Turk J Emerg Med 2014;14(3):111-114 doi: 10.5505/1304.7361.2014.66049

Submitted: February 15, 2014 Accepted: April 07, 2014 Published online: June 09, 2014

Correspondence: Dr. Sepideh Bagheri. Dr. Sheikh Childrens Hospital, Mashhad, Iran.

e-mail: bagheris@mums.ac.ir

111ORIGINAL ARTICLE

1Mashhad University of Medical Sciences, Mashhad, Iran;2Tabriz University of Medical Sciences, Tabriz, Iran

Anoush AZARFAR,1 Yalda RAVANSHAD,1 Aghillolah KEYKHOSRAVI,1

Sepideh BAGHERI,1 Ziaoddin GHARASHI,2 Mohammad ESMAEELI1

Rapid Intravenous Rehydration to Correct Dehydrationand Resolve Vomiting in Children

with Acute GastroenteritisAkut Gastroenteritli Çocuklarda Dehidratasyonu Düzeltmek ve

Kusmayı Geçirmek için Hızlı intravenöz Rehidrasyon

SUMMARYObjectivesThe objective of this study is to evaluate the effect of rapid intra-venous rehydration to resolve vomiting in children with acute gas-troenteritis.

MethodsThis randomized control trial was conducted in the pediatric emer-gency department in a tertiary care center in Tabriz, North-West of Iran. The study participants’ were 150 children with acute gastro-enteritis 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 in-travenously 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 be-tween the two groups regarding resolution of vomiting.

ConclusionsRapid intravenous rehydration in children with moderate dehydra-tion and vomiting due to gastroenteritis is effective in reducing ad-mission rates in the ED.

Key words: Emergency department; gastroenteritis; rehydration; vomiting.

ÖZETAmaçBu çalışmanın amacı, akut gastroenteritli çocuklarda, hızlı intrave-nöz rehidratasyon tedavisinin kusma üzerine etkisini değerlendir-mektir.

Gereç ve YöntemBu randomize kontrollü çalışma İran’ın Kuzeybatısındaki Tebriz ilinde üçüncü basamak çocuk acil servisinde gerçekleştirildi. Çalışmaya orta derecede dehidrate, elektrolit anormalliği olmayan ve oral rehidras-yon tedavisine yanıt vermemiş akut gastroenteritli 150 çocuk katıldı. İki saat içinde intravenöz yolla 20-30 cc/kg kristaloid çözelti verildi ve kontrol grubu standart 24 saatlik hidrasyon için acil servise alındı. Akut gastroenteritli çocuklarda, hızlı intravenöz rehidratasyon tedavi-sinin kusma üzerine etkisi değerlendirildi.

BulgularMüdahale grubundaki 75 çocuğun 63’ünde hızlı IV rehidrasyondan sonra kusma geçti ve hastalar taburcu edildi. Bu çocukların 12’si oral sıvıları tolere edemedikleri için hastaneye kabul edildi. Kontrol gru-bunda 62 hastanın kusması hastaneye kabulden sonraki ilk 4 saat içinde geçmiş olup, iki grup arasında kusmanın geçmiş olması açı-sından herhangi bir anlamlı farklılık yoktu.

SonuçGastroenterite bağlı orta derecede dehidratasyon ve kusması olan çocuklarda hızlı intravenöz rehidrasyon acil servisten yatış oranlarını azaltmada etkilidir.

Anahtar sözcükler: Acil servis; gastroenterit; rehidrasyon; kusma.

IntroductionAcute gastroenteritis is the most common cause of dehydra-tion in children and represents one of the most common conditions in pediatric emergency departments.[1,2] Oral re-hydration is appropriate for most children, but intravenous rehydration is the treatment of choice for severe dehydration and in cases of failure of oral rehydration therapy.[3] Given the high incidence of acute gastroenteritis in children, this can lead to overcrowding in emergency departments.[4] The most appropriate method of intravenous rehydration is still under investigation. The volume and rate of administration of intravenous fluids are the focal point of many discussions. Slow restoration regimens and rapid rehydration regimens have both been used by clinicians treating dehydrated chil-dren.[5,6] Rapid rehydration regimens might have the poten-tial benefits of achieving earlier rehydration and reduction in length of hospital stay and costs.[7]

Considering the large incidence of acute gastroenteritis in our country, we carried out this study to evaluate the effec-tiveness of the rapid intravenous rehydration on the resolu-tion of vomiting and correction of dehydration in moderate-ly dehydrated children with acute gastroenteritis in whom oral rehydration therapy had failed and were therefore can-didates for intravenous rehydration therapy.

Materials and Methods Settings

A randomized control trial was conducted in the emergency department of Tabriz children's hospital, North-West of Iran.

Participants

The study population consisted of 150 children with moderate dehydration or vomiting due to gastroenteritis who had not responded to oral rehydration therapy. 565 children were referred to the hospital with the diagnosis of acute gastroenteritis during the study period. We excluded children with severe dehydration, shock and hypotension, electrolyte abnormalities, those who were not dehydrated or were mildly dehydrated. Parents signed informed consent before entry into the study and the study was approved by the medical ethics committee of the Tabriz University of Medical Sciences prior to entrance into the study.

Enrollment and Intervention

Eligible patients were children with moderate dehydration or vomiting due to gastroenteritis who had not responded to an oral rehydration therapy. They were randomly assigned to each of the study groups: rapid intravenous rehydration or standard 24 hour intravenous therapy. They were allocated in a 1:1 ratio for each group. Nine patients in the intervention group were excluded from the study due to electrolyte abnormalities. In the intervention group, 54 patients received metoclopramide prior to admission and 49 patients in the control group received metoclopramide as well; this was not significantly different between two groups (p=0.7).

The intervention group received 20-30 cc/kg of a crystalloid solution over 2 hours. Four hours after the initiation of IV therapy, the patients were visited by the attending physician at which time they were discharged or admitted.

112 Turk J Emerg Med 2014;14(3):111-114

Table 1. Patients’ characteristics in intervention and control groups

Intervention group Control group p

Population 75 75 –

Age (year) 2.73±2.53 2.1±1.74 0.07

Sex (female) 27 F 31 F 0.33

Weight (kg) 12.27±5.6 11.48±4.22 0.11

Table 2. Patients’ outcomes in intervention and control groups

Outcomes Intervention group Control group p

n % n %

Stop vomiting after 4 hours 63 84 62 82 >0.05

Persistent vomiting 2 3 >0.05

Follow up information was collected on day 3 following admission. Patients in the control group were also visited at this time to control their vomiting.

Randomization

The randomization sequence was generated by the statistical adviser of the research program. A computerized randomizer was used for this purpose.

Outcome Measure

The primary outcome measure was resolution of vomiting in children with gastroenteritis receiving rapid intravenous rehydration.

Statistical Analysis

Statistical analysis was performed using SPSS software. Student’s T-test and chi square tests were used for quantitative and qualitative data. P-values less than 0.05 were considered to be significant.

ResultsDuring the study period, 150 patients met the enrollment cri-teria and were enrolled in the study (75 to rapid rehydration and 75 to standard rehydration). The two groups were similar regarding sex, age and weight (Table 1). At two hours, 84% (63) of children given rapid IV rehydration had rehydrated or experienced resolution of vomiting and were discharged. 16% (12) were admitted to the ED (Table 2). Patients in the rapid rehydration group received 20-30 cc/kg of isotonic solution over 2 hours and patients in the standard 24 hours rehydration group had received about 30-35 cc/kg of intra-venous solution over four hours according to their degree of dehydration which is not significantly different between two groups. This demonstrates that rapid intravenous rehydra-tion can result in a substantial reduction of ED admissions. Among 63 patients who were discharged, 2 cases had recur-rence of vomiting and were readmitted.

In 62 patients of the control group, vomiting resolved after 4 hours and only 3 had persistent vomiting for more than 12 hours. Comparing the two groups regarding the resolution of vomiting, chi square test did not indicate a significant differ-ence between the two groups (p>0.05) (Table 2).

DiscussionThe results of this study show that rapid intravenous rehy-dration is as effective as standard rehydration regimens in the treatment of dehydration and vomiting in children with gastroenteritis, and it can thus prevent unnecessary admis-sions to EDs and reduce unnecessary expenses. In cases

where oral rehydration therapy fails, intravenous rehydra-tion is a necessary alternative for dehydrated babies. A few studies have also reported an effective rehydration with ad-ministration of fluids in amounts of 20-40 cc/kg over varying periods.[8] Considering its benefits, this method of treatment is being adopted into clinical practice.[9-11] Almost all children in our study recovered without complications and only 2 cases had recurrence of vomiting and were admitted.

Some pediatric nephrologists believe that the prolonged deficit therapy is outdated, and they believe in the imple-mentation of high volume fluid resuscitation.[5] Although multiple studies have shown usefulness and effectiveness of rapid IV rehydration,[13,14] the amounts and rates of fluid administration have not been defined. In our study, we ad-ministered 20-30 ml/kg of fluids over two hours; this was well tolerated by patients and no significant complications were observed. In the study by Phin et al. on moderately de-hydrated children, significant reductions were observed in the admission rates and number of discharges in a period of eight hours or less in the intervention group compared with the control group; no significant differences in the rates of re-presentation or rate of procedures were observed.[12] Freedman et al.[9] have compared rapid versus standard IV rehydration and concluded that resolution of dehydration after two hours was the same in both groups and they sug-gested avoidance of using rapid rehydration due to possible complications. We did not encounter any significant compli-cations during our investigation. However, this needs to be investigated further in larger multicenter trials.

Conclusion

Rapid rehydration in children dehydrated from gastroen-teritis is effective in reducing admission rates and lengths of stay in emergency departments. According to the results of this study this method can be used safely in pediatric pa-tients with dehydration due to acute gastroenteritis.

Limitations

Our study was performed to show the preliminary advan-tages of rapid intravenous rehydration regimens. The analy-sis of serious complications and its safety and the rate and volume of fluids administered requires further investigation.

Acknowledgements

This article is extracted from the MD Thesis of Atefe Ah-madzade.

Conflict of Interest

The authors declare that there is no potential conflicts of in-terest.

Azarfar A et al. Rapid Intravenous Rehydration to Correct Dehydration and Resolve Vomiting 113

References

1. Bonadio WA. Acute infectious enteritis in children. Emergen-cy department diagnosis and management. Emerg Med Clin North Am 1995;13:457-72.

2. Wathen JE, MacKenzie T, Bothner JP. Usefulness of the serum electrolyte panel in the management of pediatric dehydra-tion treated with intravenously administered fluids. Pediat-rics 2004;114:1227-34. CrossRef

3. King CK, Glass R, Bresee JS, Duggan C; Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutri-tional therapy. MMWR Recomm Rep 2003;52:1-16.

4. Bender BJ, Ozuah PO. Intravenous rehydration for gastro-enteritis: how long does it really take? Pediatr Emerg Care 2004;20:215-8. CrossRef

5. Holliday MA, Friedman AL, Wassner SJ. Extracellular fluid res-toration in dehydration: a critique of rapid versus slow. Pedi-atr Nephrol 1999;13:292-7. CrossRef

6. Nager AL. Intravenous rehydration in paediatric gastroenteri-tis. BMJ 2011;343:d7083. CrossRef

7. Nager AL, Wang VJ. Comparison of ultrarapid and rapid intra-venous hydration in pediatric patients with dehydration. Am J Emerg Med 2010;28:123-9. CrossRef

8. Moineau G, Newman J. Rapid intravenous rehydration in the pediatric emergency department. Pediatr Emerg Care 1990;6:186-8. CrossRef

9. Freedman SB, Sivabalasundaram V, Bohn V, Powell EC, John-son DW, Boutis K. The treatment of pediatric gastroenteritis: a comparative analysis of pediatric emergency physicians’ practice patterns. Acad Emerg Med 2011;18:38-45. CrossRef

10. Nager AL. Fluid and electrolyte therapy in infants and children. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, editors. Tintinalli’s emergency medicine: a com-prehensive study guide. 7th ed. McGraw-Hill; 2010. p. 971-5.

11. Shaw KN, Spandorfer PR. Dehydration. In: Fleisher GR, Ludwig S, editors. Textbook of pediatric emergency medicine. 6th ed. Lippincott Williams & Wilkins; 2010. p. 206-11.

12. Phin SJ, McCaskill ME, Browne GJ, Lam LT. Clinical pathway using rapid rehydration for children with gastroenteritis. J Paediatr Child Health 2003;39:343-8. CrossRef

13. Pizarro D, Posada G, Mohos E. Rapid rehydration by intra-venous route in dehydrated children by diarrhea. [Article in Spanish] Bol Med Hosp Infant Mex 1980;37:365-74. [Ab-stract]

14. Vesikari T, Isolauri E, Baer M. A comparative trial of rapid oral and intravenous rehydration in acute diarrhoea. Acta Paedi-atr Scand 1987;76:300-5. CrossRef

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