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apixaban for the treatment of acute venous thromboembolism. N Eng J Med.

2013;369(9):799–808.

Bauersachs R, Berkowitz SD, Brenner B, et al; for EINSTEIN Investigators. Oral rivaroxaban for symptomatic venous thromboembolism. N Eng J Med. 2010;363(26):2499–2510.

Kyrle PA, Rosendaal FR, Eichinger S. Risk assessment for recurrent venous thrombosis. Lancet. 2010;376(9757):2032–2039.

Lyman GH, Khorana A, Kuderer N, et al; for American Society of Clinical Oncology Clinical Practice. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31(17):2189–2204.

Palareti G, Cosmi B, Legnani C, et al; for DULCIS (D-dimer and ULtrasonography in Combination Italian Study) Investigators. D-dimer to guide the duration of anticoagulation in patients with venous thromboembolism: a management study. Blood. 2014;124(2):196–203.

Prins MH, Lensing AW, Bauersachs R, et al; for EINSTEIN Investigators. Oral rivaroxaban versus standard therapy for the treatment of symptomatic venous thromboembolism: a pooled analysis of the EINSTEIN-DVT and PE randomized studies. Thromb J. 2013;11(1):21.

Schulman S, Kearon C, Kakkar AK, et al; for RE-COVER Study Group. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med. 2009;361(24):2342–2352.

Watson L, Broderick C, Armon MP. Thrombolysis for acute deep vein thrombosis. Cochrane Database Syst Rev. 2016;(11):CD002783.

SEE ALSO

Antithrombin Deficiency; Factor V Leiden; Protein C Deficiency; Protein S

Deficiency; Prothrombin 20210 (Mutation); Pulmonary Embolism

CODES

ICD10

I80.209 Phlbts and thombophlb of unsp deep vessels of unsp low extrm

I80.299 Phlebitis and thombophlb of deep vessels of unsp low extrm I80.10 Phlebitis and thrombophlebitis of unspecified femoral vein

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CLINICALPEARLS

Many cases are asymptomatic.

At time of DVT diagnosis, as many as 40% of patients also have asymptomatic PE.

Wells criteria are useful to determine the pretest probability of a DVT, but follow-up testing and/or imaging should be done if moderate to high probability.

Choice of anticoagulant therapy should be individualized based on patient’s history and compliance.

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DEHYDRATION

Tu Dan (Kathy) Nguyen, MD

BASICS

DESCRIPTION

Astate of negative fluid balance; strictly defined as free water deficiency The two types of dehydration:

–Water loss

–Salt and water loss (combination of dehydration and hypovolemia)

EPIDEMIOLOGY

Responsible for 10% of all pediatric hospitalizations in the United States

Gastroenteritis, one of its leading causes, accounts to 13/1,000 children <5 years of age annually in the United States.

Incidence

More than half a million hospital admissions annually in the United States for dehydration

Of hospitalized older persons, 8% are dehydrated (1).

Worldwide, ~3 to 5 billion cases of acute gastroenteritis occur each year in children <5 years of age, resulting in nearly 2 million deaths.

ETIOLOGYAND PATHOPHYSIOLOGY

Negative fluid balance occurs when ongoing fluid losses exceed fluid intake.

Fluid losses can be insensible (sweat, respiration), obligate (urine, stool), or abnormal (diarrhea, vomiting, osmotic diuresis in diabetic ketoacidosis).

Negative fluid balance can lead to severe intravascular volume depletion (hypovolemia) and end-organ damage from inadequate perfusion.

The elderly are at increased risk as kidney function, urine concentration, thirst sensation, aldosterone secretion, release of vasopressin, and renin activity are all significantly lowered with age.

Decreased intake

Increased output: vomiting, diarrheal illnesses, sweating, frequent urination “Third spacing” of fluids: effusions, ascites, capillary leaks from burns, or sepsis

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Genetics

Some causes of dehydration have a genetic component (diabetes), whereas others do not (gastroenteritis).

RISK FACTORS

Children <5 years of age at highest risk

Elderly

Decreased cognition

Lack of access to water such as in critically sick intubated patients

GENERALPREVENTION

Patient/parent education on early signs of dehydration

Universal precautions (including hand hygiene)

Geriatric Considerations

Systematically assessing risk factors helps with early prevention and management of dehydration in the elderly, especially those in long-term care facilities.

COMMONLYASSOCIATED CONDITIONS

Hypo-/hypernatremia

Hypokalemia

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Hypovolemic shock

Renal failure

DIAGNOSIS

Calculate percent dehydration = (preillness weight − illness weight)/preillness weight × 100. Supplement this along with the ongoing fluid loss.

HISTORY

Fever

Intake (including description and amount)

Diarrhea (including duration, frequency, consistency, ± mucus/blood)

Vomiting (including duration, frequency, consistency, ± bilious/nonbilious)

Urination pattern

Sick contacts

Medication history (e.g., diuretics, laxatives)

PHYSICALEXAM

The most useful signs for identifying dehydration in children are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern.

Vitals: pulse, BP, temperature

Orthostatic vital signs: Take BPand heart rate (HR) while supine, sitting, and standing.

– Systolic BPdecrease of 20 mm Hg, diastolic BPdecrease by 10 mm Hg, or HR increase by 20 bpm suggests hypovolemia (2).

Weight loss: <5%, 10%, or >15%

Mental status

Head: sunken anterior fontanelle (for infants)

Eyes: sunken, ± tear production

Mucous membranes: tacky, dry, or parched

Capillary refill: ranges from brisk to >3 seconds

Darker urine color

DIFFERENTIALDIAGNOSIS

Decreased intake: ineffective breastfeeding, inadequate thirst response, anorexia, malabsorption, metabolic disorder, obtunded state Excessive losses: gastroenteritis, diarrhea, febrile illness, diabetic

ketoacidosis, hyperglycemia, hyperosmolar hyperglycemic state, diabetes

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insipidus, intestinal obstruction, sepsis

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

For mild dehydration: generally not necessary For moderate to severe dehydration

–Electrolytes, BUN, creatinine, and glucose

–Urinalysis (specific gravity, hematuria, glucosuria)

Imaging does not play a role in the diagnosis of dehydration, unless the specific condition causing the dehydration requires imaging.

In adults, inferior vena cava collapsibility is a surrogate marker for volume status.

Pediatric Considerations

Infants and the elderly may not concentrate urine maximally, making urine specific gravity less helpful.

TREATMENT

MEDICATION

First Line

Oral rehydration is the first-line treatment in dehydrated children. If this is unsuccessful, use IV rehydration. If IV unobtainable, nasogastric (NG) or intraosseous (IO) rehydration can be considered (3).

Oral rehydration is the first-line treatment in dehydrated adults as long as they can tolerate fluids. Have a lower threshold for IV rehydration if needed.

If the patient is experiencing excessive vomiting, consider using an antiemetic.

Ondansetron (PO/IV) may be effective in decreasing the rate of vomiting, improving the success rate of oral hydration, preventing the need for IV hydration, and preventing the need for hospital admission (4,5).

Other antiemetics can be used.

Second Line

Loperamide may reduce the duration of diarrhea compared with placebo in children with mild to moderate dehydration (two randomized controlled trials

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[RCTs] yes, one RCT no).

In children ages 3 to 12 years with mild diarrhea and minimal dehydration, loperamide decreases diarrhea duration and frequency when used with oral rehydration.

Pediatric Considerations

Given a higher risk for serious adverse events, loperamide is not indicated for children <3 years of age with acute diarrhea.

ISSUES FOR REFERRAL

For severe dehydration, critical care referral and ICU-level care may be warranted.

Surgical consultation for acute abdominal issues

SURGERY/OTHER PROCEDURES

For specific underlying causes of dehydration, such as intestinal obstruction or appendicitis

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Intractable vomiting/diarrhea

Electrolyte abnormalities

Hemodynamic instability

Inability to tolerate oral rehydration therapy (ORT)

Stabilize airway, breathing, circulation.

If mild dehydration, try ORT.

If excessive vomiting/severe dehydration with shock, start IV access and IV fluids immediately.

IV fluids

–Stage I

For moderate to severe dehydration in children: isotonic saline or Ringer lactate solution bolus of 10 to 20 mL/kg; may repeat up to 60 mL/kg; if still hemodynamically unstable, consider colloid replacement (blood, albumin, fresh frozen plasma) and address other causes for shock.

For moderate to severe hypovolemia in adults: isotonic saline or Ringer lactate 20 mL/kg/hr until normal state of consciousness returns/vital signs stabilize. Also consider colloid replacement if continued fluids required beyond 3 L.

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–Stage II: Replace fluid deficit along with maintenance over 48 hours; fluid deficit = preillness weight − illness weight

–An alternative IV treatment option for moderate (10%) dehydration in children

Bolus with NS/LR at 20 mL/kg for 1 hour

Replete fluid deficit with D5 1/2 NS + 20 mEq KCl/L at 10 mL/kg for 8 hours (hours 2 to 9).

Replete 1.5 for maintenance fluids with D5 1/4 NS + 20 mEq/Lof KCl for 16 hours (hours 10 to 24).

–An alternative to IV fluids is hypodermoclysis, the SC infusion of fluids into the body (adults).

Indications: hydration of patients with mild to moderate dehydration who do not tolerate oral intake because of cognitive impairment, severe dysphagia, advanced terminal illness, or intractable vomiting. It is also indicated to prevent dehydration, especially in frail elderly residents living in long-term care settings who reject the oral route for any reason; useful technique for patients with difficult IV access

Contraindications: severe dehydration or shock, patients with

coagulopathy or receiving full anticoagulation, patients with severe generalized edema (anasarca) or congestive heart failure, and those with fluid overload (6)

Strict inputs and outputs: oral and IV input and output of urine and stool, which may include weighing wet diapers

Discharge criteria

–Input > output

–Underlying etiology treated and improving

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Activity as tolerated

If mild to moderate dehydration, the patient may be mobile without restrictions, although watch for orthostasis/falls.

If moderate to severe dehydration, bed rest

Patient Monitoring

Ongoing surveillance for recurrence

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DIET

Bland food bananas, rice, applesauce, toast (BRAT) diet

If diarrhea, lactose-free feeds may reduce the duration of diarrhea in children with mild to severe dehydration, compared with lactose-containing feeds.

Small frequent sips of room temperature liquids

Oral rehydration solutions are available commercially.

Continue breastfeeding ad lib.

PATIENT EDUCATION

Patients should seek medical care if they (or their child) feel faint or dizzy when rising from a sitting or lying position, becomes lethargic and/or confused, or complains of a rapid HR.

Patients should call their physician if they are unable to keep down any fluids, vomiting has been going on >24 hours in an adult or >12 hours in a child, diarrhea has lasted >2 days in an adult/child, or an infant/child is much less active than usual or is very irritable.

http://www.mayoclinic.org/diseases- conditions/dehydration/basics/definition/con-20030056

PROGNOSIS

Self-limited if treated early; potentially fatal if untreated and persistent

COMPLICATIONS

Seizures

Renal failure

Cardiovascular arrest

REFERENCES

1.Thomas DR, Cote TR, Lawhorne L, et al; for Dehydration Council. Understanding clinical dehydration and its treatment. J Am Med Dir Assoc. 2008;9(5):292–301.

2.Lanier JB, Mote MB, Clay EC. Evaluation and management of orthostatic hypotension. Am Fam Physician. 2011;84(5):527–536.

3.Rouhani S, Meloney L, Ahn R, et al. Alternative rehydration methods: a systematic review and lessons for resource-limited care. Pediatrics. 2011;127(3):e748–e757.

4.Colletti JE, Brown KM, Sharieff GQ, et al. The management of children with gastroenteritis and dehydration in the emergency department. JEmerg Med.

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2010;38(5):686–698.

5.Carter B, Fedorowicz Z. Antiemetic treatment for acute gastroenteritis in children: an updated Cochrane systematic review with meta-analysis and mixed treatment comparison in a Bayesian framework. BMJ Open.

2012;2(4):e000622.

6.Lopez JH, Reyes-Ortiz CA. Subcutaneous hydration by hypodermoclysis. Rev Clin Gerontol. 2010;20(2):105–113.

SEE ALSO

Oral Rehydration

CODES

ICD10

CLINICALPEARLS

Dehydration is the result of a negative fluid balance and is a common cause of hospitalization in both children and the elderly.

Begin by assessing the level of dehydration, determining the underlying cause, and calculating necessary replacement.

Treatment is directed at restoring fluid balance via oral rehydration (first-line) therapy or IV fluids and treating underlying causes.

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