Bull Pan Anz Health Organ 19(l), 1985
MIXED REHYDRATIONl
Gloria Posada,2 Daniel Pizarro,3 and Edgar Mohs4
To assess the usefulness of mixed (intravenous plus oral) rehydra- tion therapy, 34 severely dehydrated infants and young children admitted to the National Children’s Hospital in San Jose. Costa Rica, were given a mixed rehydration treatment. The results sug- gest this method could provide an ideal course of treatment in cases where initial IVrehydration. rather than oral rehydration, is advised.
Introduction
In 1968 it was suggested that an oral solu- tion of glucose and electrolytes could be use- ful in rehydrating patients dehydrated by cholera (1). The effectiveness of the treatment was demonstrated that same year (2), and since then many studies have been published testifying to its effectiveness in children dehy- drated by acute diarrhea of diverse etiology
(3-6).
At our hospitaL5 in keeping with Ordway’s recommendations (7) concerning rapid intra- venous (IV) rehydration and experimental results reported by Sperotto et al. (S), we found that severely dehydrated children could be rehydrated in six hours instead of the 24 to 48 hours usually recommended (9).
It has also appeared that in cases where the oral route is contraindicated, mixed rehydra- tion, first IV and then oral, should be ideal.
’ Also appearing in Spanish in the Boletin de la OIi- cina Sanitaria Panamericar~a, 1985.
2 Associate Professor. Autonomous Universitv of Cen- tral America (Universidad Aut6noma de Centvo Am&- ica 11 San Jo&, Costa Rica.
Associate Professor, University of Costa Rica, San Josh, Costa Rica.
4 Director. National Children’s Hosoital. San Jose. Costa Rica; and Associate Professor, Un’iveriity of Costa Rica.
5 The Dr. Carlos Sdenz Herrera National Children’s Hospital (Hospital Nacianul de NiGos Dr. Cdos S&m Herrera) in San Jo&.
The purpose of the work reported here was to examine in greater detail the extent to which IV and oral rehydration could be combined and the right time for switching from one to the other.
Materials and Methods
For a period of 16 months, between Febru- ary 1981 and June 1982, a study was made of 34 children admitted to the emergency ward of the National Children’s Hospital with acute diarrhea1 disease and dehydration. Intraven- ous rehydration of these children was consid- ered necessary because they exhibited one or more of the following symptoms: dehydration of 10% or more, an intoxicated appearance, paralytic ileus, an altered state of conscious- ness, convulsions, bronchopneumonia, or bronchiolitis.
As Table 1 shows, the average age of these children was 5.15 months, with 50% being between one and three months old. The nutri- tional status of over half appeared good, al- though 38% appeared undernourished, 12% severely by current standards (10). Twenty- three of the children (68%) were male. Symp- toms recorded included dehydration averag- ing 10.12% (85% of the children exhibited at least 10% dehydration), vomiting in 27 cases (79%), clinical manifestations of metabolic acidosis in eight cases (24470), an intoxicated
Table 1. Data obtained from examination of the 34 study subjects upon admission.
No. % Mean SD Range
Age (months) 51 2-3 4-6 7-12 13-24 >24
5.15 mo. fO.OBmo. 0.524mo. 25.53
26.47 20.59 23.53 5.88 0
Nutritional Status: Overweight Eutrophic Malnourished:
1 2.94
20 58.82 13 38.24
moderately 7 20.59
SCJedy 4 II.76
premature 2 5.88
Symptoms at admission: Diarrhea
Dehydration:
34 34
<.5% 5-P% 10%
>lO%
0 5 20 9
100
100 10.12% +I 95% 5-12%
0 14.70 58.82 26.47
Vomiting 27 79.41
Metabolic acidosis 8 23.53
Intoxicated appearance 5 14.70
Paralytic ileus 2 5.88
Convulsions 2 5.88
Altered consciousness 1 2.94
Bronchopneumonia 1 2.94
Bronchiolitis 1 2.94
appearance (in five cases), paralytic ileus (in two cases), convulsions (in two cases), bron- chopneumonia (in one case), bronchiolitis (in one case), and an altered state of conscious- ness (in one case). In addition, it should be mentioned that six of the subjects had otitis media, four had oral moniliasis, and a few (2- 4%) had other disorders including perineal dermatitis, impetigo, anemia, and influenza.
After examining and weighing each child and determining its degree of dehydration, a decision was made to administer IV rehydra- tion. Accordingly, during the first hour 30-50 ml/kg of fluids were administered if dehydra- tion was 510% (in cases where dehydration exceeded lO%, 50 ml/kg were administered), with lOml/kg per hour being administered thereafter. In 23 cases the solution used con- tained 77mmol/Na+ and 77mmol/Cl- per li-
ter of 2.5% dextrose; in eight cases the solu- tion contained Slmmol Na+, 71mmol Cl-, 20mmol K+ , and 30mmol NaHC03 per liter of 5% dextrose; and in the remaining three cases the former of the two solutions was ad- ministered initially, followed by the second solution without the NaHC03.”
42 PAHO BULLETIN . vol. 19, no. 1, 1985
When a child receiving IV fluid no longer showed any signs of shock, was alert, and ex- hibited neither vomiting nor nausea, it was considered that rehydration could be contin- ued by the oral route. At this point the child was weighed again, its weight gain was deter- mined, and the quantity of fluid administered intravenously was noted. The child was also reexamined, and its degree of dehydration at the time was determined. The quantity of fluid to be administered orally was calculated according to the following formula:
volume of fluid (in ml) =
% dehydration X weight (in kg) X 2
The total fluid volume administered orally consisted one-third of water and two-thirds of a rehydration solution (llOmmo1 glucose, 90 mmol Naf, 90mmol Cl-, 30mmol K+, and 30mmol HCO, per liter of water); this fluid was administered in a 240ml baby bottle, in a cup, or by gastroclysis.
After the child had been rehydrated it was again weighed, and the weight gains following IV and oral rehydration, together with the to- tal weight gain, were recorded. Provisions
were also made for recording the quantity of fluid administered orally, the duration of the IV and oral rehydration treatments, any com- plications that occurred, and concurrent ailments.
Results
The duration of IV fluid administration ranged from one to 24 hours, the average time being 3.39 hours with a standard deviation of
to.74 hours (Table 2). In all, only nine of the 34 patients received IV fluids for over two hours-in each case because of one or more of the following symptoms: severe osmotic diar- rhea, altered state of consciousness, consider- able abdominal distention, and/or persistent vomiting when oral rehydration was begun.
The duration of oral fluid administration ranged from one to 22.75 hours, the average time being 6.17 hours with a standard devia- tion of I- 0.79 hours. Data regarding the total time needed for rehydration and the volumes of oral and IV fluids administered are shown in Table 2.
As Table 3 shows, the children’s mean
Table 2. Duration of IV and oral rehydration treatments received by the 34 study subjects and the quantities of fluid administered, showing the average
values, one standard deviation (SD), and the range of values involved.
Mean SD Range
Length of IV fluid administration (hours) Length of oral fluid administration (hours) Total duration of rehydration (hours) Quantity of fluid administered by IV (ml) Quantity of fluid administered orally (ml)
3.39 + 4.30 1-24
6.17 -t 4.63 1-22.75 9.56 k 6.35
414.21 k363.3 138-1.925 788.41 k589.7 175-2.800
Table 3. A comparison of the 34 subjects’ weight at admission and weight at release from rebydration therapy, showing the average values, one standard
deviation (SD), and the range of values involved.
Mean SD Range
Weight at admission (in grams) Weight at release (in grams) % weight gain
Clinical impression of % dehydration
Posada et al. l MIXED REHYDRATION 43
weight gain over the course of the rehydration treatment was 8.70%. Their average body temperature upon admission was 38.22”C (k 0.26’C) and upon discharge was 37.39”C (+ O.ll’C). In addition, at admission the aver- age pulse was 143 beats per minute (+4.17), the average systolic blood-pressure was 65.18mm Hg (+4.03), and the average respi- ration rate was 46.53 per minute (f2.12).
Venous blood samples were taken from 15 patients for the analysis of electrolytes and gases because their clinical pictures suggested an imbalance. This analysis showed five chil- dren (14.7%) to be hyponatremic, six (17.6%) to be hypernatremic, four (11.8%) to be hypokalemic, and eight (23.5%) to have severe uncompensated metabolic acidosis. Following rehydration, these uncompensated electrolyte imbalances were redressed in all the patients.
No treatment-related complications arose among any of the 34 patients.
Discussion and Conclusions
There have been very few reports on mixed (IV and oral) rehydration in treating acute di- arrhea] disease (11,12). In our hospital, chil- dren are rehydrated intravenously if they are in a state of shock, have an altered state of consciousness, or suffer from convulsions, se- vere diarrhea, persistent vomiting, or over 10% dehydration. The present study of the response by 34 patients to mixed rehydration found that the average overall rehydration
time was 9.56 hours (k6.35 hours). The dif- ference between this time and the average times reported for rapid pediatric IV rehydra- tion alone (6.34 hours-9) and oral rehydra- tion alone (6.35 hours-9) are statistically significant (p < 0.005). Howe&r, it should be noted that the clinical pictures presented by the study children were much more severe than those presented by the other groups studied, and also that there were no complica- tions. In addition, only 10 (29.4%) of the study children were subsequently hospital- ized, a smaller percentage than the 35.5% hospitalized in the authors’ previously re- ported study on children receiving IV rehy- dration alone (9). Considering that the chil- dren receiving mixed rehydration were severely ill, these results suggest that their re- covery was faster than it would have been had they received IV rehydration alone. Overall, then, the results of this study appear to indi- cate that mixed rehydration offers an ideal course of treatment in cases where rehydra- tion therapy cannot be initiated by the oral route. Certainly this form of treatment has proved capable of rehydrating gravely ill pa- tients in far less time than the traditional 24 to 48 hours. As already noted, it is considered that the most appropriate time for changing from IV to oral rehydration is when the pa- tient is alert and exhibits no signs of nausea, vomiting, or shock. In the 34 patients stud- ied, this state was reached, on the average, 3.39 hours after IV rehydration therapy began.
SUMMARY
A study was performed at the National Chil- dren’s Hospital (San Jo&, Costa Rica) in which 34 infants and young children with acute diarrhea1 disease and marked dehydration were rehydrated with mixed intravenous (IV) and oral rehydration treatments. That is, because of the severity of their illness the patients were given rehydration fluids intravenously. Some hours later, when they were alert and showed no signs of shock, nausea, or
vomiting, the patients were switched over to oral rehydration.
44 PAHO BULLETIN l vol. 19, no. 1, 1985
being 9.56 hours. This was longer than the average hours traditionally employed. Overall, the authors times reported elsewhere for rapid oral or intraven- conclude that mixed rehydration therapy appears ous rehydration alone; but the cases treated were to offer an ideal course of treatment for many cases more severe than those treated in the other studies, where initial IV rehydration, rather than oral rehy- and the time involved was far less than the 24 to 48 dration, is advised.
REFERENCES
(1) Hirschhorn, N., J. L. Kinzie, D. B. Sacher, R. S. Northrup, J. 0. Taylor, S. F. Ahmad, and R. A. Phillips. Decrease in net output in cholera dur- ing intestinal perfusion with glucose-containing so- lutions. NE& JMed 279:176-181, 1968.
(2) Nalin, D. R., R. A. Cash, R. Islam, M. Molla, and R. A. Phillips. Oral maintenance ther- apy for cholera in adults. Lnlzcet 2:370-373, 1968.
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(7) Ordway, N. K. A Guide to Fluid Therapy. New Haven Community Hospital, New Haven, 1963, p. 3.
(8) Sperotto, G., F. R. Carraza, and E. Mar- condes. Treatment of diarrhea1 dehydration. Am J Clin Nutr 30:1447, 1977.
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(10) Homill, P.V.V. Physical growth: National Center for Health Statistics percentiles. Am J Clin Nutr 32:607-629, 1979.
(II) Organizacibn Mundial de la Salud. Man- ual para el tratamiento de la diarrea aguda. Mime- ographed document OMS/CED/SER/SO 2 1980. Geneva, 1980.
