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Published on: September 20, 2019
Rapid versus standard intravenous rehydration in paediatric gastroenteritis: pragmatic blinded randomised clinical
Stephen B Freedman1, Patricia C Parkin, Andrew R Willan
1Division of Paediatric Emergency Medicine, Hospital for Sick Children, Toronto, ON, Canada. stephen.freedman@sickkids.ca
Insights
Rapid intravenous rehydration does not improve clinical outcomes in children with gastroenteritis. Standard intravenous rehydration is as effective and does not prolong treatment time.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Hydration Therapy
- Gastroenteritis Management
Background:
- Gastroenteritis is a common cause of dehydration in children.
- Intravenous (IV) rehydration is often necessary when oral rehydration fails.
- The optimal rate of IV fluid administration for pediatric dehydration is debated.
Purpose of the Study:
- To compare the effectiveness of rapid versus standard IV rehydration in children with gastroenteritis.
- To assess clinical hydration and outcomes in pediatric patients receiving different IV rehydration rates.
- To evaluate the impact of rehydration speed on treatment duration and patient disposition.
Main Methods:
- A pragmatic randomized controlled trial involving 226 children (3 months to 11 years) with dehydration due to gastroenteritis.
- Participants received either rapid (60 mL/kg) or standard (20 mL/kg) IV rehydration with 0.9% saline.
- Clinical rehydration was assessed using a validated scale at two hours; secondary outcomes included prolonged treatment and time to discharge.
Main Results:
- No significant difference in clinical rehydration rates at two hours between rapid and standard IV groups (36% vs. 30%, P=0.32).
- Similar rates of prolonged treatment were observed (52% vs. 43%, P=0.19).
- The median time to discharge was significantly longer in the rapid rehydration group (6.3 hours vs. 5.0 hours, P=0.03).
Conclusions:
- Rapid IV rehydration offers no significant clinical benefits over standard rates in hemodynamically stable children with gastroenteritis requiring IV fluids.
- Standard IV rehydration is recommended as it does not lead to worse outcomes and may reduce discharge time.
- Further research may explore specific subgroups who might benefit from rapid fluid administration.
Objective:
To determine if rapid rather than standard intravenous rehydration results in improved hydration and clinical outcomes when administered to children with gastroenteritis.
Design:
Single centre, two arm, parallel randomised pragmatic controlled trial. Blocked randomisation stratified by site. Participants, caregivers, outcome assessors, investigators, and statisticians were blinded to the treatment assignment.
Setting:
Paediatric emergency department in a tertiary care centre in Toronto, Canada.
Participants:
226 children aged 3 months to 11 years; complete follow-up was obtained on 223 (99%). Eligible children were aged over 90 days, had a diagnosis of dehydration secondary to gastroenteritis, had not responded to oral rehydration, and had been prescribed intravenous rehydration. Children were excluded if they weighed less than 5 kg or more than 33 kg, required fluid restriction, had a suspected surgical condition, or had an insurmountable language barrier. Children were also excluded if they had a history of a chronic systemic disease, abdominal surgery, bilious or bloody vomit, hypotension, or hypoglycaemia or hyperglycaemia.
Interventions:
Rapid (60 mL/kg) or standard (20 mL/kg) rehydration with 0.9% saline over an hour; subsequent fluids administered according to protocol.
Primary Outcome:
clinical rehydration, assessed with a validated scale, two hours after the start of treatment.
Secondary Outcomes:
prolonged treatment, mean clinical dehydration scores over the four hour study period, time to discharge, repeat visits to emergency department, adequate oral intake, and physician's comfort with discharge. Data from all randomised patients were included in an intention to treat analysis.
Results:
114 patients were randomised to rapid rehydration and 112 to standard. One child was withdrawn because of severe hyponatraemia at baseline. There was no evidence of a difference between the rapid and standard rehydration groups in the proportions of participants who were rehydrated at two hours (41/114 (36%) v 33/112 (30%); difference 6.5% (95% confidence interval -5.7% to 18.7%; P=0.32). The results did not change after adjustment for weight, baseline dehydration score, and baseline pH (odds ratio 1.8, 0.90 to 3.5; P=0.10). The rates of prolonged treatment were similar (52% rapid v 43% standard; difference 8.9%, 21% to -5%; P=0.19). Although dehydration scores were similar throughout the study period (P=0.96), the median time to discharge was longer in the rapid group (6.3 v 5.0 hours; P=0.03).
Conclusions:
There are no relevant clinical benefits from the administration of rapid rather than standard intravenous rehydration to haemodynamically stable children deemed to require intravenous rehydration. Trail registration Clinical Trials NCT00392145.
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