1. Journal Club Season 8
20th August 2015
Saharwash Jamali
Bolus fluid therapy and sodium homeostasis in paediatric gastroenteritis
Freedman, S. and Geary, D.F.
Journal of Paediatrics and Child Health 49 (2013):

2. Aim
To determine the risk of developing hyponatraemia when large volume fluid bolus rehydration therapy is used.

3. Clinical question
Population – children with gastroenteritis >90 days old between 5-33kg
Intervention – large volume fluid bolus (60ml/kg)
Comparison – standard fluid bolus (20ml/kg)
Outcome – development of hyponatraemia
Design – Prospective randomised, blinded

4. Current Practice NICE Diarrhoea + Vomiting in Children CG84
Assess level of dehydration
Oral rehydration therapy (50ml/kg over 4 hours)
IVT start with 20ml/kg bolus
If second 20ml/kg bolus needed consider other causes and shock (?discuss with paediatric intensive care specialist)
Calculate dehydration – replace over 48hours + maintenance fluid

5. NICE assessing dehydration chart

6. Method December 2006 to April 2010 ED Tertiary hospital Toronto
Randomised, blinded prospective study
Inclusion criteria:
Children >90/7 old with clinical dehydration secondary to gastroenteritis who failed ORT
Exclusion criteria:
Weight <5kg/>33kg, fluid restriction, suspected surgical condition, history of significant chronic system disease, abdominal surgery, bilious or bloody vomitus, hypotension, hyper/hypoglycaemia, language barrier and no telephone follow up

7. Outcome measures Primary: Secondary:
Development of hyponatraemia at 4 hours
Secondary:
Change in sodium relative to baseline
Magnitude of decrease in serum sodium among those who experienced a decrease
Risk of developing hypernatraemia
Correlation between initial urine sodium and osmolality and change in serum sodium
Development of clinical signs of fluid overload

8. Journal of Paediatrics and Child Health Volume 49, Issue 3, pages , 26 FEB 2013 DOI: /jpc

9. Fig. 2 Correlations between change in serum sodium and biochemical parameters. The change in serum sodium between baseline and time 4h versus (a) urine osmolality and (b) urine sodium in all children. The line of best fit (r value) is depicted in both correlations. Urine osmolality = (p = 0.01); urine sodium = (p = 0.03)

10. CASP checklist: A Are the results of the study valid?
Did the study address a clearly focused issue? (Y/N/?)
Was the cohort recruited in an acceptable way? (Y/N/?)
Was the exposure accurately measured to minimise bias? (Y/N/?)
Was the outcome accurately measured to minimise bias? (Y/N/?)
Have the authors identified all important confounding factors? (Y/N/?)
Have they taken account of the confounding factors in the design or analysis? (Y/N/?)
Did the study address a clearly focused issue – yes it looked at sodium at presentation and sodium at 4 hours post intervention
Was the cohort recruited in an acceptable way – excluded a large number of patients for the study – would the study have benefited from including these particular groups i.e. very ill patients who had a language barrier
Was exposure accurately measured to minimise bias – yes
Was the outcome accurately measured to minimise bias – yes, single centre study
Have the authors identified important confounding factors – no
Have they taken account of confounding factors in the design/analysis – no due to exlcusion criteria

11. CASP Checklist: B What are the results?
What are the results of this study?
How precise are the results?
Do I believe the results?
What are the results of this study – aim was looking at risk of hyponatraemia following a large fluid bolus compared to a standard fluid bolus. Similar biochemical profile and similar number’s hyponatraemic at 4 hours
How precise are the results – mean and standard deviation figures given
Do I believe the results – with large patient population being excluded it’s difficult to believe the study is representative. Most patients who require a fluid bolus – are they being assessed correctly, therefore dehydration table – validated, but may be patients who would require a larger volume fluid bolus and in whom we would want to see the effect in were amongst those excluded

12. CASP Checklist: C Will the results help locally?
Can the results be applied to the local population?
Do the results of this study fit with other available evidence?
What are the implications of this study for practice?
Can the results be applied locally – no, it did not consider alternative oral rehydration methods that should be considered. The cultural approach is different, if patients require an IV fluid bolus – do they need further Ix and monitoring
Do the results of this study fit with other available evidence – yes it reinforced what is known about gastroenteritis and sodium homeostasis
What are the implications for practice – alternative rehydration therapy with NGT was not considered, for practical purposes this should be considered more in clinical practice

13. Summary and Conclusion
Study: Clear aims, clear inclusion + exclusion criteria
Clinical application:
I would be cautious of using this study to influence Mx of patients with gastroenteritis and moderate dehydration – raises more questions
Consider larger fluid bolus – but maintenance to continue with 0.9% saline?
Older children/heavier children – what volumes should be considered as bolus IV fluids Rx?