT fluids to give (e.g. isotonic for shock) and ‐
HOW to give them i.e. route (e.g. nasogastric (NG)), and speed (e.g. Rapid Rehydration).

Shock – SEE SHOCK PROTOCOL

1) Severe (10%) Dehydration – initial rehydration

Initial rehydration over four (4) hours (called RAPID RE-HYDRATION) is indicated in EVERY CASE, EXCEPT in these situations:

CONTRAINDICATIONS TO RAPID RE-HYDRATION

Shock – requires fluid replacement as fast as possible
Severe malnutrition – rehydrate over 24 hours (see 10 Steps protocol)
Cardio‐respiratory co‐morbidity – rehydrate over 24 hours
Neurological co‐morbidity – rehydrate over 24 hours
Suspected hypernatraemia – rehydrate over 24 hours
Small infant under 3 months of age – rehydrate over 24 hours
Child over 5 years of age – rehydrate over 24 hours

If no contraindication to Rapid Rehydration, rehydrate according to the following regimen:

Severe (10%) Dehydration [No contraindication to Rapid Rehydration]
Rapid Rehydration over 4 hours:

½ Darrow’s Dextrose solution IV or oral rehydration solution (e.g. SOROL) NG at 20 ml/kg/hour [This volume is based on a composite of estimated rehydration, maintenance and ongoing loss requirements over the first 4 hours]
Glucose test strip (“dextrostix”)
Blood tests
Nil by mouth for four hours unless breast feeding
Review in two hours (fluid intake, hydration, blood results) and adjust fluids accordingly
After 4 hours, re-assess

NB: If the child is still dehydrated at 4 hours, fluid losses are likely to have been greater than previously assessed, so consider repeating the Rapid Rehydration regimen

If any contraindication to Rapid Rehydration, rehydrate according to the following regimen:

Severe (10%) Dehydration [Child has contraindication to Rapid Rehydration]
Rehydration over 24 hours:

½ Darrow’s Dextrose solution IV or oral rehydration solution (e.g. SOROL) NG: All ages and weights: 10-15 ml/kg/hr (using higher volume if high stool output). [This volume is based on a composite of estimated rehydration, maintenance and ongoing loss requirements over the first 4 hours]
NB: volumes in severe malnutrition are lower (refer to 10 Steps Protocol)
Glucose test strip (“dextrostix”)
Blood tests
Nil by mouth for four hours unless breast feeding
Review in two hours (fluid intake, hydration, blood results) and adjust fluids accordingly
After 4 hours, re-assess

2) Some (5%) Dehydration – initial rehydration

Initial rehydration over four (4) hours (called RAPID RE-HYDRATION) is indicated in EVERY CASE, EXCEPT in these situations:

CONTRAINDICATIONS TO RAPID RE-HYDRATION

Shock – requires fluid replacement as fast as possible
Severe malnutrition – rehydrate over 24 hours (see 10 Steps protocol)
Cardio‐respiratory co‐morbidity – rehydrate over 24 hours
Neurological co‐morbidity – rehydrate over 24 hours
Suspected hypernatraemia – rehydrate over 24 hours
Small infant under 3 months of age – rehydrate over 24 hours
Child over 5 years of age – rehydrate over 24 hour

If no contraindication to Rapid Rehydration, rehydrate according to the following regimen:

Some (5%) Dehydration [No contraindication to Rapid Rehydration]
Rapid Rehydration over 4 hours:

Oral rehydration solution (e.g. SOROL) NG at 15-20 ml/kg/hour (using higher volume if high stool output). [This volume is based on a composite of estimated rehydration, maintenance and ongoing loss requirements over the first 4 hours]
Nil by mouth for four hours unless breast feeding
After 4 hours, re-assess

[Only use IV ½ Darrow’s Dextrose solution for Some (5%) Dehydration if there is severe vomiting and high stool output, or severe electrolyte derangement]

NB: If the child is still dehydrated at 4 hours, fluid losses are likely to have been greater than previously assessed, so consider repeating the Rapid Rehydration regimen

If any contraindication to Rapid Rehydration, rehydrate according to the following regimen:

Some (5%) Dehydration [Child has contraindication to Rapid Rehydration]
Rehydration over 24 hours:

Oral rehydration solution (e.g. SOROL) NG: All ages and weights: 8-10 ml/kg/hr (using higher volume if high stool output). [This volume is based on a composite of estimated rehydration, maintenance and ongoing loss requirements over the first 4 hours]
NB: Volumes in severe malnutrition are lower (refer to 10 Steps Protocol)
Nil by mouth for four hours unless breast feeding
After 4 hours, re-assess

[Only use IV ½ Darrow’s Dextrose solution for Some (5%) Dehydration if there is severe vomiting and high stool output, or severe electrolyte derangement.

This guidance is in part taken from:
WC Gastroenteritis Fam Med & Paeds Protocol 2014
&
New Somerset Hosp Paeds Gastro Protocol 2014