Journal Club

Usha Niranjan

PICU

Rationale

• 2 x cases of severe dehydration with metabolic acidosis – requesting for HDU management – as given 40mls/kg fluid bolus- ? May require more

• Case 1: 13month old with vomiting and diarrhoea( massive large watery stools)– moderate to severe dehydration stable clinically,– Gas: pH 7.13, pCO2-4.3, HC03- 8, BE-14

• Case 2: 3weeks old – severe diarrhoea, no vomiting– Hypernatremic dehydration but stable clinically– Gas : pH 7.03, pCO2- 3.8, HC03- 5, BE- 23

PICO• P: In children

• I: Rapid correction of metabolic acidosis(

severe dehydration)secondary to

gastroenteritis

• C: Slow correction

• O: Better outcomes

NHS evidence database searches• Medline• Embase

– No relevant articles on metabolic acidosis– About 130 + articles on dehydration + rapid rehydration– screened abstracts and picked up this one

Article

“Rapid versus standard intravenous rehydration in paediatric gastroenteritis: pragmatic blinded randomised clinical trial."

Freedman, Stephen B., et al. BMJ (Clinical research ed.) 343 (2010): d6976-d6976.

NICE 2009 Diarrhoea and vomiting in children

• Clinical dehydration( including hypernatraemic)– ORS solution for oral rehydration over 4hrs +maintenance– Consider NGT fluids

• Use intravenous fluid therapy for clinical dehydration if:– shock is suspected or confirmed– red flag symptoms or signs – deterioration despite oral rehydration therapy

Study• Paediatric emergency department in tertiary centre

(Toronto, Canada)- single centre• Period: Dec 2006 to April 2010• Children aged 3months -11yrs• >5kg + < 33kg

• Diagnosis of dehydration secondary to gastroenteritis – not responded to oral rehydration requiring i.v rehydration

Intervention• Rapid rehydration – 60mls/kg of 0.9% saline over 1 hr• Standard rehydration – 20mls/kg of 0.9% saline over 1 hr

• Subsequent maintenance+ oral rehydration until end of study period – 4hrs

• Telephone F/U on days 3 and 7.

Results• Primary outcome: Clinical rehydration at 2hrs

– rapid rehydration group( 114) - 36%– standard rehydration group (112) – 29%– P = 0.32

• No significant difference between two groups with regard to successful rehydration in 2hrs

Secondary outcome• Prolonged treatment(admission ; >6hrs in ED; admission

within 72hrs– P = 0.19 ( longer in rapid group)– Logistic regression( OR 0.81, P = 0.61 in favour of standard

group)

• Mean scores on clinical dehydration over the study period– No significant difference ( P =0.96)

• Proportion rehydrated at 4hrs– P >0.99 (Same for both groups -69% /69%)

Score on clinical dehydration scale as continuous variable during the study period – 4hrs (P=0.96)

Secondary outcomes• Admission to hospital in the 1st visit

– More in the rapid group ( p= 0.04)– even on excluding those admitted due to metabolic acidosis

• Time to discharge – Longer in rapid rehydration group (p=0.03) –significant

• Physicians comfort at discharge – trend in favour of standard rehydration

Critical appraisal• Validity

1)Did the trial address a clearly focussed issue?• Yes

2)Was the assignment of patients randomised?• Yes

– Computer generated ; stratified by severity of dehydration

Validity• Were all the patients who entered the trial properly

accounted for at its conclusion

– YES

• Were patients , health workers and study personnel ‘blind’ to the treatment?

• Yes – Blinded to research nurse, physician and participants– Un-blinded to bedside nurse

• Were the groups similar at the start of the trial?

– Yes

• Were the groups treated equally(apart from intervention)– Yes

Results• How large was the effect?

– Primary outcomes : At 2hrs

• rapid rehydration group( 114) - 36%• standard rehydration group (112) – 29%• P = 0.32• C.I (-5.7% to 18.7% - the absolute

difference-6.5%– No significant difference between two groups with regard to

successful rehydration in 2hrs

• Power –adequate (80%)

Secondary outcome

• Prolonged treatment (admission ; >6hrs in ED; admission within 72hrs)– P = 0.19 (longer in rapid group)

• Mean scores on clinical dehydration over the study period– No significant difference ( P =0.96)

• Proportion rehydrated at 4hrs– P >0.99

Secondary outcome• Prolonged treatment(admission ; >6hrs in ED; admission

within 72hrs– P = 0.19 ( longer in rapid group)– OR 0.81, P = 0.61 in favour of standard group

• Mean scores on clinical dehydration over the study period– No significant difference ( P =0.96)

• Proportion rehydrated at 4hrs– P >0.99 (Same for both groups -69% /69%)

Results• Were the results precise?• Yes

Limitations:• The degree of dehydration scores –could have been

added differently overestimated• Risk of mild cases being included

• No mention about ongoing losses• Ongoing oral rehydration might have had effect on

outcomes

Applicability• Can the results be applied to the local population?

• Yes

Applicability• Were all the clinically important outcomes considered?• Yes

• Are the benefits worth the harm and costs?

• Yes

Metabolic acidosis secondary to gastroenteritis

• Metabolic acidosis – secondary to bicarbonate loss

• Worsening due to large volumes of saline– Excess chloride( reduction in anion gap)– Excess renal elimination of bicarbonate

ConclusionBased on this article

• There is no significant difference to the resolution of dehydration with rapid vs standard i.v rehydration

• None of the outcomes favoured the use of rapid i.v rehydration

THANK YOU