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Three Part Question

In [pediatric ED patients who present with acute gastroenteritis and dehydration], does [dextrose added to intravenous saline solution] compared with [normal saline solution] lead to reduced hospitalization?

Clinical Scenario

A 4 year old boy comes in to the ED with 3 days of vomiting and diarrhea. Given the history and exam, you determine this child has gastroenteritis with signs of dehydration. His fingerstick blood glucose is 80 mg/dL (4.44 mmol/L). As the treating physician, you order a rapid infusion of intravenous saline with 5% dextrose. You wonder if the dextrose is really necessary.

Search Strategy

Medline 1966-06/17 using PubMed, Embase, and Cochrane Library (2017)
[(exp dextrose) AND (Diarrhea OR diarrheoa OR vomiting OR gastroenteritis OR enteritis OR dehydration)]. Limit to Children (birth-18 years) and English language.

Search Outcome

66 studies were identified; three prospective trials addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Levy et al March, 2013 USA	188 children 6mo-6yrs with gastroenteritis and dehydration. IV normal saline vs. IV D5NS	Double-blind RCT	Admission rate	No significant difference in admission rates	Small sample size, convenience sample, many in NS group also received dextrose as part of practice standard
			Change in serum ketone levels	Significant decrease in serum ketone levels for D5NS group
Rahman et al October,1988 Bangledash	67 male children with diarrhea and moderate-severe dehydration. IV crystalloid (Dhaka solution) with vs without dextrose	Blinded RCT	Glucose levels	Increased rate of hyperglycemia in dextrose group, one episode of asympomatic hypoglycemia in control group	Single center, dated study, results not clinically relevant to current US practices and population
			Urine output	No significant difference
			Electrolyte changes	No significant difference
Sendarrubias et al November, 2017 Spain	145 children 6mo-16y presenting to ED with acute gastroenteritis and dehydration, IV normal saline vs. IV normal saline+2.5% glucose (SGS 2.5%)	Open-label RCT	Hospital admission rates	No significant difference in admission rates	Small sample size, not blinded (open-label)
			72 hour ED return visit rate	17.8% vs. 5.6% bounce-back rate, being higher in the normal saline group yet not statistically significant
			Blood ketone levels	Lower blood ketone levels at 2hrs in SGS 2.5% group

Comment(s)

All 3 studies are limited by small sample sizes. One study is outdated with a different patient population compared to US practice. There does appear to be a difference in short term serum glucose and ketone levels, however the clinical relevance of these lab findings is small. Symptomatic hypoglycemia was rare in each study and hyperglycemia caused by dextrose containing solutions did not demonstrate any clinically adverse effects such as osmotic diuresis. Two studies demonstrate decreases in return visits for groups receiving dextrose (24% in NS vs 17% in D5NS, article 1) and (17.8% NS vs 5.6% in SGS, article 3). These findings were not statistically significant, but may be clinically relevant if a true difference exists. One study points out that this difference is even greater in certain (more ill?) subgroups. Given the small sample sizes for these studies, I would suggest that a larger scale blinded RCT be performed to determine if a true difference exists regarding return visits between groups.

Clinical Bottom Line

Dextrose-containing IV rehydration solutions do not demonstrate a reduction in admission rates for dehydrated children with gastroenteritis when compared to normal saline or similar solutions. Dextrose containing solutions may reduce the rate of ED return visits, however further studies are needed to better analyze this relationship.

References

1. Levy et al Intravenous dextrose for children with gastroenteritis and dehydration: a double-blind randomized controlled trial Ann Emerg Med 2013 Mar;61(3):281-288.
2. Rahman O, Bennish ML, Alam AN, Salam MA. Rapid intravenous rehydration by means of a single polyelectrolyte solution with or without dextrose. The Journal of Pediatiatrics October,1988;113:654-60.
3. Sendarrubias M, Carrón M, Molina JC, Pérez MÁ, Marañón R, Mora A. Clinical Impact of Rapid Intravenous Rehydration With Dextrose Serum in Children With Acute Gastroenteritis. Pediatric Emergency Care May, 2017 [Epub ahead of print]