Oral Rehydration Therapy is Faster

IVF Myth

Obviously dehydration is a very significant condition, particularly in the pediatric population, so much so that several Morsels have been dedicated to the topic (ex, ORT, Vomiting vs Diarrhea, Probiotics, Alternatives to IV Fluids). Yet, often I still hear that we just need to “tank ’em up” so that we can get the kid home.  Yes, of course everyone knows that the experts (WHO, AAP, etc) all recommend Oral Rehydration Therapy for mild to moderately dehydrated children, yet there seems to be the perception that IV fluids are faster.

Barriers to Oral Rehydration Therapy

So, if everyone knows that Oral Rehydration Therapy is recommended, why did a survey of Ped EM Fellowship directors show that 3/4 of them favor IVF over ORT for most of the moderately dehydrated kids?

  • Parental Preference
    • Either prior experience or recommendations from their primary care providers establish an expectation that they are coming to the ED for an “IV.”
    • This can be difficult to overcome quickly… but can be with some simple conversation, that can actually help with your Patient Satisfaction.
  • Emesis
    • Parents often look at you curiously when told about ORT… didn’t they just tell you that the kid keeps puking everything?
    • Here is where you can bring up that we need to figure out how to stay hydrated despite the emesis (after ensuring you don’t think the emesis is from something more ominous).
    • Ondanestron is often the remedy.
  • Resource Intensive
    • ORT does require that doctors, nurses, and techs continue to assess and reassess the patient and ensure that the plan is being carried out.
    • A well-developed protocol and coordinated staff efforts can remedy much of the difficulty with the logistics of ORT.
  • Education
    • ORT is not “PO Challenge.”
    • ORT is a medical strategy to help rehydrate and then maintain hydration.
    • This requires a little bit of time to educate the family.
    • Once again, a unified departmental protocol will help the distribution of the education via educational materials and continued reiteration of the strategy by all staff and providers.
  • ED Provider PERCEPTION that ORT takes too long.
    • The previously mentioned survey found that 76.7% of highly educated Peds EM providers felt that ORT was too time consuming for patient’s and staff.
    • 75% reported using IVF for most moderately dehydrated kids.

Why Do We Think IVF is Faster than ORT?

  • Seems intuitive… IV Fluids bypass the GI tract… right to where we want them… the vein.
  • When it goes smoothly, it works great!
  • ORT takes up MY time… to educate the family. Quicker to order “20 ml/kg bolus.”

What are the Potential Problems with IVF?

  • Placing an IV in a child is difficult: Placing one in a dehydrated child is often impossible!
  • Kids don’t like to be pin-cushions.
  • Parents really don’t like their children to be pin-cushions.
  • Possible complications – IV Fluid errors, Thrombophlebitis, etc.
  • Overlooking Hypoglycemia as the real issue (if you place an IV, check the sugar).
  • They can’t take it home!! You will still have to educate them on how to stay hydrated.

The Need For Speed! ORT is the Answer!

  • ORT is faster to get initiated.
    • 19.9 min vs 41.2 min
  • ORT can lead to quicker ED disposition.
    • 225 min vs 358 min
  • ORT can take up LESS staff time
    • 35.8 min vs 65 min.

Need for Speed

 

References

Hartling L, Bellemare S, Wiebe N, Russell K, Klassen TP, Craig W. Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD004390. PMID: 16856044. [PubMed] [Read by QxMD]

Spandorfer PR, Alessandrini EA, Joffe MD, Localio R, Shaw KN. Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial. Pediatrics. 2005 Feb;115(2):295-301. PMID: 15687435. [PubMed] [Read by QxMD]

Atherly-John YC, Cunningham SJ, Crain EF. A randomized trial of oral vs intravenous rehydration in a pediatric emergency department. Arch Pediatr Adolesc Med. 2002 Dec;156(12):1240-3. PMID: 12444837. [PubMed] [Read by QxMD]

Conners GP, Barker WH, Mushlin AI, Goepp JG. Oral versus intravenous: rehydration preferences of pediatric emergency medicine fellowship directors. Pediatr Emerg Care. 2000 Oct;16(5):335-8. PMID: 11063362. [PubMed] [Read by QxMD]

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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1 Response

  1. October 20, 2016

    […] have discussed many medical “myths” previously (ex, Atropine for RSI, Cuffed ETTs, ORT vs IVF, Morphine for Appendicitis), but recently one of my esteemed PEM Fellows enlightened me about […]

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