Page 92 - 15Diarrhoeaandvomiting

Fluid management

Clinical questions
What are the indications for starting IVT for rehydration?

Evidence overview
No studies were identified which gave evidence on the indications for starting IVT in children
with dehydration

GDG translation from evidence to recommendation
In the absence of any published evidence to inform this question, the GDG based its
recommendation on consensus decision. The group fully accepted established practice with
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regard to the initial management of patients with shock. Consequently, all children with
hypovolaemic shock due to dehydration require IVT. Patients with severe dehydration may be at
risk of becoming shocked. As discussed in Chapter 4, the clinical features associated with severe
dehydration may partially overlap those associated with shock. The GDG considered that if the
clinician was uncertain as to whether the child was actually in a state of shock, the child should
receive IVT.
The GDG agreed that. although ORT was recommended as the first-line treatment for dehydration.
it was occasionally unsuccessful. In cases where, despite appropriate treatment with ORS
solution, the child’s state of hydration does not improve or where it shows signs of worsening,
IVT would be required. For example, a child might fail to tolerate the necessary quantities of oral
(or perhaps nasogastric tube administered) ORS solution.
The decision to use IVT should only be taken, however, following a thorough assessment of the
child’s condition and careful consideration as to whether ORT is truly failing. It is also important
that the child’s state of hydration be monitored carefully and regularly.

Recommendation on when to use intravenous fluid therapy for treating dehydration
Use intravenous fluid therapy for clinical dehydration if:
• shock is suspected or confirmed
• a child with red flag symptoms or signs (see Table 4.6) shows clinical evidence of
deterioration despite oral rehydration therapy
• a child persistently vomits the ORS solution, given orally or via a nasogastric tube.

Clinical questions
What is the immediate IVT regimen for shock due to dehydration? What is the optimal fluid
composition for IVT in dehydration?

A range of IVT regimens and fluids have been employed in the treatment of dehydration and
shock. The fluids have included Ringer’s lactate and saline in various concentrations.

Evidence overview
No study was identified which specifically addressed the question of immediate IVT regimen in
children with hypovolaemic shock. For the second question, one good-quality RCT was found
that compared 0.9% saline plus 2.5% dextrose (NS) with 0.45% saline plus 2.5% dextrose (N/2)
for the treatment of dehydration.
In the absence of any direct evidence to answer the first question, information was collected from
various studies which had described fluid regimens in the treatment of dehydration in children
with severe dehydration and/or shock. The various regimens are summarised in Table 5.4.
For the optimal composition of fluid for IVT, one study was identified. It was a prospective
randomised study 102 conducted in Australia to determine whether the use of 0.9% saline rather
than 0.45% saline reduced the risk of hyponatraemia. Children with gastroenteritis aged between
6 months and 14 years were eligible for enrolment in the study only after a decision to treat
with IVT was made by their treating physician, independent of the study. IVT was administered

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