Extracellular fluid restoration in dehydration: a critique of rapid versusslow

We compared current recommendations for treatment of severe dehydration by World Health Organization physicians and by the American Academy of Pediatr ics Committee on Pediatric Gastroenterology with those in general textbooks of pediatrics, written mostly by pediatric nephrologists. The former recom mend rapid (1- to 2-h) and generous intravenous restoration of extracellula r fluid (ECF) volume followed by oral rehydration therapy (ORT) to replace potassium, current maintenance, and diarrheal losses - the rapid rehydratio n regimen. Oral feedings usually are resumed in 8-24 h. General textbooks o f pediatrics usually recommend giving 20 ml/kg saline "to restore circulati on," followed by the deficit therapy regimen to correct serum electrolyte a bnormalities and replace remaining deficits of water, sodium, chloride, and potassium over 1-2 days. Mortality for hospitalized patients with dehydrat ion treated with rapid rehydration was <3 per 1,000; no recent results are reported for patients treated by deficit therapy. The rapid rehydration reg imen improves patient well being and restores perfusion, so that oral feedi ngs are readily tolerated and renal function corrects serum electrolyte abn ormalities in 6 h. Amounts of saline given correspond to amounts given for treating various forms of shock. Deficit therapy regimens provide less ECF restoration and are slower at restoring perfusion; tolerance for oral feedi ngs is delayed. Two hundred pediatric nephrologists were surveyed, asking h ow they would treat a patient with severe dehydration and a patient with 40 % burns. Only 30 of 200 responded; 29 used a deficit therapy regimen, with 20-40 ml/kg ECF replacement, while a majority rapidly and generously restor ed ECF volume in burn shock. We recommend that fluid therapy chapters shoul d stop teaching deficit therapy for treating severe dehydration and instead teach the rapid rehydration regimen.