Options to Intravenous Fluids

IV option

The Morsels have focused a lot on pediatric dehydration topics in the past. We have covered the utility of Probiotics and the need to be vigilant against Hypoglycemia. We have discussed specific infections, like Salmonella, and whether antibiotics are necessary.  Naturally, we have also covered Oral Rehydration Therapy and the burden of Diarrhea. Despite what we know, we still occasionally run into “problems” when managing the pediatric patient with dehydration.

Unfortunately, regardless of the general public’s belief that getting an IV is easy, obtaining an IV in a dehydrated child is quite difficult, even when they are only moderately dehydrated.  This is one great reason to really advocate for ORT in anyone who is not severely dehydrated.  Unfortunately, on occasion, ORT will not be successful at adequately rehydrating the patient.  What are our options then?

Interosseous, Nasogastric and Subcutaneous Fluids!

Interosseous Needle

  • Is the child in SHOCK? Put in the IO!
  • Is the child severely dehydrated (which is also known as SHOCK)? Put in the IO!
  • Should be done without hesitation in a child who lacks easily obtainable IV access and signs of poor perfusion.
    • IO is known to be faster than IV placement.
    • Fluids can be delivered as effectively as IV.
    • Can be used in any age (IO shown to be faster than UVC in newborns).
    • For those patients who are not obtunded, the worse part of the IO seems to be associated with the infusion of the fluids not the IO placement.
      • Infusing lidocaine into the IO can assist in relieving discomfort.

Nasogastric Tube

  • For those who have moderate dehydration and no IV access, IO is an option, but parental opinion of it may be unfavorable.
  • When compared to IV, NG rehydration has similar efficacy. (Rouhani Pediatrics 2011)
    • Emesis is not a contraindication to NG use.
    • The palatability of the ORS is not an issue (which is good… have you ever tried ORS? Try it sometime.)
    • Can also be used for patients with Severe Dehydration (as long as not obtunded).
    • Shown to have cost saving over IV, even for those who require admission.

Subcutaneous Fluids (Hypodermoclysis)

  • Hyaluronidase aided hypodermoclysis is method by which the hyaluronic acid in the intercellular matrix is hydrolysized.
  • This makes the intercellular matrix less viscous and allows for diffusion of injected subcutaneous fluids.
  • At 48 hours after the administration of the hyaluronidase, the matrix is completely restored.
  • Initial pilot study in 2009 (Allen Pediatrics 2009) demonstrated the method is effective at rehydrating mild or moderately dehydrated children (2mo – 10 yrs) and that it was safe and was well tolerated.
  • It is also noted that the SubQ catheter can typically be placed within 2 minutes.
  • Recent randomized study of hyaluronidase-facilitated subcutaneous fluid vs IV showed similar mean fluid volume administration in the ED along with higher successfully placed catheters and physician and parental satisfaction. (INFUSE-II Clinic Therap 2012).

 

Moral of the Story:

It is easy to order an IV… but it is not always easy to obtain an IV, particularly in the child who is dehydrated.  It is useful to consider your other options before you request that IV is attempted for the 7th time.  The 7th attempt is usually not that lucky.

 

Rouhani S, Meloney L, Ahn R, Nelson BD, Burke TF. Alternative rehydration methods: a systematic literature review and lessons for resource-limited care. Pediatrics 2011; 127(3): e1-10
Allen CH, Etzwiler LS, Miller MK, Maher G, Mace S, Hostetler MA, Smith SR, Reinhardt N, Hahn B, Harb G. Recombinant human hyaluranidase-enabled subcutaneous pediatric rehydration. Pediatrics 2009; 124: e858-67.
Spandorfer PR. Subcutaneous Rehydration: Updating a traditional technique. Pediatr Emerg Care 2011; 27: 230-236.
Spandorger PR, Mace SE, Okada PJ, Simon HK, Allen CH, Spiro DM, Friend K, Harb G, Lebel F, INFUSE-Peds II Study Group. A Randomized clinical trial of recombinant human hyaluronidase-facilitated subcutaneous versus intravenous rehydration in mild to moderately dehydrated children in the Emergency Department. Clinical Therapuetics 2012; 34(11): 2232-2245.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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