Rapid Intravenous Rehydration Research Articles

Clinical and laboratory evaluation and management of children with vomiting, diarrhea, and dehydration.

Dehydration is responsible for the morbidity and, rarely, mortality secondary to vomiting and diarrhea from acute gastroenteritis. Despite the abundance of literature in the last 20 to 30 years focused on the treatment of dehydration with oral rehydration therapy, few studies have focused on the actual clinical diagnosis of dehydration. Conventional classification systems for assessing dehydration have not been subjected to rigorous prospective validation until recently. This article reviews the recent clinical evidence that validates the use of clinical signs and symptoms in assessing dehydration in children. The utility and limitations of measuring capillary refill time as a sign are also reviewed. In addition, the scant literature examining the utility of laboratory studies in evaluating dehydration is summarized. Oral rehydration therapy for the management of dehydration in children is reviewed. Finally, recent literature examining the effectiveness and advantages of rapid intravenous rehydration in the outpatient setting is discussed.

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

Study objective: To determine the efficacy of outpatient rapid IV rehydration in correcting dehydration and resolving vomiting in children with mild to moderate dehydration resulting from acute gastroenteritis. Methods: We carried out a prospective cohort study in an urban children's hospital. A convenience sample of 58 children aged 6 months to 13 years, with acute gastroenteritis and clinically estimated dehydration of 5% to 10% body weight, was assembled. All patients had been vomiting for less than 48 hours, had vomited at least five times in the 24 hours preceding presentation, and had metabolic acidosis (serum bicarbonate concentration, 18 mEq/L or less). Each patient received an IV infusion of 20 to 30 mL/kg isotonic crystalloid solution over 1 to 2 hours, followed by the oral administration of 1 to 3 ounces of clear fluid. Patients who subsequently vomited were admitted for continued IV fluid therapy. Patients who tolerated oral fluid were discharged; their caregivers were contacted by telephone 24 to 48 hours after discharge. Results: All patients had improved hydration status after rapid IV rehydration. Sixteen patients (28%) did not tolerate oral fluids after rapid IV rehydration and were admitted; 11 of these patients had a serum bicarbonate concentration of 13 mEq/L or less. The other 42 patients (72%) tolerated oral fluids after rapid IV rehydration and were discharged; 41 of these patients had a serum bicarbonate concentration greater than 13 mEq/L. The frequency of serum bicarbonate concentration of 13 mEq/L or less on presentation was significantly greater ( P=.001) in patients requiring hospitalization than in those discharged from the emergency department after rapid IV rehydration. Of 40 patients whose caregivers were contacted after discharge, 34 (85%) required no further medical evaluation or treatment for any reason, including inadequate hydration; 29 of these patients vomited no more than once. Six of the discharged patients (15%) required further medical evaluation and were admitted; four had recurrent vomiting and dehydration, two had not vomited but were dehydrated as a result of diarrheal fluid loss or inadequate oral fluid intake. Conclusion: Outpatient rapid IV rehydration is safe and effective in correcting dehydration and resolving vomiting in selected children with acute gastroenteritis and mild to moderate dehydration. In our study, most children who presented with a serum bicarbonate concentration greater than 13 mEq/L tolerated oral fluids after rapid IV rehydration and were further managed as outpatients without complications. By contrast, most children with a serum bicarbonate concentration of 13 mEq/L or less usually did not tolerate oral fluids after rapid IV rehydration and required more prolonged IV fluid therapy. All discharged patients, regardless of their serum bicarbonate concentration, demonstrated the ability to tolerate orally administered fluid. [Reid SR, Bonadio WA: Outpatient rapid intravenous rehydration to correct dehydration and resolve vomiting in children with acute gastroenteritis. Ann Emerg Med September 1996;28:318-323.] See related editorial, p 353.

Rapid intravenous rehydration in the pediatric emergency department

Children suffering from mild to moderate (3 to 6%) dehydration likely caused by viral gastroenteritis are often hospitalized because they are unable to tolerate oral fluids. We studied 17 such children, aged one to six years, who were otherwise healthy. All had isonatremic dehydration and were treated with 30 ml/kg of 3.3% dextrose and 0.3% saline over a period of three hours in the emergency department before being discharged. No patient required admission to the hospital. Only one patient required another course of rapid intravenous rehydration and subsequently improved without hospitalization. Although all our patients experienced vomiting before treatment, 65% had no vomiting after treatment. Rapid intravenous rehydration is an effective treatment, for children with mild to moderate dehydration secondary to presumed viral gastroenteritis, that obviates the need for hospitalization.

Rapid intravenous rehydration by means of a single polyelectrolyte solution with or without dextrose

We compared the efficacy and safety of a single polyelectrolyte solution, Dhaka solution (DS), containing 133 mmol/L sodium, 13 mmol/L potassium, 98 mmol/L chloride, and 48 mmol/L acetate with and without 139 mmol/L (25 gm/L) dextrose in the rapid (4 hours) rehydration of 67 patients with diarrhea and moderate or severe dehydration requiring parenteral fluid therapy. Of the 67 patient, 31 were randomly assigned to receive the dextrose-containing solution (DS + D) and 36 DS without dextrose. On admission to the hospital, the two groups of patients were similar with respect to enteric pathogens detected, proportion with hyponatremia, magnitude of dehydration as assessed by clinical criteria, serum protein or creatinine concentration, and plasma glucose levels. At the end of the 4-hour infusion, both groups of patients had similar decreases in serum creatinine and protein levels and similar volume of urine output, but patients receiving DS + D had a significantly higher plasma glucose level than patients receiving DS (7.8 mmol/L (140 mg/dl) vs 5.39 mmol/L (97 mg/dl), P less than 0.01). One patient in the DS group had hypoglycemia (plasma glucose 2.0 mmol/L (36 mg/dl) at 4 hours. No other complications were noted. Serum protein values 24 hours after admission were little changed from 4-hour values, suggesting that rehydration was complete at the end of 4 hours. We conclude that, in our patients, rehydration can be carried out safely and rapidly with the use of a single solution and that adding 139 mmol/L (25 gm/L) of dextrose to the solution can prevent hypoglycemia without producing an osmotic diuresis.

Oral therapy for acute diarrhoea.

There are 3 mainand related problems that must be considered in managing acute watery diarrheas -- the treatment of fluid loss and related metabolic disturbances nutritional management and drug therapy but the prime objective in the treamtment of patients with acute diarrhea is to replace lost fluids. The importance of the intact sodium ion glucose absorption system in the toxigenic diarrheas is that it provides a mechanism for hydration via the intestine despite the enterotoxin induced fluid secretion into the gut lumen. This is the basic for oral rehydration therapy (ORT) which is being promoted vigorously by the World Health Organization (WHO) and has been adopted with considerable success in dozens of developing countries. The current question is whether this medical advance can be transferred from the developing to the developed countries. There is good evidence that the time is right for this change. The rehydration solution recommended by WHO has the following composition: sodium 90 mmol/L; potassium 20 mmol/L; chloride 80 mmol/L; bicarbonate 30 mmol/L; and glucose 111 mmol/L and can be made by dissolving 3.5 gm of sodium chloride 2.5 gm of sodium bicarbonate 1.5 gm of potassium chloride and 20 gm of glucose (or 40 gm of sucrose) in 1 liter of water. Experience in field trials has shown that most patients with mild to moderate dehydration can be managed effectively by oral therapy based on the above mentioned electrolyte solution. It must be recongnized that more seriously dehydrated patients will require initially more rapid intravenous rehydration followed by oral rehydration to replace continuing fluid losses. It is important also to appreciate that once a person becomes dehydrated replacement therapy should cover both the rehydration pase and the maintenance phase. The aim of ORT is to avoid unnecessary intravenous therapy and its attendant risks. It must supply maintenance fluid requirements and replace fluids lost in watery stools. ORT can work even in patients who are vomiting provided that small volumes of fluid are given frequently but special care must be taken in children under age 2 and particularly in infants under 6 months of age in whom dehydration tends to be rapid. In general terms the WHO formulation has proven satisfactory as a basis for ORT in patients with acute diarrheas and some commercially available products closely resemble this formulation. The WHO formulation perhaps with a lower sodium content could be used as a safe guide for oral therapy for patients with acute diarrhea in Australia.