Effects of Rapid Intravenous Rehydration in Children With Mild-to-Moderate Dehydration

The Prevalence and Indications of Intravenous Rehydration Therapy in Hospital Settings: A Systematic Review

(1) Objective: We performed a systematic review to explore the prevalence of intravenous (IV) rehydration therapy in hospital settings, and we assessed it by patient groups and populations. (2) Methods: A systematic review of major databases and grey literature was undertaken from inception to 28 March 2022. Studies reporting prevalence of IV rehydration therapy in a hospital setting were identified. The data were synthesised in a narrative approach. (3) Results: Overall, 29 papers met the inclusion criteria. The prevalence of IV rehydration therapy in paediatric patients ranged from 4.5% (hospitalised with diarrhoea and dehydration) to 100% (admitted to the emergency department with mild to moderate dehydration caused by viral gastroenteritis), and in adults this ranged from 1.5% (had single substance ingestion of modafinil) to 100% (hospitalised with hypercalcemia). The most common indication for IV rehydration therapy in paediatric patients was dehydration due to fluid loss from the gastrointestinal tract. Other causes included malnutrition, neuromuscular disease, bronchiolitis, and influenza. In adults, indications for IV rehydration therapy were much more diverse: fever, diarrhoea, drug intoxication, hypercalcemia, cancer, and postural tachycardia syndrome; (4) Conclusions: This systematic review showed that IV rehydration therapy in paediatric patients is often used to treat dehydration and diarrhoea, while in adults it has a broader spectrum of use. While IV rehydration therapy is important in correcting fluid problems and electrolyte status, the maintenance fluid prescribing practices vary considerably, and guidelines are scarce.

Alterations and diagnostic performance of capillary ketonemia in pediatric acute appendicitis: a pilot study

INTRODUCTION

The diagnostic performance of capillary ketonemia (CK) has been previously evaluated in context of pediatric acute gastroenteritis. To our knowledge, there is no literature on its performance in the setting of pediatric acute appendicitis (PAA).

MATERIALS AND METHODS

In this study, 151 patients were prospectively included and divided into two groups: (1) patients with non-surgical abdominal pain in whom the diagnosis of PAA was excluded (n = 53) and (2) patients with a confirmed diagnosis of PAA (n = 98). In 80 patients (Group 1, n = 23 and group 2, n = 57) a CK was measured at the time of diagnosis. The PAA group was further classified into complicated (n = 18) and uncomplicated PAA (n = 39). Quantitative variables were compared between groups using the Mann-Whitney U test. Diagnostic performance of CK was evaluated with ROC curves.

RESULTS

CK values were 0.3 [0.1-0.9] mmol/L in group 1 and 0.7 [0.4-1.4] mmol/L in group 2 (p = 0.01). Regarding the type of PAA, CK values were 0.6 [0.4-0.9] mmol/L in uncomplicated PAA and 1.2 [0.8-1.4] mmol/L in complicated PAA (p = 0.02). The AUC for the discrimination between groups 1 and 2 was 0.68 (95% IC 0.53-0.82) (p = 0.24) and the AUC for the discrimination between uncomplicated PAA and complicated PAA was 0.69 (95% IC 0.54-0.85) (p = 0.04). The best cut-off point (group 1 vs group 2) resulted in 0.4 mmol/L, with a sensitivity of 80.7% and a specificity of 52.2%. The best cut-off point (non-complicated vs complicated PAA) resulted in 1.1 mmol/L, with a sensitivity of 61.1% and a specificity of 76.9%.

CONCLUSIONS

This study found significantly higher levels of CK in patients with PAA than in those with NSAP. Similarly, significantly higher levels were observed in patients with complicated than in those with uncomplicated PAA. Nevertheless, the diagnostic performance of CK was only moderate in the two settings analyzed. The potential usefulness of CK determination as a tool to guide the preoperative rehydration regimen of patients with PAA to prevent postoperative hyporexia and vomiting is a promising line of research and should be evaluated in future studies.

Recommendation document on rapid intravenous rehydration in acute gastroenteritis

INTRODUCTION

The efficacy and safety of the Rapid Intravenous Rehydration (RIR) guidelines in children affected by dehydration secondary to acute gastroenteritis is supported by current scientific evidence, but there is also great variability in its use in clinical practice.

OBJECTIVE

To prepare a document with evidence-based recommendations about RIR in paediatric population.

METHODS

The project was developed based on GRADE methodology, according to the following work schedule: Working Group training; creation of a catalogue of questions about research and definition of "relevant outcomes"; score and selection criteria for each item; bibliographic review; scientific evidence evaluation and synthesis (GRADE); review, discussion and creation of recommendations. 10 clinical questions and 15 relevant outcomes were created (7 about efficacy and 8 about security).

RESULTS

16 recommendations were set up, from which we can highlight as the main ones: 1) RIR is safe for children affected by mild-moderate dehydration secondary to acute gastroenteritis, unless expressly contraindicated or acute severe comorbidity (strong recommendation, moderate evidence). 2) Its use is recommended in this situation when oral rehydration has failed or due to contraindication (strong, high). 3) Isotonic fluids are recommended (strong, high), suggesting saline fluid as the first option (light, low), supplemented by glucose (2.5%) in those patients showing normoglycemia and ketosis (strong, moderate). 4) A rhythm of 20cc/kg/h is recommended (strong, high) during 1-4 h (strong, moderate).

CONCLUSIONS

This document establishes consensus recommendations, based on the available scientific evidence, which could contribute to the standardisation of the use of RIR in our setting.

[Recommendation document on rapid intravenous rehydration in acute gastroenteritis]

INTRODUCTION

The efficacy and safety of the rapid intravenous rehydration (RIR) guidelines in children affected by dehydration secondary to acute gastroenteritis is supported by current scientific evidence, but there is also great variability in its use in clinical practice.

OBJECTIVE

To prepare a document with evidence-based recommendations about RIR in paediatric population.

METHODS

The project was developed based on GRADE methodology, according to the following work schedule: Working Group training; creation of a catalogue of questions about research and definition of «relevant outcomes»; score and selection criteria for each item; bibliographic review; scientific evidence evaluation and synthesis (GRADE); review, discussion and creation of recommendations. 10 clinical questions and 15 relevant outcomes were created (7 about efficacy and 8 about security).

RESULTS

Sixteen recommendations were set up, from which we can highlight as the main ones: (1) RIR is safe for children affected by mild-moderate dehydration secondary to acute gastroenteritis, unless expressly contraindicated or acute severe comorbidity (strong recommendation and moderate evidence). (2) Its use is recommended in this situation when oral rehydration has failed or due to contraindication (strong and high). (3) Isotonic fluids are recommended (strong and high), suggesting saline fluid as the first option (light and low), supplemented by glucose (2.5%) in those patients showing normoglycemia and ketosis (strong and moderate). (4) A rhythm of 20 cc/kg/h is recommended (strong and high) during 1-4 h (strong and moderate).

CONCLUSIONS

This document establishes consensus recommendations, based on the available scientific evidence, which could contribute to the standardisation of the use of RIR in our setting.

Outcomes and predictors of early emergency department discharge among children with acute gastroenteritis and moderate dehydration

Background

Gastroenteritis is one of the most common diseases that affects children and remains a leading cause of morbidity and mortality around the world. There is conflicting evidence regarding the effect of rapid intravenous fluid regimen on the clinical outcome of patients with acute gastroenteritis. This study aimed to assess the current practice of intravenous hydration on the clinical outcomes of pediatric patients with acute gastroenteritis and determine the predictive factors for early discharge and emergency department (ED) revisit.

Methods

A cohort study was carried out among children aged from 1 month to 14 years who presented to the ED in a tertiary care hospital between September 2015 and September 2017. Children diagnosed with acute gastroenteritis and moderate dehydration who require intravenous hydration were included in the study. The patients were followed up until discharge from ED, admission to the hospital or revisit to the ED. Collected variables were demographics, presenting symptoms, biochemical marker, amount of intravenous fluid (IVF) received and prescription of anti-emetics. Descriptive statistics were summarized as mean, standard deviation for continuous variables and proportions for categorical variables. Logistic regression was used to identify risk factors.

Results

Out of 284 patients, 148 (52%) were males, 20 (7%) were infants, 80 (28%) were toddlers, 90 (32%) were in preschool, 88 (31%) were in school and 6 (2.1%) were adolescents. No significant difference was observed in the admission rate, discharge within 12 h or less and ED revisits for those who received IVF ≥40 ml/kg as compared to those who received <40 ml/kg. Patients with bicarbonate level closer to normal are more likely to be discharged after 4 h (odds ratio (OR) 1.2 and 95% CI 1.12–1.43). Patients presenting only with vomiting/diarrhoea were less likely to revisit ED (OR 0.33 (95% CI 0.143 - 0.776), while patients with an increase in CO₂ level (OR 1.19 and 95% CI 1.0 -1.436) and anion gap (OR 1.29 and 95% CI 1.08–1.54) were more likely to revisit within 1 week post discharge.

Conclusion

This study did not show any additional benefits of receiving IVF ≥ 40 ml/kg over 4 h neither in early discharge nor in reducing the ED revisit. CO₂ closer to normal was a significant predictor for early discharge in 4 h where the closer level of CO₂ and AGAP were associated with an increase in the chance of a revisit to the ED within 1 week after discharge.

The utility of ketones at triage: a prospective cohort study

OBJECTIVE

To establish the relationship between serum point-of-care (POC) ketones at triage and moderate-to-severe dehydration based on the validated Gorelick Scales.

DESIGN, SETTING AND PATIENTS

Prospective unblinded study from April 2016 to February 2017 in a paediatric emergency department. Patients aged 1 month to 5 years, with vomiting and/or diarrhoea and/or decreased intake with signs of moderate or severe dehydration or clinical concern for hypoglycaemia were eligible.

MAIN OUTCOME MEASURES

The primary outcome was to describe the relationship between triage POC ketones to the two Gorelick Scales. Secondary outcomes were to examine the response of ketone levels to fluid/glucose administration and patient disposition.

RESULTS

One-hundred and ninety-eight patients were included; median age 1.8 years. The median triage ketones were 4.6 (IQR 2.8-5.6) mmol/L. A weak correlation was identified between triage ketones and the 10-point Gorelick Scale (Spearman's ρ=0.217, p=0.002), however no correlation between triage ketones and the 4-point Gorelick Scale was identified. Those admitted had median triage ketones of 5.2 (IQR 4-6) mmol/L and repeat ketones of 4.6 (IQR 3.3-5.7) mmol/L compared with 4.2 (IQR 2.4-5.3) mmol/L and 2.9 (IQR 1.6-4.2) mmol/L in those discharged home.

CONCLUSION

No correlation between triage POC ketones and the 4-point Gorelick Scale was established. POC ketones at triage have poor accuracy for predicting hospital admission. The elevated profile of POC ketones in non-diabetic children with acute illness suggests a potential target of tailored treatments for further research.

Clinical Impact of Rapid Intravenous Rehydration With Dextrose Serum in Children With Acute Gastroenteritis

OBJECTIVES

We designed a study to compare rapid intravenous rehydration based on 0.9% normal saline (NS) or on NS + glucose 2.5% serum (SGS 2.5%) in patients with dehydration secondary to acute gastroenteritis. Our hypothesis is that the addition of glucose 2.5% serum (SGS 2.5%) to 0.9% saline solution could reduce the proportion of hospital admissions and return emergency visits in these patients. The secondary objective was to identify differences in the evolution of blood glucose and ketonemia between the groups.

METHODS

We designed a prospective randomized open-label clinical trial that was conducted in 2 tertiary hospitals over 9 months. Patients were randomized to receive SGS 2.5% or NS. Baseline clinical, analytical, and disease-related data were collected. Data were analyzed using SPSS.

RESULTS

The frequency of hospitalization in the SGS 2.5% group was 30.3% (n = 23) compared with 34.8% (n = 24) in the NS group, although the difference was not statistically significant (P = 0.59). The frequency of return visits to the emergency department was 17.8% (n = 8) in the NS group and 5.6% (n = 3) in the SGS 2.5% group (P = 0.091). Changes in glucose and ketone levels were more favorable in the SGS 2.5% group.

CONCLUSIONS

Our results enabled us to conclude that there were no significant differences in hospital admission or return visits to the emergency department between children with dehydration secondary to acute gastroenteritis.

Recruitment of extravascular fluid by hyperoncotic albumin

BACKGROUND

Although hyperoncotic albumin may be used to recruit oedema, its effectiveness remains unclear. Therefore, this issue was studied during infusion experiments in healthy volunteers.

METHOD

Fifteen healthy volunteers (mean age 31 years) received an infusion of 3 mL/kg of 20% albumin over 30 minutes. Their urinary excretion was recorded, and venous blood samples were taken to measure blood haemoglobin (Hb), haematocrit, colloid osmotic pressure as well as plasma albumin and sodium concentrations on 15 occasions over a period of 300 minutes. Plasma volume expansion was taken as the inverse of the fluid-induced dilution of venous plasma, as given by the blood Hb concentration. Mass balance calculations were used to estimate the mobilisation of fluid from the tissues.

RESULTS

Maximum plasma volume expansion was reached 20 minutes after completing an infusion of 20% albumin. Urinary excretion was effectively increased, and the mobilised fluid from the tissues at 300 minutes amounted to 3.4 ± 1.2 mL for each infused mL of 20% albumin, of which 19% was of intracellular origin. The urinary excretion correlated strongly with the amount of recruited fluid (R²  = 0.87) and inversely with the plasma volume expansion (R²  = 0.53).

CONCLUSION

The infusion of 20% albumin significantly increases the plasma volume by recruiting interstitial fluid. After completing the infusion, there is a delay of 20 minutes until maximum plasma dilution is reached, and the duration of the plasma volume expansion lasts far beyond 5 hours.

Clinical Practice: Nausea and vomiting in acute gastroenteritis: physiopathology and management

Currently recommended management of acute gastroenteritis is supportive. Although the affected children habitually have vomiting, recommendations do not focus on the correction of this symptom. In this condition, elevated ketone bodies and stimuli initiated by gut mucosa damage produced by the enteral pathogen likely underlay nausea and vomiting. As compared to 0.9% saline, intravenous administration of a dextrose-containing bolus of 0.9% saline is associated with a greater reduction of circulating ketones and a shorter duration of nausea and vomiting. Nonetheless, this treatment strategy is not followed by a lower rate of hospitalization.

CONCLUSION

Well-designed investigations suggest that antagonists of the type 3 serotonin receptor, most frequently oral ondansetron, reduce the rate of vomiting, improve the tolerance of oral rehydration, and reduce the need for intravenous rehydration. What is Known: • Although children with gastroenteritis habitually have vomiting, current recommendations do not focus on the correction of this symptom. What is New: • Recently acquired evidence supports the prescription of ondansetron, an antagonist of the type 3 serotonin receptor, to increase the success rate of oral rehydration therapy.