Dehydration in Gastroenteritis: To IV or Not To IV?

In light of the ACEP board of directors recently approving 5 Choosing Wisely recommendations for patients seen in the ED, this post is to bare some light on point #5:

For children with mild to moderate, uncomplicated dehydration, clinicians should avoid giving intravenous fluids before a trial of oral rehydration therapy.

Important items from the history of a pediatric patient with likely gastroenteritis include: onset, frequency, quantity and character of the vomiting and diarrhea. Also important to know is weight before illness, current weight, oral intake, urine output (or number of wet diapers and change in said number) and associated symptoms such as fever or mental status changes.

So what is mild to moderate dehydration?  Short answer: those who have lost 3-9% of body weight.  These are children who may appear normal, fatigued or restless, are eager to drink, with a dry tongue and decreased tears, who may be normal or tachycardic with prolonged capillary refill and decreased urine output.

A literature review was performed by Colletti et al (2010) on all published articles from 1966-2006 related to assessing dehydration, oral rehydration therapy and antiemetics in PEM.  Some of the important points to note from the articles they reviewed are as follows:

  1. Shorter ED length of stay with ORT (Oral Rehydration Therapy) vs IVT (IV Therapy) - 225 min vs 358 min
  2. The efficacy of ORT vs IVT is almost identifical with one study showing improvement in dehydration scores at 2 hrs (79% ORT vs. 80% IVT) and successful rehydration at 4 h (55% ORT vs. 57% IVT).
  3. Anti-emetic use increases the success of ORT in patients with vomiting
  4. It is significantly cheaper to treat a patient with ORT than IVT

And what is the proper way to rehydrate? One source from the literature review article recommended rehydration at 50-100cc/kg body weight over 3-4 hours, initiated with 5 cc every 1-2 minutes.  If no improvement is seen with ORT, then IV therapy may be considered.  Replacement of losses was recommended to be done at 60-120 mL oral rehydration solution per vomiting/diarrhea episode if <10kg and 120-240mL per episode if >10kg.

So as those pediatric patients start coming in with vomiting and diarrhea this autumn, let's be cognizant of the fact that oral rehydration therapy is the recommended treatment for mild to moderate dehydration in the ED!