Gastroenteritis 7: Fluid Management after the First 4 Hours
Management after the first four hours of hydration
After the first four hours of rehydration, a full reassessment is required. The following principles apply to prescribing fluid regimens in this phase:
Do regular assessment of fluid requirements: If the child is STILL dehydrated, fluid losses are likely to have been greater than previously assessed, so consider repeating the Rapid Rehydration Regimen.
Alternative to repeating rapid rehydration – add (1) + (2) + (3) give over 24hours
- Rehydration volume: Reassess hydration as above:
- Some (5%) dehydration: 50ml/kg above Maintenance Volume spread over 24 hours
- Severe (10%) dehydration: 100ml/kg above Maintenance Volume spread over 24 hours, oral, nasogastric or IV depending on vomiting history, degree of dehydration and willingness to feed, but always moving towards enteral fluids as quickly as possible. (The gut is an effective absorber of fluid. This approach will shorten the time to discharge)
- Maintenance volume: in most cases this can all be given as oral feeds (breast or formula)
0-3 months 150ml/kg/day 3-12months & < 10kg 120ml/kg/d 10 -20kg 1000ml + 50ml/kg over 10kg >20kg 1500ml + 20ml/kg over 20kg Remember: Any child with diarrhoea asking for food or taking oral fluids can be fed
- Ongoing losses: 10‐15ml/kg for each loose stool or vomit, preferably using oral rehydration fluid orally. (This volume is a WHO standard)
Do regular reassessments of clinical status, hydration and any acute complications
Clinical reassessments are required at least every four hours in the first 24 hours in hospital. Less frequent assessment is required as diarrhoea and hydration improve. The hydration check form or continuous assessment form can be useful for these assessments. Wherever possible, reduce IV and nasogastric fluids and increase oral fluids.
- Assess hydration in relation to fluids given
- Assess stool output (consistency, frequency)
- Assess vomiting (amount, frequency, content)
- Assess oral intake (amount, attitude)
- Assess complications and co‐morbidities
- Re‐write fluid and feed regimens in the light of this information
Most children do not require repeated blood tests (the kidneys, once perfused well, are very good at retaining ions and correcting acid‐base derangements).
Call senior opinion under the following circumstances:
- Recurrence of shock
- Severe dehydration: No improvement of hydration status despite high fluid intake
- Repeated deterioration in hydration status despite increasing fluid intake
- Any other deterioration or lack of improvement (e.g. lethargy, respiratory distress)
Ongoing dehydrating diarrhoea
If after 48‐72 hours of admission (2 full nights) there is no clear improvement, further testing and feed manipulation may be required for possible lactose intolerance or systemic disease.
Use the protocol for ongoing diarrhoea and get senior advice.
This guidance is in part taken from:
WC Gastroenteritis Fam Med & Paeds Protocol 2014
&
New Somerset Hosp Paeds Gastro Protocol 2014