Hydration Question

A reader writes: “I have been told that under most circumstances a properly hydrated person should be urinating every 1 and 1/2 to 2 hours. Is this accurate?”

This is probably a reasonable statement, although there is no absolute correlation of time interval between episodes of spontaneous (e.g., associated with the urge to urinate) urination and state of hydration. For instance, a person might be well hydrated and exercising, so not appreciate an urge to urinate. Exercise is also the reason why a person may not appreciate thirst, so until someone takes a break from the exercise and attempts to urinate, it may be difficult to tell exactly where someone is from a hydration perspective.

The general rule is to drink enough liquid so that the urine is light-colored and copious, no matter what the interval between episodes of urination. If the urine is dark-colored, this may indicate that it is concentrated (with waste products), which occurs when the kidneys (and body) are working to conserve fluid. “Cloudy” (not clear) urine may be caused by excess protein in the urine, a urinary tract infection, or some other reason. Using the urine hydration chart depicted above, urine should not be darker in color than #4.

It’s easy to become dehydrated outdoors, as most people underestimate their fluid requirements. Situations of particularly high risk include cold, dry weather (respiratory fluid loss from breathing, particularly if it is rapid), high altitude (loss of thirst and breathing cold, dry air), extreme heat (nausea, inadequate thirst), during times of great exertion, and with any intercurrent illness (particularly if it involves nausea and vomiting). These are times when it is important to drink a minimum of two liters (quarts) of water when there is no significant fluid loss (e.g., at rest in a non-stressful environment), and more if conditions warrant. So long as alcohol is not ingested and one avoids any beverage with a diuretic effect, it doesn’t make much difference what beverage is chosen. Drink what you like, and drink enough.

Preview the 25th Anniversary & Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 25-30, 2008.

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Hospitalito Atitlan 2

Each day working at the Hospitalito Atitlan brought new challenges. At every opportunity, the staff rose to the occasion. They were resourceful to the maximum, and by the end of the week, I fully realized that I had received much more of an education than I had contributed.

A young mother brought her 10 day old baby to us because it was feeding poorly, with little interest in breast-feeding. The infant weighed only 2 kilograms (4.4 pounds), was breathing shallowly and rapidly, had a weak pulse, rapid heart rate, poor cry, was jaundiced (yellow in skin coloration), had an obviously infected eye covered with swollen eyelids draining pus, and had a low body temperature. The tiny child was clearly dehydrated and hypothermic, which are often signs of sepsis (an overwhelming systemic infection). If the source of the infection was the child's eye, then a likely culprit would be the bacterium Chlamydia trachomatis, for which we did not have a rapid test available. If the baby had a Chlamydia eye infection, there was a good chance that it also had pneumonia caused by the same organism. We took a chest X-ray, which did not show a pneumonia, but that might have been because of the dehydration, which would not allow hydration of the infected lung tissue, and so prevent it from "blossoming" in appearance on the radiograph.

It was our impression that this child was in a very precarious situation. Indeed, if the visit to the Hospitalito had been delayed a few more hours, the child might have died. First and foremost, the child needed to receive life-saving fluid. Its inability to feed made it essential for us to place an intravenous catheter for fluid administration. I searched the tiny arms and didn't see anything that looked like a vein. I was fearful that we might need to perform a "cut-down," an incision through the skin to find a vein that we might cannulate, but one of the young Guatemalan technicians who performed many tasks at the Hospitalito gently caressed and patted the baby's arm, then slid a tiny catheter into a vein that none of us could see, and only he could feel. It was an awesome, and for this child lifesaving, performance.

We administered fluid, but realized that this child also needed nutrition. Another staff member suggested that she place a tiny feeding tube through the child's nose and into its stomach, through which we could push small amounts of breast milk provided by the mother. This was done, and now we could begin to give the child nourishment. Two antibiotics were given through the IV, and a third (necessary for the eye infection) was given through the feeding tube. To warm the child, we bundled it in blankets, and had the mother hold it close to her body. We had the option to transfer the child to Guatemala City, but decided that it was in too critical a condition to send on a four hour car ride without constant medical observation. It was going to survive at our Hospitalito, or not make it.

Fortunately, the child did not stop breathing. By the next morning, the infant offered small sucking gestures, and began to weakly breastfeed. It grew stronger over the next couple of days, and survived what I hope will be its closest call with death. Only time will tell what effects this episode will have on the child's development.

In America, we live in a relative haven where there is a neonatal intensive care unit around every corner. Mothers for the most part enjoy excellent prenatal care, and it is relatively rare for an infant to be in such a dire condition before it is brought to medical attention. That is not the norm in many other parts of the world, where infant morbidity and morality are much higher, and accepted as a fact of life. It is a worthy cause indeed to address the inequities that exist because of lack of education and finances, and differing social and moral values. All doctors should spend time thinking about these things.

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