Abstract & Commentary
Source: Nager AL, Wang VJ. Comparison of nasogastric and intravenous methods of rehydration in pediatric patients with acute dehydration. Pediatrics 2002;109:566-572.
Traditional therapy for dehydration in developed countries centers around hospitalization and intravenous fluid (IVF) therapy. Oral replacement therapy (ORT) solutions containing glucose and electrolytes are used widely in developing countries, but often are regarded as substandard or less preferable by clinicians in the United States. In an effort to evaluate alternatives to IVF, Nager and Wang studied rapid nasogastric (RNG) volume resuscitation, comparing this approach to rapid intravenous (RIV) hydration.
The authors analyzed 90 children, ages 3-36 months, with acute dehydration from presumed viral gastroenteritis presenting to the emergency department (ED) of Children’s Hospital of Los Angeles. All cases had acute illnesses (< 7 days) featuring vomiting, diarrhea, and insufficient oral intake. Attending physicians judged each case as mild (3-5%) or moderate (6-9%) dehydration based on 11 published clinical criteria.1 Children with severe (> 10%) dehydration, bowel obstruction, or specific acute systemic illness were excluded.
Each patient had body weight determined before and after ED therapy; intake and output recorded; and blood, urine, and stool studies performed. In 92% of cases, final diagnosis was viral gastroenteritis. Initial serum bicarbonate was 15.2 mmol/L, with anion gap averaging 19.5. Cases were randomized to either RNG (n=46) with 50 mL/kg of Pedialyte over a three-hour period via a 5 French silastic feeding tube passed over Cetacaine nasal analgesia and into the stomach, or to RIV (n=44) with normal saline at 50 mL/kg over a three-hour period via a 22- or 24-gauge IV catheter. Children whose vital signs and clinical dehydration indicators improved, and who could tolerate ORT in improved amounts, were discharged to telephone follow-up 24 hours later.
Assessments at the conclusion of the three-hour therapy period revealed some unexpected findings. Only two (4%) RNG placements were unsuccessful (one tube pulled out; one nosebleed), whereas 27 (61%) attempts to place an IV needle required multiple procedures (p < 0.0001). Final heart rate was 126 beats per minute in both groups. Weight gain after treatment was greater for RIV (3.5% body weight) than for RNG (2.2% body weight; p = 0.008). Return rate for additional ED therapy was 18% for RNG vs. 15% for RIV (p = 0.78). Post-treatment determinations for urine specific gravity were 1.012 vs. 1.019 (p < 0.001), for serum bicarbonate were 17.0 vs. 14.7 mmol/L (p < 0.001), for blood urea nitrogen (BUN) were 8 vs. 9 mmol/L (p < 0.001), for persistent ketonuria were 43% vs. 82% (p < 0.001), and for urine specific gravity exceeding 1.025 were 11% vs. 32% (p < 0.001) for RNG vs. RIV, respectively. Cost per case was calculated at $525.90 for RNG vs. $642.64 for RIV (18% difference). The authors conclude that RNG at 50 mL/kg over a three-hour period is just as effective as RIV in volume-contracted children and improves overall ED efficiency of therapy.
Commentary by Michael Felz, MD
The "hassle" of fluid administration is reduced by NG tube placement as compared to often-difficult intravenous catheterization. In somewhat surprising fashion, several laboratory markers of volume contraction and metabolic acidosis were statistically better for RNG therapy compared to IVF infusion, which commonly is regarded as "superior." Estimated cost reductions also favored RNG statistically. Failure rates were below 20% and statistically similar for each group. RNG even worked in a small subset of patients proved to have bacterial enteritis and urinary tract infections, in addition to cases with presumed viral illness.
The authors cite prior studies comparing RNG to IVF therapy, but these all involved hospitalized children treated over a 24-hour span, or were done in developing countries such as those in Africa. What impressed me about this three-hour NG "rehydration" approach was its simplicity, success rate, and convincing superiority in laboratory markers of volume contraction. The RNG approach offers patient, parent, and ED staff acceptance, ease of administration, laboratory improvements, cost benefits, and recovery rates that equal—and for the most part surpass—the benefits of traditional IVF therapy. And it requires only three hours.
I readily admit that NG administration of fluid would be an unfamiliar mode of therapy for most parents with sick children in the ED. Yet perhaps this is directly related to lack of familiarity among the physicians caring for such children.
Dr. Felz, Associate Professor, Department of Family Medicine, Medical College of Georgia, Augusta, GA, is on the Editorial Board of Emergency Medicine Alert.
References
1. Gorelick MH et al. Validity and reliability of clinical signs in the diagnosis of dehydration in children. Pediatrics 1997;99:e6.
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