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

SUMMARY Objectives The objective of this study is to evaluate the effect of rapid intravenous rehydration to resolve vomiting in children with acute gastroenteritis. Methods This randomized control trial was conducted in the pediatric emergency department in a tertiary care center in Tabriz, North-West of Iran. The study participants' were 150 children with acute gastroenteritis 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 intravenously 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. Results In 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 between the two groups regarding resolution of vomiting. Conclusions Rapid intravenous rehydration in children with moderate dehydration and vomiting due to gastroenteritis is effective in reducing admission rates in the ED.


Introduction
Acute gastroenteritis is the most common cause of dehydration in children and represents one of the most common conditions in pediatric emergency departments. [1,2] Oral rehydration 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 children. [5,6] Rapid rehydration regimens might have the potential 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 effectiveness of the rapid intravenous rehydration on the resolution of vomiting and correction of dehydration in moderately dehydrated children with acute gastroenteritis in whom oral rehydration therapy had failed and were therefore candidates for intravenous rehydration therapy.

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. 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.

Results
During the study period, 150 patients met the enrollment criteria 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 intravenous solution over four hours according to their degree of dehydration which is not significantly different between two groups. This demonstrates that rapid intravenous rehydration can result in a substantial reduction of ED admissions. Among 63 patients who were discharged, 2 cases had recurrence 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 difference between the two groups (p>0.05) ( Table 2).

Discussion
The results of this study show that rapid intravenous rehydration is as effective as standard rehydration regimens in the treatment of dehydration and vomiting in children with gastroenteritis, and it can thus prevent unnecessary admissions to EDs and reduce unnecessary expenses. In cases where oral rehydration therapy fails, intravenous rehydration is a necessary alternative for dehydrated babies. A few studies have also reported an effective rehydration with administration 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][10][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 implementation 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 administered 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 dehydrated 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 suggested avoidance of using rapid rehydration due to possible complications. We did not encounter any significant complications during our investigation. However, this needs to be investigated further in larger multicenter trials.

Conclusion
Rapid rehydration in children dehydrated from gastroenteritis 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 patients with dehydration due to acute gastroenteritis.

Limitations
Our study was performed to show the preliminary advantages of rapid intravenous rehydration regimens. The analysis of serious complications and its safety and the rate and volume of fluids administered requires further investigation.