5.3 Severe dehydration

Severe dehydration is a medical emergency. The patient must be treated immediately with IV fluid according to the following protocol.

For pregnant women, see Section 5.7, for severely malnourished children, see Section 5.8, for children with severe anaemia, see also Section 5.9.

5.3.1 Treatment protocol (Plan C)

Intravenous rehydration

Children ≥ 5 years and adults

30 ml/kg of Ringer lactate (RL)1 over 30 minutes
Repeat once if danger signs are still present
70 ml/kg of RL over 3 hours

One-third of the volume is given as a very rapid infusion (bolus) in 30 minutes. This is intended to re-establish a circulating volume sufficient to correct tissue hypoperfusion. The remaining twothirds are given slowly, over 3 hours.

An adult (60 kg) will receive 6 litres (100 ml x 60 kg) of RL as follows:
2 litres (30 ml x 60 kg) in 30 minutes then, if s/he has improved (conscious, palpable pulse), 4 litres (70 ml x 60 kg) over the next 3-4 hours (1 litre every 45 minutes or more simply 1 litre per hour).
If, however, after the initial bolus, the patient continues to have a weak pulse and/or remains lethargic, a second bolus of 2 litres over 30 minutes should be given before moving on to 4 litres over 3-4 hours.
For volumes to prescribe, see Appendix 5.

Children under 5 years

20 ml/kg of RL over 15 minutes
If danger signs still present, repeat bolus up to 2 times
70 ml/kg of RL over 3 hours

A child (11 kg) should receive approximately 1 litre (90 ml x 11 kg) of RL as follows:
250 ml of RL (20 ml x 11 kg) in 15 minutes, and if s/he has improved (no danger signs), then 750 ml (70 ml x 11 kg) over 3 hours.
If, however, any danger signs are present after the initial bolus, repeat up to 2 times, assessing for danger signs after each bolus. Then, give 750 ml over 3 hours.
For volumes to prescribe, see Appendix 5.

If the patient is able to tolerate oral treatment, ORS should be started immediately.

Compensation for on-going losses

During the rehydration phase, the losses from on-going diarrhoea must be compensated. As soon as the patient can drink:

Give after each loose stool:
• 50-100 ml of ORS for children under 2 years
• 100-200 ml of ORS for children between 2 and 10 years
• 200-250 ml of ORS for children over 10 years and adults

The number of cups of ORS consumed must approximate the number of stools produced.

If the patient cannot drink or is vomiting all oral intake, on-going losses can be replaced intravenously using RL (Section 5.3.3) until oral intake is possible.

Complementary therapy

These treatments should be administered as soon as the patient is haemodynamically stable and can tolerate oral treatment.

– Antibiotic therapy
Depending on the drug-sensitivity testing, administer one of these antibiotics:
Table 5.4 – Antibiotic therapy

doxycycline PO4 mg/kg single dose300 mg single dose
azithromycin PO20 mg/kg single dose1 g single dose

ciprofloxacin PO2

20 mg/kg single dose1 g single dose

– Zinc supplementation
Start a 10 day course of zinc sulfate PO:
Children under 6 months: 10 mg once daily
Children 6 months-5 years: 20 mg once daily
Show the attendant how the treatment is given so that the 10-day course can be completed at home (Section 5.6.1).
For dosage charts, see Appendix 7.

5.3.2 Patient supervision

During the first 30 minutes

– Observe closely until a strong radial pulse is present and mental status improves.
– Check the volume of fluid infused. Ensure that the infusion rate is sufficient to administer the prescribed quantity within the correct time frame.
– If there is no improvement with the first bolus, administer a second bolus (in total, children under 5 years may receive up to 3 boluses max.).
– If after the second bolus, the mental status has not improved, consider hypoglycaemia, measure blood glucose and/or administer glucose empirically (Section 5.10.1).

During the next 3 hours

– Assess every 30 minutes:
• That the prescribed volume of infusion will be administered in the correct time frame (correct infusion rate, functional catheter).
• That danger signs are absent.
– Note the amount of fluid given (RL and ORS).
– Note the number of stools and vomiting episodes (mark a cross for each stool or vomiting).
– Check more frequently patients with abundant diarrhoea and vomiting, children under 5 years and elderly patients.
– If any danger signs reappear, repeat bolus therapy until resolution, and then continue prior fluid therapy. For children under 5, assess for hypoglycaemia. In the event of hypoglycaemia, see Section 5.10.1.
– If the patient develops an onset of extremity or peri-orbital oedema or difficulty breathing, consider fluid overload (Section 5.10.4).

End of the rehydration phase

After the prescribed amount of RL has been given, reassess the hydration status; if there are no signs of dehydration, the patient can then move to the maintenance phase. Stop the infusion but leave the catheter in place.

However, if a patient was more dehydrated than initially assessed or if on-going losses have not replaced, signs of dehydration may still be present at this point.
– If signs of severe dehydration are still present, repeat the 3-hour IV rehydration treatment, including bolus.
– If signs of some dehydration are present, continue the rehydration phase with 75 ml/kg of ORS over 4 hours (Section 5.4). Stop the infusion but leave the catheter in place. In these patients, continue the clinical evaluation hourly until the signs of dehydration have resolved and the patient can switch to maintenance therapy.

5.3.3 Practical tips

IV rehydration

– Venous access3
• Use 18G for adults (20G in adults with small veins) and 22G or 24G for children.
• The veins of the forearm or antecubital fossae are preferred. Hand and foot veins do not permit the needed infusion rate and catheters placed there are easily dislodged.
• In adults, a second catheter may initially be placed in the other arm to deliver the full bolus volume in the correct time frame (2 litres in 30 minutes). It must be removed once a strong pulse has returned, keeping a single catheter in place.
• Always have an intra-osseous needle kit available at hand in case of failure to establish IV access.
• Failure to quickly place an IV catheter in a peripheral vein after 90 seconds should prompt the use of the external jugular or intra-osseous route (Appendix 6). Scalp veins can also be used temporarily in infants when a peripheral IV catheter cannot be rapidly inserted, but an intra-osseous catheter is preferred.

– Infusions
• Raise the IV pouch as high as possible above the catheter insertion site to increase flow rate.
• In children, keeping the arm straight can be achieved by taping a piece of cardboard or a tongue depressor across the posterior aspect of the elbow.
• Mark each pouch of IV fluid with a marker, indicating the current pouch number and the total prescribed (i.e. 1/6, 2/6, 3/6, etc.). In young children, use a paediatric infusion set with a burette (150 ml). In older children, draw a line on the bag corresponding to the volume prescribed.
• Record in the patient’s file the volume of IV fluid administered (in litres or ml).
• Assess the IV catheter insertion site. The catheter must be replaced in the event of dislodgment, infiltration, local inflammation, or unexplained fever. Catheters do not need to be changed systematically if they remain clean and function properly.

– End of the infusion
Once IV therapy has been completed, leave the catheter in place and disconnect the infusion bag. If after 4 to 6 hours of oral therapy, the patient has 1) no profuse diarrhoea or severe vomiting, 2) can compensate the losses by consuming ORS and 3) no longer has signs of dehydration, the catheter can be removed to minimize risks of complications. This decision should take into account the possible difficulties in re-establishing IV access if needed in young children, the elderly, and the obese.

ORS administration

Often the patient attendant is left to administer ORS to the patient. However, it is the responsibility
of the medical personnel to ensure that the correct amount is being consumed.

Estimation of on-going losses

– Diarrhoea and vomiting
Do not try to measure the volume of diarrhoea and vomiting, but note each episode of diarrhoea or vomiting over time.
The number of stools is used to estimate the volume to be replaced.
Vomiting is not counted as fluid to be replaced, but must be followed to know if the patient can (or cannot) retain ORS.

– Urine
Urine output is not counted as fluid loss as such. However, it is necessary to check that the patient has urinated at least once during or by the end of the rehydration phase.

Compensation for on-going losses

It is roughly estimated that each stool should be compensated by 50-100 ml of ORS for children < 2 years; 100-200 ml of ORS for children 2-10 years; 200-250 ml of ORS for children > 10 years and adults.

If the patient is incapable of drinking, on-going losses must be compensated via the IV route. Two techniques are possible:
– Compensate losses progressively over time (hour by hour): attach a second bag of IV fluid by a Y-connector to the principal IV line, open this “supplemental fluid IV line” to administer the estimated volume (e.g. 4 stools passed by a child < 2 years = 200 ml of RL in one hour) and then close the line. An hour later, total the number of stools passed during that time and administer the desired quantity, etc. This set-up permits administration of a volume of RL corresponding to that lost in diarrhoea without interrupting the principal infusion (for rehydration). This option requires well-trained staff.
– Compensate the total number of stools lost at the end of the 3-hour rehydration phase over a time period appropriate for the amount of volume to be replaced (do not exceed 25 ml/kg/hour).
For example, for a 3-year old child, 8 stools were passed during the 3-hour rehydration, thus give 800 ml (8 x 100 ml) over 3 hours at the end of rehydration.

Ref Notes
1 The fluid of choice is Ringer lactate. If RL is not available, 0.9% sodium chloride, with or without glucose, can be
used. IV fluid containing only glucose (e.g. 5% glucose) should not be used.
2 Ciprofloxacin should not be used unless there is resistance to doxycycline and azithromycin and demonstrated sensitivity to ciprofloxacin. Recently, cholera strains are showing increased resistance to ciprofloxacin and its widespread use may worsen the problem. In addition, ciprofloxacin is the drug of choice for other bacterial
diarrhoea (E. coli, salmonella, shigella) and its widespread single-dose use during cholera outbreaks might lead to resistance in these pathogens.
3 A nasogastric tube should not be used in the treatment of severe dehydration or shock as it does not permit rapid fluid replacement in the quantities required.