When should I consider referring a patient with dehydration for specialist assessment?

Consider referring a patient with dehydration for specialist assessment if they show any signs of shock, red flag symptoms, or clinical deterioration despite initial treatment.

Specifically, urgent referral is indicated if the patient has:

• Symptoms or signs suggesting shock, such as altered responsiveness (irritability, lethargy), decreased level of consciousness, tachycardia, tachypnoea, prolonged capillary refill time, weak peripheral pulses, hypotension, cold extremities, or pale/mottled skin.
• Red flag symptoms or signs indicating severe dehydration or hypernatraemic dehydration, including sunken eyes, dry mucous membranes, reduced skin turgor, or neurological signs like jittery movements, increased muscle tone, hyperreflexia, convulsions, drowsiness, or coma.
• Persistent vomiting of oral rehydration solution (ORS) or inability to tolerate oral fluids.
• Clinical evidence of deterioration despite oral rehydration therapy.
• Need for intravenous fluid therapy, especially if hypernatraemic dehydration is suspected, requiring expert advice on fluid management.

Additionally, if a child remains shocked after two rapid intravenous fluid boluses, specialist paediatric intensive care consultation should be considered.

In summary, refer for specialist assessment when dehydration is severe, complicated by shock, not responding to oral rehydration, or when hypernatraemia is suspected or confirmed.

References: NICE CG84, NICE NG29