Journal Club

1. Journal Club UshaNiranjan PICU

2. Rationale • 2 x cases of severe dehydration with metabolic acidosis • requesting for HDU management • as given 40mls/kg fluid bolus- ? May require more • Case 1: 13month old with vomiting and diarrhoea( massive large watery stools) • moderate to severe dehydration stable clinically, • Gas: pH 7.13, pCO2-4.3, HC03- 8, BE-14 • Case 2: 3weeks old – severe diarrhoea, no vomiting • Hypernatremic dehydration but stable clinically • Gas : pH 7.03, pCO2- 3.8, HC03- 5, BE- 23

3. PICO P: In children I: Rapid correction of metabolic acidosis( severe dehydration)secondary to gastroenteritis C: Slow correction O: Better outcomes

4. NHS evidence database searches • Medline • Embase • No relevant articles on metabolic acidosis • About 130 + articles on dehydration + rapid rehydration • screened abstracts and picked up this one

5. Article “Rapid versus standard intravenous rehydration in paediatric gastroenteritis: pragmatic blinded randomised clinical trial." Freedman, Stephen B., et al. BMJ (Clinical research ed.) 343 (2010): d6976-d6976.

6. NICE 2009 Diarrhoea and vomiting in children • Clinical dehydration( including hypernatraemic) • ORS solution for oral rehydration  over 4hrs +maintenance • Consider NGT fluids • Use intravenous fluid therapy for clinical dehydration if: • shock is suspected or confirmed • red flag symptoms or signs • deterioration despite oral rehydration therapy

7. Study Paediatric emergency department in tertiary centre (Toronto, Canada)- single centre Period: Dec 2006 to April 2010 Children aged 3months -11yrs >5kg + < 33kg Diagnosis of dehydration secondary to gastroenteritis – not responded to oral rehydration  requiring i.v rehydration

8. Intervention Rapid rehydration – 60mls/kg of 0.9% saline over 1 hr Standard rehydration – 20mls/kg of 0.9% saline over 1 hr Subsequent maintenance+ oral rehydration until end of study period – 4hrs Telephone F/U on days 3 and 7.

10. Results • Primary outcome: Clinical rehydrationat 2hrs • rapid rehydration group( 114) - 36% • standard rehydration group (112) – 29% • P = 0.32 • No significant difference between two groups with regard to successful rehydration in 2hrs

11. Secondary outcome • Prolonged treatment(admission ; >6hrs in ED; admission within 72hrs • P = 0.19 ( longer in rapid group) • Logistic regression( OR 0.81, P = 0.61 in favour of standard group) • Mean scores on clinical dehydration over the study period • No significant difference ( P =0.96) • Proportion rehydrated at 4hrs • P >0.99 (Same for both groups -69% /69%)

12. Score on clinical dehydration scale as continuous variable during the study period – 4hrs (P=0.96)

13. Secondary outcomes • Admission to hospital in the 1st visit • More in the rapid group ( p= 0.04) • even on excluding those admitted due to metabolic acidosis • Time to discharge • Longer in rapid rehydration group (p=0.03) –significant • Physicians comfort at discharge – trend in favour of standard rehydration

14. Critical appraisal • Validity 1)Did the trial address a clearly focussed issue? • Yes 2)Was the assignment of patients randomised? • Yes • Computer generated; stratified by severity of dehydration

15. Validity • Were all the patients who entered the trial properly accounted for at its conclusion • YES

16. Were patients , health workers and study personnel ‘blind’ to the treatment? • Yes • Blinded to research nurse, physician and participants • Un-blinded to bedside nurse

17. Were the groups similar at the start of the trial? • Yes • Were the groups treated equally(apart from intervention) • Yes

18. Results • How large was the effect? • Primary outcomes : At 2hrs • rapid rehydration group( 114) - 36% • standard rehydration group (112) – 29% • P = 0.32 • C.I (-5.7% to 18.7% - the absolute difference-6.5% • No significant difference between two groups with regard to successful rehydration in 2hrs • Power –adequate (80%)

19. Secondary outcome • Prolonged treatment (admission ; >6hrs in ED; admission within 72hrs) • P = 0.19 (longer in rapid group) • Mean scores on clinical dehydration over the study period • No significant difference ( P =0.96) • Proportion rehydrated at 4hrs • P >0.99

20. Secondary outcome • Prolonged treatment(admission ; >6hrs in ED; admission within 72hrs • P = 0.19 ( longer in rapid group) • OR 0.81, P = 0.61 in favour of standard group • Mean scores on clinical dehydration over the study period • No significant difference ( P =0.96) • Proportion rehydrated at 4hrs • P >0.99 (Same for both groups -69% /69%)

21. Results Were the results precise? Yes Limitations: The degree of dehydration scores –could have been added differently overestimated Risk of mild cases being included No mention about ongoing losses Ongoing oral rehydration might have had effect on outcomes

22. Applicability Can the results be applied to the local population? Yes

23. Applicability Were all the clinically important outcomes considered? Yes Are the benefits worth the harm and costs? Yes

24. Metabolic acidosis secondary to gastroenteritis • Metabolic acidosis • secondary to bicarbonate loss • Worsening due to large volumes of saline • Excess chloride( reduction in anion gap) • Excess renal elimination of bicarbonate

25. ConclusionBased on this article There is no significant difference to the resolution of dehydration with rapid vs standard i.v rehydration None of the outcomes favoured the use of rapid i.v rehydration

26. THANK YOU