From the Guidelines
Severe dehydration requires immediate medical attention with intravenous fluid resuscitation as the cornerstone of management, using isotonic crystalloid solutions such as lactated Ringer’s and normal saline solution, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines 1. Treatment begins with rapid IV administration of these solutions, typically at 20-30 mL/kg over the first hour for adults, potentially repeated based on clinical response, and boluses of 20 mL/kg for children, repeated if necessary. After initial resuscitation, maintenance fluids should continue with careful monitoring of:
- Vital signs
- Urine output
- Electrolytes
- Mental status Electrolyte abnormalities, particularly sodium, potassium, and bicarbonate imbalances, must be corrected gradually. The underlying cause of dehydration must be identified and treated simultaneously, whether it's excessive fluid loss from vomiting, diarrhea, burns, or inadequate intake. Oral rehydration can begin once the patient is hemodynamically stable and able to tolerate oral intake, using oral rehydration solutions containing appropriate electrolytes, as supported by the guidelines 1. Severe dehydration is life-threatening because it compromises tissue perfusion, leading to organ dysfunction, metabolic acidosis, and potentially shock if not promptly corrected, highlighting the importance of careful monitoring during rehydration to prevent complications like cerebral edema from overly rapid correction, especially in chronic dehydration cases 1.
From the Research
Severe Dehydration Management
- Severe dehydration resulting from diarrhea can be managed with rapid and generous intravenous restoration of extracellular fluid, followed by oral rehydration therapy (ORT) 2.
- Children with clinical evidence of severe dehydration should receive intravenous fluids, 60-100 ml/kg of 0.9% saline in the first 2-4 h to restore circulation 2.
- Oliguric patients with severe acidosis should receive a physiological dose of bicarbonate to correct blood pH level to 7.25 2.
- The management of intravenous fluids in critically ill adults requires an understanding of the properties of various intravenous fluids and their corresponding impact on human physiology 3.
- Balanced salt solutions may be preferred in some patient populations, and the bedside critical care nurse must understand the goals of fluid therapy to determine the optimal patient-specific selection and dose of fluid for administration 3.
Fluid Therapy
- The use of crystalloids, such as normal saline or Lactated Ringer's, should be considered in patients with hypovolemia or acutely ill patients 4.
- However, the restoration of volume status is the primary target in hypovolemic state, and the correction of any associated acid-base or electrolyte disorders is also of vital importance 4.
- Lactated Ringer's infusate should not be given in patients with severe metabolic alkalosis, lactic acidosis with decreased lactate clearance, or severe hyperkalemia, and in patients with traumatic brain injury or at risk of increased intracranial pressure 4.
- The optimal choice of infusate should be guided by the cause of hypovolemia, the cardiovascular state of the patient, the renal function, as well as the serum osmolality and the coexisting acid-base and electrolyte disorders 4.
Diagnosis and Treatment
- Dehydration in clinical practice refers to the loss of body water, with or without salt, at a rate greater than the body can replace it 5.
- The diagnosis of dehydration requires an appraisal of the patient and laboratory testing, clinical assessment, and knowledge of the patient's history 5.
- Subcutaneous infusion of fluids (hypodermoclysis) provides a better opportunity to treat mild to moderate dehydration in the nursing home and at home 5.
- Approaches to fluid resuscitation in the context of hypernatraemia and the hyperosmolar state should be considered and judiciously combined to manage complex cases with a successful outcome 6.