Rapid Intravenous Rehydration Research Articles

Recommendation document on rapid intravenous rehydration in acute gastroenteritis

IntroductionThe 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. ObjectiveTo prepare a document with evidence-based recommendations about RIR in paediatric population. MethodsThe 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). Results16 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). ConclusionsThis document establishes consensus recommendations, based on the available scientific evidence, which could contribute to the standardisation of the use of RIR in our setting.

Documento de recomendaciones sobre la rehidratación intravenosa rápida en gastroenteritis aguda

IntroductionThe 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. ObjectiveTo prepare a document with evidence-based recommendations about RIR in paediatric population. MethodsThe 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). ResultsSixteen 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). ConclusionsThis document establishes consensus recommendations, based on the available scientific evidence, which could contribute to the standardisation of the use of RIR in our setting.

Evaluación de la efectividad de acciones correctivas derivadas de la notificación de incidentes en urgencias pediátricas

ObjectiveTo analyse the effectiveness of corrective measures arising from the analysis of safety incident notifications in the Paediatric Emergency Unit. MethodsA quasi-experimental, prospective, and single-centre study was carried out between 2015 and 2018. In the first phase, incidents notified throughout one year were analysed. Corrective measures were then implemented for 5 specific kinds of incidents. These incidents were finally compared to those notified within 12 months after the implementation of those measures. Results were expressed as relative risk and relative risk reduction. ResultsA total of 1587 safety incidents were notified (0.9% of patients treated) between January 2015 and December 2017. After implementation of corrective measures, there was a decrease in all kinds of incidents notifications analysed. The incidents related to patient identification were reduced by 60.9% (RR 0.39, 95% CI; 0.25-0.60), and those regarding communication between professionals were reduced by 74.5% (RR 0.25, 95% CI; 0.12-0.55). Incidents related to sedation and analgesic procedures totally disappeared. No significant reduction was found in incidents concerning the triage system, or in those related to rapid intravenous rehydration procedures. ConclusionsThe implementation of improvement actions arising from the analysis of voluntary notification of incidents is an effective strategy to improve patient effective strategy to improve.

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

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. 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. 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. 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.

Rapid intravenous rehydration of children with acute gastroenteritis and dehydration: a systematic review and meta-analysis

BackgroundThe World Health Organization (WHO) recommends rapid intravenous rehydration, using fluid volumes of 70-100mls/kg over 3–6 h, with some of the initial volume given rapidly as initial fluid boluses to treat hypovolaemic shock for children with acute gastroenteritis (AGE) and severe dehydration. The evidence supporting the safety and efficacy of rapid versus slower rehydration remains uncertain.MethodsWe conducted a systematic review of randomised controlled trials (RCTs) on 11th of May 2017 comparing different rates of intravenous fluid therapy in children with AGE and moderate or severe dehydration, using standard search terms. Two authors independently assessed trial quality and extracted data. Non-RCTs and non-English articles were excluded. The primary endpoint was mortality and secondary endpoints included adverse events (safety) and treatment efficacy.Main resultsOf the 1390 studies initially identified, 18 were assessed for eligibility. Of these, 3 studies (n = 464) fulfilled a priori criteria for inclusion; most studied children with moderate dehydration and none were conducted in resource-poor settings. Volumes and rates of fluid replacement varied from 20 to 60 ml/kg given over 1-2 h (fast) versus 2-4 h (slow). There was substantial heterogeneity in methodology between the studies with only one adjudicated to be of high quality. There were no deaths in any study. Safety endpoints only identified oedema (n = 6) and dysnatraemia (n = 2). Pooled analysis showed no significant difference between the rapid and slow intravenous rehydration groups for the proportion of treatment failures (N = 468): pooled RR 1.30 (95% CI: 0.87, 1.93) and the readmission rates (N = 439): pooled RR 1.39 (95% CI: 0.68, 2.85).ConclusionsDespite wide implementation of WHO Plan C guideline for severe AGE, we found no clinical evaluation in resource-limited settings, and only limited evaluation of the rate and volume of rehydration in other parts of the world. Recent concerns over aggressive fluid expansion warrants further research to inform guidelines on rates of intravenous rehydration therapy for severe AGE.

Gastroenteritis Aggressive Versus Slow Treatment For Rehydration (GASTRO). A pilot rehydration study for severe dehydration: WHO plan C versus slower rehydration

Background: The World Health Organization (WHO) rehydration management guidelines (Plan C) for children with acute gastroenteritis (AGE) and severe dehydration are widely practiced in resource-poor settings, yet have never been formally evaluated in a clinical trial. A recent audit of outcome of AGE at Kilifi County Hospital, Kenya noted that 10% of children required high dependency care (20% mortality) and a number developed fluid-related complications. The fluid resuscitation trial, FEAST, conducted in African children with severe febrile illness, demonstrated higher mortality with fluid bolus therapy and raised concerns regarding the safety of rapid intravenous rehydration therapy. Those findings warrant a detailed physiological study of children’s responses to rehydration therapy incorporating quantification of myocardial performance and haemodynamic changes. Methods: GASTRO is a multi-centre, unblinded Phase II randomised controlled trial of 120 children aged 2 months to 12 years admitted to hospital with severe dehydration secondary to AGE. Children with severe malnutrition, chronic diarrhoea and congenital/rheumatic heart disease are excluded. Children will be enrolled over 18 months in 3 centres in Kenya and Uganda and followed until 7 days post-discharge. The trial will randomise children 1:1 to standard rapid rehydration using Ringers Lactate (WHO plan ‘C’ – 100mls/kg over 3-6 hours according to age, plus additional 0.9% saline boluses for children presenting in shock) or to a slower rehydration regimen (100mls/kg given over 8 hours and without the addition of fluid boluses). Enrolment started in November 2016 and is on-going. Primary outcome is frequency of adverse events, particularly related to cardiovascular compromise and neurological sequelae. Secondary outcomes focus on clinical, biochemical, and physiological measures related to assessment of severity of dehydration, and response to treatment by intravenous rehydration. Discussion: Results from this pilot will contribute to generating robust definitions of outcomes (in particular for non-mortality endpoints) for a larger Phase III trial.

Gastroenteritis Aggressive Versus Slow Treatment For Rehydration (GASTRO). A pilot rehydration study for severe dehydration: WHO plan C versus slower rehydration.

The World Health Organization (WHO) rehydration management guidelines (Plan C) for children with acute gastroenteritis (AGE) and severe dehydration are widely practiced in resource-poor settings, yet have never been formally evaluated in a clinical trial. A recent audit of outcome of AGE at Kilifi County Hospital, Kenya noted that 10% of children required high dependency care (20% mortality) and a number developed fluid-related complications. The fluid resuscitation trial, FEAST, conducted in African children with severe febrile illness, demonstrated higher mortality with fluid bolus therapy and raised concerns regarding the safety of rapid intravenous rehydration therapy. Those findings warrant a detailed physiological study of children's responses to rehydration therapy incorporating quantification of myocardial performance and haemodynamic changes. Methods: GASTRO is a multi-centre, unblinded Phase II randomised controlled trial of 120 children aged 2 months to 12 years admitted to hospital with severe dehydration secondary to AGE. Children with severe malnutrition, chronic diarrhoea and congenital/rheumatic heart disease are excluded. Children will be enrolled over 18 months in 3 centres in Kenya and Uganda and followed until 7 days post-discharge. The trial will randomise children 1:1 to standard rapid rehydration using Ringers Lactate (WHO plan 'C' - 100mls/kg over 3-6 hours according to age, plus additional 0.9% saline boluses for children presenting in shock) or to a slower rehydration regimen (100mls/kg given over 8 hours and without the addition of fluid boluses). Enrolment started in November 2016 and is on-going. Primary outcome is frequency of adverse events, particularly related to cardiovascular compromise and neurological sequelae. Secondary outcomes focus on clinical, biochemical, and physiological measures related to assessment of severity of dehydration, and response to treatment by intravenous rehydration. Results from this pilot will contribute to generating robust definitions of outcomes (in particular for non-mortality endpoints) for a larger Phase III trial.

Hyperemesis in Pregnancy Study: a pilot randomised controlled trial of midwife-led outpatient care

ObjectiveTo assess the feasibility of implementing a complex intervention involving rapid intravenous rehydration and ongoing midwifery support as compared to routine in-patient care for women suffering from severe nausea and vomiting in pregnancy, (NVP)/hyperemesis gravidarum (HG). Study design53 pregnant women attending the Maternity Assessment Unit (MAU), Newcastle upon Tyne NHS Foundation Trust, Newcastle, UK with moderate-severe NVP, (as determined by a Pregnancy Unique Quantification of Emesis and Vomiting [PUQE] score ≥nine), consented to participate in this pilot randomised controlled trial (RCT). Subsequently 27 were randomised to the intervention group, 26 to the control group.Women in the intervention group received rapid rehydration (three litres Hartman's solution over 6h) and symptom relief on the MAU followed by ongoing midwifery telephone support. The control group were admitted to the antenatal ward for routine in-patient care.Quality of life (QoL) determined by SF36.V2 score and PUQE score were measured 7 days following randomisation. Completion rates, readmission rate, length of hospital stay and pregnancy outcomes data were collected. ResultsGroups were comparable at baseline. Questionnaire two return rate was disappointing, only 18 women in the control group (69%) and 13 women in the intervention groups (44%). Nonetheless there were no differences between groups on Day 7 in terms of QoL, mean PUQE score, satisfaction with care, obstetric and neonatal outcomes or readmission rates. However, total combined admission time was higher in the control group (94h versus 27h, p=0.001). ConclusionsThis study suggests that day-case management plus ongoing midwifery support may be an effective alternative for treating women with severe NVP/HG. A larger trial is needed to determine if this intervention affects women's QoL.

Rapid Intravenous Rehydration Therapy in Children With Acute Gastroenteritis: A Systematic Review.

Rapid intravenous (IV) rehydration is commonly used for the management of pediatric gastroenteritis in the emergency department. The current practice shows wide variation in the volume and rate of rapid IV hydration. The aim of this review was to assess the efficacy of rapid IV rehydration compared with standard method in children with gastroenteritis. MEDLINE (1946-2014), EMBASE (1974-2014), and CENTRAL via the Cochrane Library (Issue 8, 2014) were systematically searched to identify eligible studies. Inclusion criteria were randomized controlled trials of rapid IV rehydration in children with gastroenteritis. A total of 1513 articles were retrieved, and our inclusion criteria were met by 3 studies, with a total of 464 participants. The percentage of children who were successfully rehydrated and tolerated oral fluids at 2 to 4 hours after starting IV fluid therapy ranged from 69% to 100% in both rapid IV rehydration and standard method. Time to discharge ranged from 2 to 6 hours (rapid rehydration) versus 2 to 5 hours (standard rehydration). Emergency department revisits ranged from 3% to 16% (rapid rehydration) versus 5% to 14% (standard). Summarized results suggested that rapid IV rehydration may be associated with longer time-to-discharge and higher readmission rates. The new evidence fails to demonstrate superiority of large-volume (60 mL/kg/h) over standard (20 mL/kg/h) IV rehydration. Standard volume IV rehydration for 1 to 4 hours followed by oral hydration or maintenance IV fluids seems sufficient for most children with gastroenteritis requiring IV fluid administration. However, more evidence is needed to establish an optimal IV rehydration regimen.

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

New guidelines for "rapid or ultrarapid" intravenous rehydration are being developed in different emergency departments. These new guidelines propose a faster administration of fluids and electrolytes than in traditional protocols. However, there is still insufficient evidence to establish a standard protocol. Our objective was to determine the effects of an outpatient rapid intravenous rehydration regimen based on the administration of 0.9% saline + 2.5% dextrose, at a rate of 20 mL/kg per hour for 2 hours, in children with mild-to-moderate isonatremic dehydration resulting from acute gastroenteritis. We performed a 2-institution, prospective, observational, descriptive study. Eighty-three patients were included in the study. All patients underwent a first evaluation, including physical examination, laboratory tests, and assessment of clinical degree of dehydration. After this initial evaluation, all children received our intravenous rehydration regimen. A second evaluation including the same items as in the first one was made after in all the children. Intravenous rehydration was successful in 69 patients (83.1%). It failed in 14 patients (16.8%), who required hospitalization because of persistent vomiting in 9 patients and poor general appearance in 5 patients. After intravenous rehydration, we observed a statistically significant decrease in the levels of ketonemia and uremia and in the Gorelick scale score. However, no significant changes were observed in sodium, chloride, potassium, and osmolarity values. We conclude that, in children with mild-to-moderate dehydration, the administration of 20 mL/kg per hour for 2 hours of 0.9% saline solution + 2.5% glucose improved clinical scores and may be used as an alternative and safe way for intravenous rehydration.

Gastroenteritis Therapies in Developed Countries: Systematic Review and Meta-Analysis.

ContextGastroenteritis remains a leading cause of childhood morbidity.ObjectiveBecause prior reviews have focused on isolated symptoms and studies conducted in developing countries, this study focused on interventions commonly considered for use in developed countries. Intervention specific, patient-centered outcomes were selected.Data SourcesMEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, trial registries, grey literature, and scientific meetings.Study SelectionRandomized controlled trials, conducted in developed countries, of children aged <18 years, with gastroenteritis, performed in emergency department or outpatient settings which evaluated oral rehydration therapy (ORT), antiemetics, probiotics or intravenous fluid administration rate.Data ExtractionThe study was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. Data were independently extracted by multiple investigators. Analyses employed random effects models.Results31 trials (4,444 patients) were included. ORT: Compared with intravenous rehydration, hospitalization (RR 0.80, 95%CI 0.24, 2.71) and emergency department return visits (RR 0.86, 95%CI 0.39, 1.89) were similar. Antiemetics: Fewer children administered an antiemetic required intravenous rehydration (RR 0.40, 95%CI 0.26, 0.60) While the data could not be meta-analyzed, three studies reported that ondansetron administration does increase the frequency of diarrhea. Probiotics: No studies reported on the primary outcome, three studies evaluated hospitalization within 7 days (RR 0.87, 95%CI 0.25, 2.98). Rehydration: No difference in length of stay was identified for rapid vs. standard intravenous or nasogastric rehydration. A single study found that 5% dextrose in normal saline reduced hospitalizations compared with normal saline alone (RR 0.70, 95% CI 0.53, 0.92).ConclusionsThere is a paucity of patient-centered outcome evidence to support many interventions. Since ORT is a low-cost, non-invasive intervention, it should continue to be used. Routine probiotic use cannot be endorsed at this time in outpatient children with gastroenteritis. Despite some evidence that ondansetron administration increases diarrhea frequency, emergency department use leads to reductions in intravenous rehydration and hospitalization. No benefits were associated with ondansetron use following emergency department discharge.

Rapid Intravenous Rehydration to Correct Dehydration and Resolve Vomiting in Children with Acute Gastroenteritis

SUMMARYObjectivesThe objective of this study is to evaluate the effect of rapid intravenous rehydration to resolve vomiting in children with acute gastroenteritis.MethodsThis randomized control trial was conducted in the pediatric emergency department in a tertiary care center in Tabriz, North-West of Iran. The study participants' were 150 children with acute gastroenteritis and vomiting who were moderately dehydrated, had not responded to oral rehydration therapy and without any electrolyte abnormalities. 20–30 cc/kg of a crystalloid solution was given intravenously over 2 hours and the control group was admitted in the emergency department (ED) for a standard 24 hour hydration. Effectiveness of rapid intravenous rehydration in the resolution of vomiting in children with acute gastroenteritis was evaluated.ResultsIn 63 children of the intervention group (out of 75) vomiting was resolved after rapid IV rehydration and they were discharged. Among them, 12 that did not tolerate oral fluids were admitted. In the control group, 62 patients' vomiting was resolved in the first 4 hours after admission, and there was no significant difference between the two groups regarding resolution of vomiting.ConclusionsRapid intravenous rehydration in children with moderate dehydration and vomiting due to gastroenteritis is effective in reducing admission rates in the ED.

Cerebral Hyperemia Measured with Near Infrared Spectroscopy during Treatment of Diabetic Ketoacidosis in Children

To use near infrared spectroscopy (NIRS) to evaluate the timing of onset and duration of cerebral hyperemia during diabetic ketoacidosis (DKA) treatment in children, and to investigate the relationship of cerebral hyperemia to intravenous fluid treatment. We randomized children aged 8-18 years with DKA to either more rapid or slower intravenous fluid treatment (19 total DKA episodes). NIRS was used to measure rSo2 during DKA treatment. NIRS monitoring began as soon as informed consent was obtained and continued until the patient was transferred out of the critical care unit. rSo2 values above the normal range (>80%) were detected in 17 of 19 DKA episodes (mean rSo2 during initial 8 hours of DKA treatment: 86% ± 7%, range 65%-95%). Elevated rSo2 values were detected as early as the second hour of DKA treatment and persisted for as long as 27 hours. Hourly mean rSo2 levels during treatment did not differ significantly by fluid treatment group. During DKA treatment, children have elevated rSo2 values consistent with cerebral hyperemia. Hyperemia occurs as early as the second hour of DKA treatment and may persist for ≥ 27 hours. Cerebral rSo2 levels during treatment did not differ significantly in patients treated with slower versus more rapid intravenous rehydration.

Ringer’s lactate vs normal saline for children with acute diarrhea and severe dehydration: A double blind randomized controlled trial

WHO recommends Ringers lactate (RL) and Normal Saline (NS) for rapid intravenous rehydration in childhood diarrhea and severe dehydration. We compared these two fluids for improvement in pH over baseline during rapid intravenous rehydration in children with acute diarrhea. Double-blind randomized controlled trial Pediatric emergency facilities at a tertiary-care referral hospital. Children with acute diarrhea and severe dehydration received either RL (RL-group) or NS (NS-group), 100 mL/kg over three or six hours. Children were reassessed after three or six hours. Rapid rehydration was repeated if severe dehydration persisted. Blood gas was done at baseline and repeated after signs of severe dehydration disappeared. Primary outcome was change in pH from baseline. Secondary outcomes included changes in serum electrolytes, bicarbonate levels, and base-deficit from baseline; mortality, duration of hospital stay, and fluids requirement. Twenty two children, 11 each were randomized to the two study groups. At primary end point (disappearance of signs of severe dehydration), the improvement in pH from baseline was not significant in RL-group [from 7.17 (0.11) to 7.28 (0.09)] as compared to NS-group [7.09 (0.11) to 7.21 (0.09)], P=0.17 (after adjusting for baseline serum Na/ Cl). Among this limited sample size, children in RL group required less fluids [median 310 vs 530 mL/kg, P=0.01] and had shorter median hospital stay [38 vs 51 hours, P=0.03]. There was no difference in improvement in pH over baseline between RL and NS among children with acute diarrhea and severe dehydration.

Intravenous rehydration for diarrheal dehydration of eutrophic children: survey of protocols provided at Colombian medical schools

In all cases of severe dehydration from diarrhea, WHO recommends rapid rehydration. If oral rehydration in children is contraindicated, intravenous rehydration is recommended for immediate administration. However, methods of intravenous rehydration appear to be inadequately addressed in the medical schools of Colombia. Current approaches to oral rehydration were summarized, and instructors were informed concerning current WHO recommendations. A survey was designed for pediatric instructors in Colombian medical schools. Direct questions about rehydration methods were included as well as presentation of theoretical clinical situations with dehydrated children. The survey also asked for the conditions necessary for intravenous rehydration and method of administration (volume, solution, concentration and speed of infusion). Forty-one surveys were included (82% of medical schools in Colombia). Inadequate contraindications for oral rehydration therapy were made in 41%. Rapid and slow intravenous rehydration was recommended in 71% and 29%, respectively; 57% recommended fluid bolus to rehydrate. Adequate volumes were recommended by less than half of the respondents and adequate sodium concentration was recommended by 85%. In 56% of medical schools, glucose was not included in solutions and 66% use Ringer lactate. Normal saline solution, dextrose solution with electrolytes and polyelectrolytes solutions are also used. Misconceptions are common concerning the contraindications to oral rehydration therapy. One-third of medical schools promote a slow therapy despite the superiority of the rapid therapy. Uniformity for rapid therapy schemes is lacking. Bolus rehydration is commonly advocated despite the fact that this method is unsupported by the literature. Concepts about rehydration must be updated in medical schools and a national guide for intravenous rehydration is recommended.

Safety of Rapid Intravenous Rehydration and Comparative Efficacy of 3 Oral Rehydration Solutions in the Treatment of Severely Malnourished Children With Dehydrating Cholera

Assess the safety of rapid intravenous rehydration of severely malnourished children and compare the efficacy of 3 formulations of oral rehydration salts solutions. A group of 175 severely malnourished children of either sex (weight/length <70% of National Center for Health Statistics median), ages 6 to 36 months with cholera, were randomly assigned to receive 1 of 3 oral rehydration solutions (ORSs): glucose-ORS (n=58), glucose-ORS plus 50 g/L of amylase-resistant starch (n=59), or rice-ORS (n=58). Severely dehydrated children at enrollment were administered 100 mL/kg of an intravenous solution for 4 to 6 hours before randomisation, and those with some dehydration were randomised on enrollment. The electrolytes of the 3 ORSs were identical. In acute and convalescence phases, treatment was similar other than the nature of the ORSs. Intravenous fluid (mean) administered to 149 study children was 103 mL/kg (95% confidence interval [CI] 96-109), and all were rehydrated within 6 hours. None of them developed overhydration or heart failure. During the first 24 hours, stool output (31%; 95% CI 14%-42%; P=0.004) and the ORS intake (26%; 95% CI 12%-37%; P=0.002) of children receiving rice-ORS were significantly less compared with children receiving glucose-ORS. The mean duration of diarrhoea in all children (66 hours; 95% CI 62-71), and time to attain 80% of median weight/length (7.15+/-2.81 days) were not different. Dehydration in severely malnourished children can safely be corrected within 6 hours. All study ORSs were equally efficient in correcting dehydration. Rice-ORS significantly reduced the stool output and ORS intake, confirming previous reports.

Efficacy and safety of normal saline in rapid intravenous rehydration

Efficacy and safety of normal saline in rapid intravenous rehydration

Intravenous Dextrose during Outpatient Rehydration in Pediatric Gastroenteritis

Rapid intravenous (IV) rehydration in the emergency department (ED) is required for certain children with acute gastroenteritis (AGE). To determine whether the amount of IV dextrose administered is related to a return visit with admission (RVA) in children with AGE and dehydration, and to determine which clinical, laboratory, and treatment parameters are associated with an RVA. The investigators performed a case control study of children aged 6 months to 6 years who presented to an urban ED with AGE and dehydration and who received IV rehydration before discharge from the ED. Dehydration was defined a priori on the basis of parameters used in prior studies. Cases were defined as those patients who had an RVA within 72 hours of an original visit for ongoing symptoms. Controls were defined as those patients who met inclusion criteria who did not have an RVA. The authors studied whether the amount of IV dextrose administered at the initial visit was related to an RVA as well as which other clinical and treatment parameters were associated with an RVA. A total of 56 cases and 112 controls were studied. Patients who had an RVA received significantly less IV dextrose (mean: 399 mg/kg vs. 747 mg/kg, p < 0.001) than those who did not have an RVA. Patients who received no IV dextrose had 3.9 times greater odds of having a return visit with admission than those who received some dextrose. Controlling for fluid volume, the amount of dextrose administered remained statistically significant by logistic regression; for every 500 mg/kg of IV dextrose administered, the patient was 1.9 times less likely to have an RVA. Patients with length of symptoms less than or equal to one day were more likely to have an RVA than were those with symptom length of two or more days. No other historical or physical exam findings or laboratory parameters (including mean serum bicarbonate) were associated with a return visit requiring admission. Administration of larger amounts of IV dextrose is associated with reduced return visits requiring admission in children with gastroenteritis and dehydration.

Rapid IV versus Oral Rehydration

This study sought to determine the effect of rapid intravenous (IV) versus oral (ORAL) rehydration immediately after dehydration, on cardiovascular, thermoregulatory, and perceptual responses during subsequent exercise in the heat. Eight males (21.4 +/- 0.7 yr; 176.2 +/- 1.6 cm; 75.2 +/- 3.7 kg; 63.7 +/- 3.6 mL.kg.min VO2max, 9.0 +/- 1.7% fat) participated in three randomized trials. Each trial consisted of a 75-min dehydration phase (36 degrees C; 42.5% rh, 47 +/- 0.9% VO2max) where subjects lost 1.7 L (IV and no-fluid (NF) trials) to 1.8 L of fluid (ORAL trial). In the heat, fluid lost was matched with 0.45% saline in 20 min by either IV or ORAL rehydration; no fluid was given in the NF trial. Subjects then performed a heat-tolerance test (HTT; 37.0 degrees C, 45% rh, treadmill speed of 2.4 m.s, 2.3% grade) for 75 min or until exhaustion (Tre of 39.5 degrees C). During the HTT, thermal and thirst sensations, RPE, rectal temperature (Tre), heart rate (HR), and mean weighted skin temperature (Tsk) were measured. Plasma volume in the IV treatment was greater (P < 0.05) after rehydration compared with ORAL and NF. However, during the HTT there were no overall differences (P > 0.05) in HR, Tre, Tsk, RPE, thermal sensations, or HTT time (ORAL, 71 +/- 8 min; IV, 73 +/- 5 min; NF, 39 +/- 29 min) between the ORAL and IV treatments. Sensations of thirst were lower (P < 0.05) in ORAL compared with IV and NF, likely because of oropharyngeal stimuli. Despite a more rapid restoration of plasma volume, IV rehydration was not advantageous over ORAL rehydration in regards to physiological strain, heat tolerance, RPE, or thermal sensations.

Fluid Resuscitation in Malaria: The Need for New Randomised Clinical Trials

Very little clinical research has been conducted on how to manage children with severemalaria, despite it accounting for the deaths of around 1 million children each year in Africa alone. Antimalarial drugs remain the mainstay of treatment (and are the subject of several current or planned clinical trials), but there is increasing debate around aspects of supportive care and the treatment of complications. No aspect of care has been more controversial in recent years than the initial fluid management of children with severe malaria, particularly given the resourcepoor health-care context in which most such children are treated. The debate centres around the role of hypovolaemia (i.e., insufficient circulating blood volume) in the pathophysiology of severe malaria. Hypovolaemia has been incriminated as an important cause of metabolic acidosis, which has been shown repeatedly to be associated with a poor prognosis. The key question is whether hypovolaemia contributes to impaired tissue perfusion in severe malaria, contributing to the anaerobic glycolysis and consequent acidosis. Some studies of severe malaria in children have supported this hypothesis by providing indirect evidence (e.g., capillary refill time, central venous p r e s s u r e mea su r emen t s , r a i s e d creatinine, and clinical dehydration) that severely ill patients are commonly hypovolaemic on admission, and that this contributes to the severity of the disease [1,2]. In febrile children hypovolaemia often results from dehydration, but a detailed study in Gabon showed that the children with severe malaria investigated had only a mild or moderate degree of dehydration (as measured by total body water, not necessarily synonymous with hypovolaemia) [3]. So, should children with severe malaria all receive rapid intravenous fluid rehydration? And if so, with what fluid? Proponents of rapid fluid repletion cite the standards of care applied in resourcerich settings for severely ill children with bacterial sepsis, whilst those advocating caution argue that malaria should be considered differently, particularly given the haemodynamic and circulatory differences from sepsis and the concerns of precipitating or worsening pulmonary or cerebral oedema [2,4]. It is clear that clinical trials are the only way forward to resolve the debate. There have been several previously published intervention studies, all conducted by Maitland and the Kilifi team on the Kenyan coast, but to date all have been too small and heterogenous to provide conclusive answers.