Hypernatremic Dehydration

Dr Rajesh
05/12/07
 Hypenatremic Dehydration
• 10 DAYS fch, HOME DELIVERY,
ADMITTED ON DAY 10, POOR feeding,
lethargy, FTT wt: 1695 grams
• Sugar 61, Na: 178, K:4.7.
• On day 2: Na: 163. K: 4.7
• Day 4: Na: 137. K: 5.9. Wt at discahrge:
1920 grams
• 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
• ABG: Na >180, 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
 Mistakes
• RL was used instead of NS
• Iso P was used after 12 hours
 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
• 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.
 Mistakes
• Higher fluid was used
• Iso P was used
 Importance of hypernatremic
dehydration
• Hypernatraemic dehydration is a potentially
lethal condition and is associated with
cerebral oedema, intracranial haemorrhage,
hydrocephalus and gangrene
 IJP:Year : 2006 | Volume : 73 | Issue : 1 | Page : 39-41

Dehydration and hypernatremia in breast-fed term healthy neonates

Bhat 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 (> 10 % cumulative
weight loss or per day weight loss > 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.
Hypernatraemic dehydration in newborn infants
Ian 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
• Hypernatraemia may be associated with
– decreased fluid intake,
– excessive fluid loss or
– excessive sodium intake
• The infant’s 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
 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 (22±12) mmol/
L, and of transitional milk from day five to ten is
(13±3) mmol/L, and of mature milk after 15 d is
(7±2) mmol/ L. Morton[22] studied the breast
milk of 130 women as they began to breast-feed.
 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 infant’s apparent
well-being. Signs may be non-specific, including
lethargy and irritability. Occasionally there is an
acute deterioration which precipitates the infant’s
emergency admission to hospital.
• Non-depressed AF is often confusing
 Morbidity and mortality
• Seizures
• Apnea
• Facial palsy
• Thrombosis
• DIC
• Cerebral infarction
• Renal failure
 Rehydration
• If the infant appears well, then slow
rehydration at a rate of 100 mL·kg-1·d-1
can be carried out using expressed breast
milk or proprietory milk or a combination
of both.
 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 mL·kg-1·d-1 were more likely to develop
convulsions and peripheral oedema than the infants
whose fluid intake was restricted to 100 mL· kg-1·d-1.
 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.
 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.
 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
 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+ < 175 mEq/L
For Na+ > 175 mEq/L you do not want to correct faster
than 0.5-1 mEq/L/hr because of risk of cerebral edema
 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
 Clinical features
• Preserved intra-vascular volume
• Appears less dehydrated
• Doughy feeling
• Lethargic but irritable when touched
• Assume at least 10% dehydration
 Hypernatremic Dehydration
 Before you start any fluid and electrolyte calculations you
need to determine free water (FW) amount
(Na+)actual – (Na+)desired
x 100 ml/L x 0.6L/kg of body weight = ml/kg FW
(Na ) actual
+

 Based on above formula for Na+ < 170 mEq/L

approximately 4 ml of FW needed to bring Na+ down by 1
mEq/L/kg; for Na+ > 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
 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?

 Hypernatremic Dehydration
H2O Na K Cl
(ml) (mEq)(mEq)(mEq)
Maintenance 500 15 10 20
Total deficit = 500 ml
Free water deficit
{(165-145)x1/2x4x5} 200 - - -
Remainder of deficit
(500-200) = 300 ml
Extracellular (60%) 180 26 - 18
Intracellular (40%) 120 - 18 -
Total 1000 42 29 38
 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
 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
 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
 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
 Sodium stuff : Hyponatremia

• Sodium levels often reflect fluid status

rather than sodium intake

ECF Exces