- Levy, JA, et al. “Intravenous Dextrose for Children With Gastroenteritis and Dehydration: A Double Blinded Randomized Controlled Trial.” Annals of Emer Med. Vol 61. No3. Mar 2013. doi: 10.1016/j.annemergmed.2012.08.007 (Link)
- Levy JA, Bachur RG, et al. “Intravenous dextrose during outpatient rehydration in pediatric gastroenteritis.” Acad Emerg Med. 2007; 14:324-331. doi: 10.1197/j.aem.2006.10.098 (Link)
Why this topic? Imaging you are caring for a 3 year old female with abdominal cramping, diarrhea, and vomiting for the past 72h. She is refusing oral intake and has urinated only once in the past 24hr. On exam, she has dry oral mucosa, sunken dark eyes, and generally appears weak. You’ve learned in medical school and residency that you should only bolus with normal saline. However, you wonder if a bolus of dextrose could make the patient feel better and decrease the chance that mom will bring her back to your emergency department. However, you aren’t confident that dextrose containing fluid bolus is safe and effective when used as a bolus. You perform a literature search to answer your question.
- P: pediatric patients with gastroenteritis
- I: dextrose containing IV fluid bolus
- C: normal saline bolus
- O: decrease return ED visits/admissions
Literature search: Dr. Beard performed a Pubmed and Ovid search with the search terms ‘dehydration/glucose/or gastroenteritis’, ‘emergency services’, ‘intravenous or infusion’ and limited for children ages 0-18yr, humans, and English language. In total, 21 articles were found to be relatively pertinent to the question and two were selected to answer the specific question.
Article 1: “Intravenous Dextrose for Children With Gastroenteritis and Dehydration: A Double Blinded Randomized Controlled Trial”
Methods: This was a randomized controlled trial of children ages 6mo-6yrs with gastroenteritis at Boston Children’s Hospital. Subjects were randomized to receive a single 20ml/kg bolus of either 5% dextrose in normal saline or normal saline alone. Serum ketone levels and glucose were measured before bolus and again at 1 and 2hr intervals after the fluid bolus. Primary outcome was hospitalization rates. Secondary outcomes were change in serum ketone levels over time.
Results: 188 children were enrolled. The proportion of children hospitalized did not differ between groups (35% in D5 group, 44% in NS group) although there was a trend towards less admission in the dextrose group. Those children who received D5 had a greater reduction in mean serum ketone levels both at 1hr and 2hr. Of those children discharged, 30% of patients in the normal saline group and 11% of patients in the D5 group required unscheduled medical care after discharge home.
Conclusion: The study showed no significant difference in admission rates, however, there was a decrease in ketone levels in the D5 bolus group. Although there was a significant decrease in ketone levels, this did not seem to show any clinical difference in outcomes. Although the study outcome did not specifically study outpatient medical needs, it appears that the D5 group might have experienced less ongoing symptoms and need for medical care (i.e. PCP appointments) once released from the hospital however more research is needed. This may also translate into less repeat ED visits, however, this was not a study outcome in this paper.
Article 2: “Intravenous dextrose during outpatient rehydration in pediatric gastroenteritis”
Methods: This is a case control study of children aged 6mo to 6yr who presented to an urban ED with acute gastroenteritis and dehydration and who received IV rehydration before ED discharge. The study looked at whether the amount of IV dextrose administered at the initial visit was related to return visit admission (RVA).
Results: A total of 168 children diagnosed with gastro and discharged from the ED were studied (56 cases and 112 controls). Cases were defined as children who returned and were admitted within 72hr of initial ED visit and discharge. Patients who had a RVA received significantly less IV dextrose than those who did not have a RVA. Those who received no dextrose had a 3.9 greater odds of having a RVA. The study also found that those who received more dextrose containing IV fluids were 1.9 times less likely to have a RVA. Also, the study found that patients who had been ill for <24hr were more likely to have return visits than those ill for 1-2 days. No other demographic, clinical, or lab factors were associated with greater odds of having a return visit.
Conclusion: Larger amounts of IV dextrose is associated with reduced RVA in children with gastro and dehydration. Those that are sicker for shorter period of time may need to be more highly considered for admission.
Limitations: This was a retrospective study and the degree of symptoms could not be evaluated. It is therefore not known if patients who received more dextrose were sicker. Also, confounding variables influencing the primary outcome measure (return visit in 72hr) could not be controlled. Finally, the patient disposition regarding discharge or admission as well as the original diagnosis of dehydration was not standardized by the physician.
Take Home Points:
Physiologically, it makes sense that patients with dehydration from gastro will have metabolic acidosis with higher ketone levels which could contribute to symptom severity. However, both studies above shown that ketone levels do not contribute to re-admission rates. More research needs to be done to determine if ketone levels actually contribute to symptoms. A bolus with dextrose containing fluids appears to be safe and cheap and seems to show a decrease in re-admission rates as well as outpatient medical care needs. There also needs to be more research in the actual volume and dextrose dose, which has yet to be determined. In patients with very limited oral intake and signs of dehydration I will consider dextrose IV fluid boluses as part of the ED management plan based on the results of these two studies.
Additional Comments from Dr. Dietrich-Kusch:
From the inpatient side of things, I would really love to see bigger study on this. As a hospitalist admitting the children who still fail outpatient management of their gastroenteritis it seems like the use of D5 boluses lead to more labs because nearly always the patients end up with glucosuria and ketonuria on their UA and then people get concerned about DM, which leads to further labs (Hgb A1C, fasting glucose, repeat UA, etc). I personally wonder if there is a smaller amount of glucose that would be just as beneficial, but wouldn’t shoot up the blood sugar so much that they started spilling glucose into their urine.