What are the guidelines for treating dehydration?

Guidelines for Treating Dehydration

Reduced osmolarity oral rehydration solution (ORS) is the first-line therapy for mild to moderate dehydration in infants, children, and adults with dehydration from any cause, while isotonic intravenous fluids such as lactated Ringer's and normal saline should be administered for severe dehydration, shock, altered mental status, or when ORS therapy fails. 1

Assessment of Dehydration

• Assess severity of dehydration based on clinical signs including pulse, perfusion, mental status, skin turgor, and presence of sunken eyes 1
• For older adults, measured serum or plasma osmolality >300 mOsm/kg (or calculated osmolarity >295 mmol/L) indicates dehydration 1
• Evaluate for specific causes of dehydration (diarrhea, vomiting, decreased intake, excessive losses) to guide appropriate treatment 1

Treatment Algorithm Based on Severity

Mild to Moderate Dehydration

1. Oral Rehydration

   • Use reduced osmolarity ORS as first-line therapy 1
   • Recommended ORS dosing:
     • Children <2 years: 50-100 mL after each stool 1
     • Older children: 100-200 mL after each stool 1
     • Adults: As much as needed 1
   • Continue until clinical dehydration is corrected 1

2. Nasogastric Administration

   • Consider for patients who cannot tolerate oral intake or refuse to drink adequately 1
   • Administer at rate of 15 mL/kg body weight/hour for infants unable to drink 1

Severe Dehydration

1. Intravenous Rehydration

   • Use isotonic fluids such as lactated Ringer's or normal saline 1
   • Continue until pulse, perfusion, and mental status normalize 1
   • For patients with ketonemia, initial IV hydration may be needed before transitioning to oral rehydration 1
   • Once stabilized, transition to ORS to replace remaining deficit 1

2. Special Considerations for Older Adults

   • For older adults with dehydration who appear well, encourage increased fluid intake with preferred beverages (tea, coffee, fruit juice, water) 1
   • For older adults who appear unwell, offer subcutaneous or intravenous fluids in parallel with oral intake 1
   • Subcutaneous dextrose infusions can be effective with similar adverse effect rates as IV infusion 1

Maintenance Phase

• Once rehydrated, administer maintenance fluids and replace ongoing losses 1
• Continue ORS to replace ongoing losses until diarrhea and vomiting resolve 1
• Human milk feeding should be continued in infants throughout the diarrheal episode 1
• Resume age-appropriate diet during or immediately after rehydration 1

Important Considerations and Cautions

• Commercially available ORS formulations include Pedialyte, CeraLyte, and Enfalac Lytren 1
• Popular beverages that should NOT be used for rehydration include apple juice, sports drinks (like Gatorade), and commercial soft drinks 1, 2
• Oral rehydration therapy has been shown to prevent up to 93% of diarrhea deaths 3
• Antimotility drugs should not be given to children <18 years with acute diarrhea 1
• Patients with dysphagia require careful monitoring of hydration status, especially when using thickened fluids 1
• In hypernatremic dehydration, slow administration of ORS containing either 90 or 75 mEq/L Na+ has been shown to be safe and effective 4, 5

Monitoring Response to Treatment

• Reassess hydration status after 3-4 hours of treatment 1
• Continue treatment according to degree of dehydration at reassessment 1
• Monitor for signs of worsening condition (continued high stool output, persistent thirst, sunken eyes, fever) 1
• For severe cases, monitor vital signs, mental status, and laboratory parameters as needed 1