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Three Part Question

In [children with acute gastroenteritis complicated by moderate dehydration] is [rapid nasogastric rehydration] [effective at reducing admission rates, and is it safe]

Clinical Scenario

A 2 year-old girl is brought into the Emergency Department with vomiting and watery diarrhoea. She has dry mucous membranes, reduced skin turgor and her central capillary refill time is 3 seconds. You estimate that she is moderately (4-6%) dehydrated. She is refusing oral fluids. Beds on the wards are limited. You wonder whether rapid nasogastric rehydration (RNGR) with an oral rehydration solution (ORS) is an effective and safe strategy to try and avoid the need for hospital admission?

Search Strategy

Primary source: Medline database using ISI Web of Knowledge SM interface: 1950 – October 12, 2006:
Secondary source:Cochrane Database:
Medline: ((TS=nasogastric OR (TS=rehydration OR MH:exp=Fluid Therapy)) AND (TS=gastroenteritis OR MH:exp=Gastroenteritis)) AND TS=rapid (Limits: all child: 0-18 years, English language)
Cochrane: Nasogastric AND gastroenteritis

Search Outcome

Medline: 15 articles: 2 relevant articles
Cochrane central register of controlled trials: 4 articles, 1 abstract relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Powell et al, 2005, Australia	199 patients aged 6m – 6y with acute gastroenteritis with moderate dehydration at ED Randomised to: RNGR (Nasogastric 100ml/kg ORS over 4hrs) Vs. Standard Nasogastric Rehydration (SNGR) (Admitted and ORS over 24 hrs to replace estimated fluid deficit)	RCT	Treatment failure: further weight loss >2% from admission.	RNGR: 12.2% (6.2-18.2) [95% CI] failure rate. SNGR: 8.6% (2.6-14.6) [95% CI] failure rate	Difficult to assess weaknesses as full article is not yet available
			Parental satisfaction:	Similar for both regimens (statistics not available)
			Cost to families	No difference in cost at 24 hrs After 1 week: SR had greater travel expenses. RR required more time off work.
Phin et al, 2003, Australia	315 patients aged 6m – 16y with acute gastroenteritis with mild or moderate dehydration at ED Intervention group: Observed following implementation of a rapid rehydration (RR) clinical pathway: Either: RNGR with ORS, 20ml/kg/hr for 2 hrs (n=23) OR Rapid IV rehydration (RIVR) (0.45% NaCl + 2.5% Dextrose) 20ml/kg/hr for 2hrs (n=83) Groups analysed together (n=106) Historical control group Non-standardised Oral ± IV rehydration over 24 hours (n=170)	Prospective observational study with historical controls	Admission rates	Moderately dehydrated: RR: 55.8%, Control: 96.3% (p<0.001) Mildly dehydrated: RR: 26.9%, Control: 25.9% (non sig.)	Use of historical controls: may introduce important bias and confounding. Analyses rapid nasogastric and rapid IV rehydration together, therefore, evaluation of efficacy and safety of either method on its own is not possible. Only a small number of patients received RNGR.
			Readmission within 48 hours	Moderately dehydrated: RR: 5.8%, Control 3.7% (non sig.) Mildly dehydrated: RR: 4.3%, Control 4.2% (non sig.)
Nager et al, 2002, Los Angeles	96 patients aged 3m – 3y with acute viral gastroenteritis with moderate dehydration Randomised to: RNGR: 50ml/kg (ORS) over 3 hours (n=46) RIVR: 50ml/kg (0.9% NaCl) over 3 hours (n=44)	RCT	Safety:	No Adverse outcomes in either RNG or RIV groups at this rate of fluid therapy	Telephone follow-up. Non-blinded. Variable diagnoses in a small number of patients (8% bacterial gastroenteritis or UTI).
			Efficacy and representation within 24 hrs of discharge:	No differences in rehydration efficacy. Representation rate: 18% (RNGR), 15% (RIVR) (non sig.)
			Cost:	RNGR: $525 per case, RIVR: $642 per case. (18.2% saving)

Comment(s)

The efficacy and safety of RNGR in the treatment of acute gastroenteritis complicated by mild to moderate dehydration in children is yet to be clearly established. There is level D evidence that rapid rehydration (intravenous or nasogastric) is an effective strategy to reduce admission rates. RNGR and RIVR appear to be equally effective, however RNGR is more cost-effective. Limited data indicates the RNGR is safe, but the studies are too small to exclude an increase in rare adverse events such as hyponatremic seizures or aspiration.

Clinical Bottom Line

In the treatment of patients with gastroenteritis complicated by mild to moderate dehydration, RNGR: - may reduce hospital admission rates (Level C) - is as effective as rapid intravenous rehydration (Level A) - appears to be safe (Level B)

References

1. Powell, C.V.E., Hein, R.G., Priestley, S.J. Randomised-controlled trial of rapid vs 24-hour nasogastric rehydration in children with acute gastroenteritis and moderate dehydration: PG3-13. J Pediatr Gastroenterol Nutr, Vol. 40, No. 5, May 2005 pg 651.
2. Phin et al. Clinical pathway using rapid rehydration for children with gastroenteritis. J Paed. Child Health, Vol.39, 2003, p343-348.
3. Nager et al. Comparison of Nasogastric and Intravenous Methods of Rehydration in Pediatric Patients With Acute Dehydration. Pediatrics, 109(4) April 2002 p.566-572.