Hypernatremic Dehydration

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Hypernatremic Dehydration

• Dr Rajesh
• 05/12/07

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Hypenatremic Dehydration

• 10 DAYS fch, HOME DELIVERY, ADMITTED ON DAY 10,
  POOR feeding, lethargy, FTT wt 1695 grams
• Sugar 61, Na 178, K4.7.
• On day 2 Na 163. K 4.7
• Day 4 Na 137. K 5.9. Wt at discahrge 1920
  grams

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• 6 months FCH
• H/O loose stool for 4 days, fever and seizure one
  episode
• At admission febrile, having uprolling of eye
  balls, given midazolam and Fosolin
• Was in shock, 120 ml RL given, 60 ml again given

4

• ABG Na gt180, BE -22, pH 7.27
• ½ DNS 100 ml 3 hly started
• Na after 8 hours 209, Iso P 100 ml 3 hrly
• after 16 hours 193,
• At 30 hours 146, At 54 hrs 149
• Had two episodes of seizures
• Now better Day 4 of admission

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Mistakes

• RL was used instead of NS
• Iso P was used after 12 hours

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Neonatal Hypernatremic Dehydration

• 9 days, exclusively breast fed baby, LSCS
• Admitted on day 9 with poor feeding, lethargy and
  sudden wt loss
• EP 50 ml 6 hourly and T/F 20 ml 2 hourly (
  formula) started
• Serum NA 191, Na 4.8

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• Had seizure after 22 hours, rt focal seizuew,
  again had seizure after 34 hours of admission ,
  USG cranium mild cerebral edema.
• Serum Na 24 hrs later 171
• On third day Na 144
• Baby discharged after 5 days of hospital stay
• Follow up baby was normal.

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Mistakes

• Higher fluid was used
• Iso P was used

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Importance of hypernatremic dehydration

• Hypernatraemic dehydration is a potentially
  lethal condition and is associated with cerebral
  oedema, intracranial haemorrhage, hydrocephalus
  and gangrene

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IJPYear 2006    Volume 73    Issue 1   
Page 39-41 Dehydration and hypernatremia in
breast-fed term healthy neonatesBhat Swarna
Rekha, Lewis Patricia, David Angela, Liza Sr.
Maria

• Objective The aim of the study was to determine
  the incidence of significant weight loss,
  dehydration, hypernatremia and hyperbilirubinemia
  in exclusively breast-fed term healthy neonates
  and compare the incidence of these problems in
  the warm and cool months.
• Methods During the study period 496 neonates
  were recruited.
• Results 157 neonates (31.6) had significant
  weight loss (gt 10 cumulative weight loss or per
  day weight loss gt 5). Clinical dehydration was
  present in 2.2 of neonates. Of these 157
  neonates, 31.8 had hypernatremia and 28 had
  hyperbilirubinemia.
• Conclusion The incidence of the above mentioned
  problems were higher in the warm months but the
  difference was not statistically significant.

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Hypernatraemic dehydration in newborn infantsIan
A LAING (2002) Neonatal Unit, Simpson
Centre for Reproductive Health, Royal Infirmary,
Edinburgh EH16 4SU, UK

• Over a period of 18 months in Edinburgh, 13 of
  almost 9000 infants born were admitted to the
  Neonatal Unit at less than three weeks of age
  with hypernatraemic dehydration. All were
  breast-fed. In our study the plasma sodium
  concentrations of these infants ranged from 150
  to 173 mmol/L. Seven infants were readmitted
  having already been discharged home but six were
  diagnosed on the postnatal wards prior to
  discharge

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• Hypernatraemia may be associated with
• decreased fluid intake,
• excessive fluid loss or
• excessive sodium intake

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• The infants plasma sodium concentration is
  elevated due predominantly to loss of
  extracellular water.
• In the past, hypernatraemia occurred most
  frequently when artificial feeds of too high a
  sodium concentration were fed to babies

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Breast milk sodium

• The sodium content of breast milk at birth is
  high and declines rapidly over the subsequent
  days. In 1949 Macyestablished that the sodium
  content of colostrum in the first five days is
  (2212) mmol/ L, and of transitional milk from
  day five to ten is (133) mmol/L, and of mature
  milk after 15 d is (72) mmol/ L. Morton22
  studied the breast milk of 130 women as they
  began to breast-feed.

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Clinical presentation

• Presentation is around 10th day in the literature
  from 3 to 21 d. The parents may have failed to
  identify that the infant is ill, and
  professionals may also be falsely reassured by
  the infants apparent well-being. Signs may be
  non-specific, including lethargy and
  irritability. Occasionally there is an acute
  deterioration which precipitates the infants
  emergency admission to hospital.
• Non-depressed AF is often confusing

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Morbidity and mortality

• Seizures
• Apnea
• Facial palsy
• Thrombosis
• DIC
• Cerebral infarction
• Renal failure

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Rehydration

• If the infant appears well, then slow
  rehydration at a rate of 100 mLkg-1d-1 can be
  carried out using expressed breast milk or
  proprietory milk or a combination of both.

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Rehydration

• If the child is unwell then rehydration should be
  carried out intravenously.
• In 1975 Banister et al reported on the
  intravenous treatment of 38 infants with severe
  hyperosmolar dehydration and hypernatraemia.
  Infants rehydrated at a rate of 150 mLkg-1d-1
  were more likely to develop convulsions and
  peripheral oedema than the infants whose fluid
  intake was restricted to 100 mL kg-1d-1.

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Rehydration

• If in shock resuscitate initially with 20 mL/kg
  of 0.9 saline infused over half an hour.
• If the child is not in shock, then rehydration
  may be commenced intravenously using DNS
• Plasma urea and electrolyte concentrations are
  measured 6-hourly. In our experience it is not
  uncommon to see the plasma urea concentrations
  fall quickly in the first 24 h but little change
  is seen in the plasma sodium concentration.
• After 24 h our regimen recommends continuing
  rehydration at the same rate, but using 0.45
  saline in 5 -10 dextrose.
• Thereafter oral rehydration with breast milk or
  artificial milk should be possible.

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Sodium stuff Hypernatremia

• Hypernatremia is usually due to excessive IWL in
  first few days in VLBW infants (micropremies).
  Increase fluid intake and decrease IWL.
• Rarely due to excessive hypertonic fluids (sod
  bicarb in babies with PPHN). Decrease sodium
  intake.

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Incidence of hypernatremic dehydration

• Of 1045 children admitted with gastroenteritis
  over a 12-month period and studied
  retrospectively, serum sodium level was tested in
  802.
• Sixty patients (7.5) had hypernatremic
  dehydration (HD).
• The peak incidence of HD, the highest serum
  sodium levels, and the worst outcome were all
  encountered in infants under the age of 3 months.
  
• An association with pre-admission high solute
  feeding was less obvious.
• One patient (1.7) died, another (1.7) developed
  peripheral gangrene, and four (6.7) were left
  with significant neurologic complications. All of
  these patients were under the age of 4 months

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Hypernatremic Dehydration cont.

• Mortality can be high
• Often iatrogenic
• The circulating volume is preserved at the
  expense of the
• intracellular volume and circulatory disturbance
  is delayed
• The patient looks better than you would expect
  based on
• fluid loss
• Always assume total fluid deficit of at least 10
• You only want to correct half of the free water
  deficit in first 24 hours if Na lt 175 mEq/L
• For Na gt 175 mEq/L you do not want to correct
  faster than 0.5-1 mEq/L/hr because of risk of
  cerebral edema

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Cerebral Edema in Hypernatremic Dehydration

• Brain develops idiogenic osmoles
• On correction these take time to decrease
• Faster correction will cause excessive shift of
  water into the cells and thus cerebral edema

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Clinical features

• Preserved intra-vascular volume
• Appears less dehydrated
• Doughy feeling
• Lethargic but irritable when touched
• Assume at least 10 dehydration

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Hypernatremic Dehydration

• Before you start any fluid and electrolyte
  calculations you need to determine free water
  (FW) amount
• (Na)actual (Na)desired
• (Na) actual
• Based on above formula for Na lt 170 mEq/L
  approximately 4 ml of FW needed to bring Na down
  by 1 mEq/L/kg for Na gt 170 mEq/L approximately
  3 ml of FW needed to bring Na down by 1 mEq/L/kg
• Subtract FW from total fluid deficit and replace
  remainder in same way as done for isonatremic
  dehydration

x 100 ml/L x 0.6L/kg of body weight ml/kg FW
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Hypernatremic Dehydration
You see a 6 month old suffering for 4 days
from severe diarrhea. The mucous membranes are
dry, skin feels doughy and the child is somnolent
and lethargic. The serum Na is 165 mEq/L. The
child weighs 5 kg and you assume the fluid
deficit is at least 10. What are the fluid and
electrolyte requirements?
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Hypernatremic Dehydration
H2O Na K Cl (ml) (mEq) (mEq) (mEq) Mainten
ance Total deficit 500 ml Free water
deficit (165-145)x1/2x4x5 Remainder of
deficit (500-200) 300 ml Extracellular
(60) Intracellular (40) Total
500 15 10 20
200 - - -
180 26 - 18
120 - 18 -
1000 42 29 38
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Phase Approach

• PHASE 1
• Emergency restoration of circulation if patient
  is hypovolemic
• 10-20 ml/kg of isotonic fluids only
• PHASE 2
• Replacement of ½ of the fluid loss (deficit and
  maintenance) in first 8 hours
• PHASE 3
• Replacement of remaining ½ of the fluid loss
  (maintenance and remaining deficit) in next 16
  hours
• Replacement of potassium after voids

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Treatment of hypernatremic dehydration

• Phase 1 Restoration of intra-vascular volume, 20
  ml/kg NS ( not ringer)
• Phase 2 Determine the time of correction
• 145-157 24 hrs
• 158-170 48 hrs
• 171-183 72 hrs
• 184-196 84 hrs
• Replace ongoing losses with N/2 saline with KCl

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Type of fluid

• Does not matter, rate of correction matters
• N/4 to N/2 saline
• May run two drips
• 1st N/2 DNS with KCl
• 2nd Iso P
• Monitor Na 6 hourly and adjust the rate
• Less decrease increase Iso P
• More decrease increase N/2 DNS

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Treatment of cerebral edema

• Cerebral edema, seizures should be treated with
  3 NS
• Dose 4-6 ml/kg
• 1ml/kg of 3 NS will change Na concentration by 1
  meq/L
• Oral fluid ORS is preferred over formula, ORS
  has higher sodium

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Sodium stuff Hyponatremia

• Sodium levels often reflect fluid status rather
  than sodium intake