Treatment of Severe Dehydration After 7 Days Without Food or Water
A patient presenting after 7 days without food or water will have life-threatening severe dehydration (≥10% fluid deficit) requiring immediate intravenous resuscitation with isotonic crystalloid solutions—this is a medical emergency demanding aggressive fluid replacement before any other interventions. 1
Immediate Resuscitation Protocol
Begin IV rehydration immediately with boluses of 20 mL/kg of Ringer's lactate solution or normal saline until pulse, perfusion, and mental status return to normal. 1 This may require:
- Two IV lines for rapid administration 1
- Alternate access sites if peripheral access fails (venous cutdown, femoral vein, or intraosseous infusion) 1, 2
- Continuous reassessment of hemodynamic stability 1
The evidence strongly supports balanced crystalloid solutions (Ringer's lactate) over normal saline, as they likely reduce hospital stay by approximately 0.35 days and produce better biochemical outcomes including higher pH and bicarbonate levels. 3
Clinical Assessment Priorities
Assess for signs of severe dehydration (≥10% fluid deficit): 1, 4
- Severe lethargy or altered state of consciousness
- Prolonged skin tenting (>2 seconds)
- Cool and poorly perfused extremities
- Decreased capillary refill
- Rapid, deep breathing (indicating acidosis)
Critical pitfall: Rapid, deep breathing, prolonged skin retraction time, and decreased perfusion are more reliable indicators than sunken fontanelle or absence of tears. 1, 4
Transition to Oral Rehydration
Once the patient's level of consciousness returns to normal and hemodynamic stability is achieved, transition the remaining estimated fluid deficit to oral rehydration solution (ORS). 1 This approach:
- Reduces complications from prolonged IV therapy 1
- Maintains mucosal function 1
- Allows for continued replacement of ongoing losses 1
Nutritional Considerations After Prolonged Starvation
Starvation for more than 7 days induces severe undernutrition with protein and energy catabolism, worsening prognosis—nutritional support must begin as soon as hemodynamic stability is achieved. 1 However:
- Do not introduce nutritional therapy until the patient is hemodynamically stable 1
- After initial stabilization, provide 25-33 kcal/kg with 20-30% from intravenous lipids if needed 1
- Begin oral feeding progressively as tolerated, avoiding prolonged fasting 1
The evidence shows that as little as 5 days without nutritional support in previously healthy individuals results in severe undernutrition, water retention, and decreased muscle function proportional to protein store depletion. 1 After 7 days, these effects are magnified.
Electrolyte Management
Monitor and correct electrolyte abnormalities aggressively, particularly sodium, potassium, and magnesium. 1, 5 Severe dehydration after prolonged deprivation can cause:
- Marked hypernatremia (sodium >198 mEq/L reported) 5
- Hypokalemia with risk of cardiac arrhythmias 1, 5
- Hypomagnesemia interacting with other electrolyte imbalances 1
Special attention to magnesium is critical, as deficiency interacts with sodium, potassium, and calcium balance. 1
Monitoring and Complications
Assess hydration status frequently during replacement therapy: 1, 4
- Pulse and perfusion
- Mental status
- Urine output (target ≥800-1000 mL with random urine sodium >20 mmol/L) 1
- Blood glucose (monitor at least daily) 1
Watch for rhabdomyolysis, which can develop from severe dehydration combined with metabolic abnormalities, hypothermia, and metabolic acidosis—serum CPK and myoglobin should be monitored. 5
Ongoing Fluid Replacement
After initial resuscitation, replace ongoing losses: 1
- 10 mL/kg ORS for each watery stool
- 2 mL/kg ORS for each episode of emesis
- Continue until clinical signs resolve 1, 6
Critical consideration: The evidence indicates that chronic mild dehydration may lead to permanent kidney damage through vasopressin effects, aldose reductase-fructokinase pathway activation, and chronic hyperuricemia. 7 After severe prolonged dehydration, renal function monitoring is essential.