A review of some of the latest low-resources emergency medicine evidence

ORS monitoring charts to improve treatment of mild/moderate dehydration.

Caregiver oral rehydration solution fluid monitoring charts versus standard care for the management of some dehydration among Kenyan children: a randomized controlled trial

Kailemia M, Kariuki N, Laving A, Agweyu A, Wamalwa D.  Int Health. 2018;10(6):442-450. doi:10.1093/inthealth/ihy040

Aim

To evaluate the effectiveness of a care-giver administered fluid balanced chart

Rationale

Dehydration is an incredibly common pathology causing significant pathology in low resource settings. In these settings there is often a large volume of patients and minimal staff to ensure that the prescribed Oral Rehydration solution (ORS) is being given. The author’s only identified studies in high-resource settings evaluation nurse led interventions and none regarding care-giver led observations.


Design

Open label single centre randomised control trial

Setting

Paediatric department of district hospital in Nairobi, Kenya.

Population

Inclusion criteria; Patient aged 2-59 months with “some” dehydration based on clinical signs as per WHO guidelines.

Exclusion criteria; Severe dehydration, shock, severe acute malnutrition, bloody stools or illiterate caregivers .

268 patients enrolled.

Intervention

All patients received ORS 75mls/kg over 4 hours by cup or cup and spoon. Evaluated at 4 hours and management continued as per guidelines.

Intervention group; carers received instruction on how to complete the chart which included how much fluid to give over one hour and advice to give more if not sufficient quantity over that hour 

Standard group; no intervention

Primary outcome

Dehydration status at 4 hours

Secondary outcomes

Acceptability of fluid monitoring chart 

Results

7/122 (5.7%) were still dehydrated following 4 h of ORS administration vs 20/130 (15.4%) in the control group (risk ratio 0.37 [95% confidence interval 0.16–0.85])

Author’s Discussion

The use of fluid monitoring charts reduced the frequency of dehydration and was well accepted by caregivers, representing a promising innovation for the management of diarrhoea and dehydration in resource-limited settings.

Strengths

Useful clinical question

Simple intervention, easily applied in most low resource settings.

Sensible patient-orientated outcome, resolution of dehydration is presumably something the care-giver cares about, in addition is resource saving if saves admission and more aggressive fluid regimes (nasogastric or intravenous)

Pragmatic intervention

Uses standard interventions and definitions for dehydration

Easily implementable in any clinic or hospital 

Cheap! No cost effectiveness calculations but one would presume it would be

Plausible difference in levels of dehydration

Weakness

High literacy rates decreases generalisability

Daytime hours; possible selection bias- however in my experience overnight mild paediatric presentations are less common so not inappropriate.

Single-centre trial

No blinding of clinicians who were assessing dehydration; this would seem a relatively simple intervention to decrease bias.

The chart seems quite complicated to me; although the care-givers seemed to understand without difficulty

My humble opinion

This small single centre RCT demonstrates a plausible impact on children with mild or moderate dehydration. Certainly in my practice I see lots of children with ORS prescribed but an uncertain amount of fluid actually inside the patient. The chart could be easily adapted to local needs (e.g. made simpler) but I would have concerns about forcing on some care-givers who had limited literacy (it was nice in the study they did not implement with care-givers who seem fearful of it; good acknowledgement of cultural context), however for select populations and care-givers it would be a really simple tool to save nursing time and to enable staff to monitor fluid intake more easily. It would be nice to see a similar RCT in a different context. However, it would be little harm in implementing this strategy if working in context with a significant proportion of children with mild/moderate dehydration who do not improve.

Written by Daniel Roberts

Any questions or comments @notdocdan on twitter, or by email me directly.