Rapid hydration in gastroenteritis , how is it effective?

1. RAPID
HYDRATION
IN GE
HOW IS IT
EFFECTIVE?
D R A B D U L L A H A L Z A H R A N I
P E M F 1
K S U M C

2. • Acute gastroenteritis in infants and children is a common
reason for visiting the emergency department .
• Dehydration remains the most frequent and serious
complication of gastroenteritis.
• Oral rehydration therapy for 4 hour period is the first-line
treatment
• Where oral rehydration is not feasible, rehydration by NGT is
the preferred option before IV rehydration in some guidelines .
• The standard hydration is replacing fluid deficits over 24 hours
in haemodynamically stable children, traditional teaching
support such an approach
• prolonged IV rehydration contributes to overcrowding in the
emergency department

3. • As compare to standard rehydration , the experts
noticed the rapid rehydration regimens reduces a
child’s level of agitation and clinical signs of
dehydration, in addition to enhancing alertness and
appetite.
• These benefits enable clinicians to achieve earlier
rehydration with subsequent reductions in length
stay and costs
• Because of its potential benefits, rapid IV
rehydration has gradually become incorporated into
clinical practice and is recommended in a leading
textbook of emergency medicine.

4. • Current practice of rapid IV rehydration shows wide
variation in the volume and rate of rapid IV
hydration.
• IVF: bolus 20ml/kg over one hour followed by
Dextrose and NS, 10ml/kg/hr for 2 hours.
• The evidence supporting the safety and efficacy of
rapid versus standard rehydration remains uncertain

5. LITERATURE REVIEW
• Nager AL, Wang VJ. Comparison of ultrarapid and rapid
intravenous hydration in pediatric patients with dehydration.
Am J Emerg Med. 2010;28(2):123–9.
• Freedman SB, Parkin PC, Willan AR, Schuh S. Rapid versus
standard intravenous rehydration in paediatric gastroenteritis:
pragmatic blinded randomised clinical trial. BMJ.
2011;343:d6976.
• Azarfar A, Ravarshad Y, Keykhosravi A, Bagheri S, Gharashi Z,
Esmaeeli M. Rapid intravenous rehydration to correct
dehydration and resolve vomiting in children with acute
gastroenteritis. Turk J Em Medicine. 2014;14(3):111–4.

6. LITERATURE REVIEW
• Rapid Intravenous Rehydration Therapy in Children With Acute
Gastroenteritis : A Systematic Review , Pediatric Emergency
Care , Volume 32, Number 2, February 2016
• Rapid intravenous rehydration of children with acute
gastroenteritis and dehydration: a systematic review and meta-
analysis , M. A. Iro1, T. Sell1, N. Brown and K. Maitland , Iro et al.
BMC Pediatrics , February 2018

7. • 3 studies , 464 participants

8. RESULT

10. RESULT : FREEDMAN 2011
• No significant difference between treatment assignment and
successful rehydration by 2 hours (odds ratio 1.8 (95% CI
3.5); p=0.10).
• At 4 hours, clinical rehydration was achieved in 69% of patients
receiving either treatment (difference of 0.5%; 95% CI,−12.6% to
11.5%).
• Prolonged treatment was observed in 52% of large volume
versus 43% of standard volume rehydration patients (difference
of 8.9%; 95% CI,−5.0% to 21.0%).
• No clinically significant difference was observed between large
volume and standard rehydration regarding ED length of stay
greater than 6 hours (35% vs 33%) or ED revisits requiring
admission (6% vs5%).

11. RESULT : FREEDMAN 2011
• Both groups, similar numbers of children were hyponatremic at
4 hours of treatment (large volume,21% [23/112]; standard, 20%
[21/105];P= 0.92).
• At 4 hours of treatment, there was no difference in the number
of children who developed hypernatremia (standard, 1/105;
large, 3/112;P= 0.62).
• Among children with hyponatremia before the start of
treatment, 63% (30/48) in the large-volume group and 44%
(15/34) in the standard-volume group had improvement of
their hyponatremia at 4 hours (P= 0.10).

12. RESULT
Nager 2010 :
– ED time to discharge ranged from 2 to6 hours (rapid rehydration)
versus 2 to 5 hours (standard method).
• None of the studies reported on length of hospital stay or
mean duration of diarrhea.
• None of the studies was sufficiently powered to assess safety
concerns.
• There were no deaths in any study.

13. LIMITATIONS
• Each study used a different methodology,
• Wide variation in rehydration regimens and tools of
dehydration assessment.
• Small sample size
• Only one trial was sufficiently powered to detect any treatment
effects. In that trial the estimated sample size provided 80%
power to detect a 20%point difference between in the
proportion of children rehydrated after two hours of
rehydration treatment

14. CONCLUSION
• IV rehydration should be reserved for patients who fail ORT
(insufficient intake, persistent vomiting, worsening diarrhea, or
dehydration) or those with severe dehydration.
• Rapid IV rehydration may be associated with longer time to
discharge and higher readmission rates.
• The meta analysis of these trials did not suggest superiority of
rapid or ultra-rapid over standard rehydration
• Large multicenter randomized trials are needed to achieve the
optimal IV rehydration approach for pediatric gastroenteritis.

15. THANK YOU

16. Nager 2010
• Methods
– Pilot randomized controlled convenience sample study in the emergency department of the
Children Hospital in Los Angeles, USA
• Study aim
– To provide some evidence for our belief that the ultra-protocol could be performed effectively
with similar results as the standard hydrating method.
• Participants
– Ninety-two children aged 3 to 36 months
– Inclusion criteria: acute (< 7 days) complaints of vomiting and/or diarrhea) and moderate
dehydration and failure of oral rehydration.
– Exclusion criteria: severe dehydration, shock, suspected intussusception, appendicitis, mal-
rotation, recent trauma, meningitis, or congestive heart failure or if any of these diagnoses
appeared as the study progressed; chronic disease or significant laboratory abnormality
including Na < 130 or > 150 mmol/L and/or K < 3.2 or > 5.5mmol/L.
• Interventions
– 50 mL/kg of normal saline IV administered for 1 h (ultra rapid IV hydration) or 50 mL/kg
normal saline IV for 3 h(standard hydration)
• Allocation1:1
• Outcomes
– Efficacy of treatment by assessing Success and timing of rehydration, study failures (defined
as requirement for admission), output (urine, emesis, stool) during the treatment phase, pre-
and post-treatment laboratory abnormalities, number of return visits, and whether serious
complications occurred.

17. Freedman 2011
• Methods
– Randomized controlled trial conducted in the emergency department of the Hospital for Sick Children, Toronto,
Canada. Study period between December 2006 and April 2010
• Study aim
– To determine if rapid rather than standard intravenous rehydration results in improved hydration and clinical
outcomes when administered to children with gastroenteritis.
• Participants
– Inclusion criteria:
• Age > 90 days; diagnosis of dehydration secondary to gastroenteritis and refractory to oral rehydration.
– Exclusion criteria:
• children weighing < 5 kg or > 33 kg, requiring for fluid restriction, had a suspected surgical condition, had a history
of a severe chronic systemic disease, abdominal surgery, or bilious vomit, had hypotension, hypoglycaemia or
hyperglycaemia, insurmountable language barrier or lack of telephone for follow up call.
• Interventions
– One hundred and twelve infants received 60 mL/kg of 0.9% saline over 60 min (rapid rehydration) and 114children
received 20 mL/kg over 60 min (standard rehydration).
• Allocation 1:1
• Outcomes
– Primary:
• Rehydration defined as a score on the clinical dehydration scale of≤1 two hours after the start of treatment.
– Secondary:
• Prolonged treatment–a composite measure defined as admission to an inpatient unit at the index visit or admission
within 72 h of randomization or a stay in the emergency department longer than 6 h after the start of treatment;
score on a clinical dehydration scale; adequate oral fluid intake defined as consuming at least 5 mL/kg of liquid per 2
h time period; time to discharge defined as time between start of treatment and discharge from the emergency
department of inpatient unit; repeat emergency department visit within 72 h; and attending physician’s comfort with
discharge at two and four hours, reported on a 5-pointLikert scale

18. Azarfar 2014
• Methods
– Randomized controlled trial conducted in the emergency department in a
tertiary center (Tabriz children’s hospital) in Tabriz, North-West of Iran.
• Objective
– To evaluate the effect of rapid intra- venous rehydration to resolve vomiting in
children with acute gastroenteritis.
• Participants
– Inclusion criteria: 150 Children with moderate dehydration or vomiting due to
gastroenteritis who had not responded to oral rehydration therapy.
– Exclusion criteria: severe dehydration, shock, and hypotension, electrolyte
abnormalities, none or mild dehydration.
• Intervention
– 20-30 mL/kg of a crystalloid solution over either 2 h (intervention group) or 24 h
(control group).
• Allocation1:1
• Outcomes
– Primary outcome: Resolution of vomiting in children receiving rapid intravenous
rehydration.
• No secondary outcomes. Iroet al.