A novel approach to the rehydration of children with gastroenteritis in the emergency department
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Background Children with gastroenteritis comprise 6% of all Emergency Department presentations and with growing pressure to complete care in six hours, a rehydration Best Care Bundle (BCB) was created to deliver evidence based but timely interventions to children presenting to the emergency departments (ED) at Waitemata District Health Board (WDHB). Method A modified systematic review was undertaken to validate the interventions in the BCB and to identify additional interventions from the best available contemporary evidence. A search was executed through Medline, Cinahl and Scopus focussing on the last 5 years and those studies published in English. Results Forty one articles were retrieved and appraised; the outcome measures were collated and compared with the BCB interventions. The use of a categorical hydration assessment scale and the components thereof were consistent with contemporary best practice although the evidence suggests that clinical sign based scales have better sensitivity than specificity and are most accurate for predicting severe dehydration. The use of (low osmolality) oral rehydration solutions (ORS) to rehydrate mild to moderately dehydrated children was confirmed to be effective and associated with fewer adverse effects than intravenous fluids (IVF). The BCB promotes nasogastric (NG) rehydration in young children with dehydration but not severe dehydration where oral rehydration therapy (ORT) failed and was shown to reduce the need for IV fluids. IV fluids were found to be associated with higher admission rates, length of stay and revisit rates; the latter was noted regardless of severity of disease. There is little evidence but general agreement that intravenous fluids (IV) are warranted for severe dehydration with signs of shock (Schutz, Babl, Sheriff, & Borland, 2008; Simpson & Teach, 2011). There is scant evidence for the most effective volume or rate of rehydration but rapid rehydration over 4 hours was found to improve the discharge rates without an increase in adverse events and revisits. The use of intravenous fluids containing 5% Dextrose and 0.9% Sodium Chloride IV fluids was found to be effective at correcting serum ketone levels with fewer incidences of hyponatraemia when compared with hypotonic solutions. Ondansetron administration was associated with fewer ORT failures, lower requirements for IV fluids, reduced admission rates and reduced length of stay in ED. Parental advice to continue/resume normal feeds early was associated with earlier cessation of diarrhoea than clear fluids alone or diluted feeds; advice to avoid high sugar foods was supported by historical evidence that high sugar ORS increased duration and volume of diarrhoea. Other possible interventions that warrant further examination include: the use of lactose free feeds, probiotics, zinc and Racecadotril to reduce the duration of diarrhoea; also subcutaneous fluids as an alternative to IV fluids in the under-3 age group. Finally, some small studies for the objective assessment of hydration (such as digital capillary refill or serum ketones) show promise but further work is required to confirm initial findings and to develop a meaningful clinical application. Conclusions The WDHB hydration BCB contains interventions that are evidence based and the structure is likely to promote earlier disposition decisions, which should have a positive impact on ED LOS, admission rates and revisits but this has yet to be measured empirically.