Predictive value of capnography for severity of acute gastroenteritis in the emergency department.

OBJECTIVE: This study first aims to assess the utility of ETCO2 levels in evaluating the severity of dehydration in adult patients that present to the ED with acute gastroenteritis. AGE. Second, it intends to evaluate the correlation between ETCO2 and several metabolic parameters: creatinine, pH, bicarbonate (HCO3), and bases excessive (BE). METHOD: This prospective study was conducted with AGE patients in the ED of a training and research hospital between June 2018 and April 2019 after approval of the local ethical-committee. The two groups were defined according to the severity of AGE: mild and non-mild groups. For both groups, ETCO2 levels were measured and recorded on admission of the patients. RESULTS: 87 patients were included in the analyses. The median of ETCO2 values was found as lower in non-mild group than mild group; 30 (25-35) & 39 (33-34), respectively (p < 0.001). In ROC analysis for distinguishing between the both groups, the AUC value was found to be 0.988 and the best cut-off level was found as 33.5 with 95% sensitivity and 93% specificity. In addition, strong negative correlation between ETCO2 and creatinine (p < 0.001, r: -0.771) were found. CONCLUSION: ETCO2 levels decreased in the non-mild group of AGE patients; it could be useful to distinguish the mild group from the non-mild group. ETCO2 could be a reliable marker in predicting AKI in the management of AGE patients.

[THE MODES OF EVALUATION OF TYPE OF DEHYDRATION IN CHILDREN HOSPITALIZED BECAUSE OF ACUTE INTESTINAL INFECTION].

Every year about 800,000 cases of intestinal infections end in lethal outcome due to dehydration. The different types of dehydration acquire differential approach to correction. Everywhere there is no application of routine detection of osmolarity of blood plasma under exicosis in children in view of absence of possibility of instrumental measurement. The search of techniques is needed to make it possible to indirectly detect types of dehydration in children hospitalized because of acute intestinal infection with purpose to apply rationale therapy of water-electrolyte disorders. The sampling of 32 patients with intestinal infections accompanied with signs of exicosis degree I-III was examined. The detection of osmolarity of blood was implemented by instrumental technique using gas analyzer ABL 800 Flex (Radiometer; Denmark) and five estimate techniques according to results of biochemical analysis of blood. The differences in precision of measurement of osmolarity of blood plasma by instrumental and estimate techniques were compared using Bland-Altman graphic technique. It is established that formula: 2x[Na+kp] + [glucosekp] (mmol/l) is the most recise. Its application provided results comparable with values detected by instrumental mode.

Analysis of 2009⁻2012 Nutrition Health and Examination Survey (NHANES) Data to Estimate the Median Water Intake Associated with Meeting Hydration Criteria for Individuals Aged 12⁻80 in the US Population.

In 2005, US water intake recommendations were based on analyses of Nutrition Healthand Examination Surveys (NHANES) III data that examined if hydration classification varied bywater intake and estimated the median water intake associated with hydration in persons aged 19⁻30. Given the upcoming 2020⁻2025 Dietary Guidelines review, this analysis addresses the same twoaims with the 2009⁻2012 NHANES data. Methods were updated by defining hydration criteria interms of multiple measures (serum sodium 135⁻144 mmol/L and urine osmolality < 500 mmol/kg),expressing water intake as ml/kg, distinguishing plain water intake (PWI) from total water intake(TWI), using weighted age- and sex-specific multivariable models to control for determinants ofwater intake requirements, and selecting two study samples (non-acutely ill US population and asub-group without selected chronic disease risk factors). In the US population and sub-group, therelative risk (RR) of meeting the hydration criteria was significantly greater for individuals withTWI ≥ 45 mL/kg or PWI ≥ 20 mL/kg (for the US population 19⁻50 years of age: adjusted RR (RRrepresents Relative Risk, which is a very standard term that probably does not need to be spelledout) = 1.36, 95% CI: 1.10⁻1.68 for males; adjusted RR = 1.70, 95% CI: 1.49⁻1.95 for females. For thesub-group 51⁻70 years of age: adjusted RR = 2.20, 95% CI: 1.15⁻4.18 for males; adjusted RR = 2.00,95% CI: 1.18⁻3.40 for females). The median (SE, which stands for Standard Error, which is also verywell known. Up to you if your journal prefers to spell it out in the abstract) TWI and PWI associatedwith meeting the hydration criteria for males and females 19⁻50 years of age were 42 (2) mL/kg and14 (1) mL/kg and 43 (2) mL/kg and 16 (1) mL/kg, respectively. The significant association betweenwater intake and hydration classification differs from the null association, underlying the 2005 waterintake recommendations, and may lead to different reasoning and inferences for the 2020⁻2025Dietary Guidelines.

Mild Dehydration Identification Using Machine Learning to Assess Autonomic Responses to Cognitive Stress.

The feasibility of detecting mild dehydration by using autonomic responses to cognitive stress was studied. To induce cognitive stress, subjects (n = 17) performed the Stroop task, which comprised four minutes of rest and four minutes of test. Nine indices of autonomic control based on electrodermal activity (EDA) and pulse rate variability (PRV) were obtained during both the rest and test stages of the Stroop task. Measurements were taken on three consecutive days in which subjects were "wet" (not dehydrated) and "dry" (experiencing mild dehydration caused by fluid restriction). Nine approaches were tested for classification of "wet" and "dry" conditions: (1) linear (LDA) and (2) quadratic discriminant analysis (QDA), (3) logistic regression, (4) support vector machines (SVM) with cubic, (5) fine Gaussian kernel, (6) medium Gaussian kernel, (7) a k-nearest neighbor (KNN) classifier, (8) decision trees, and (9) subspace ensemble of KNN classifiers (SE-KNN). The classification models were tested for all possible combinations of the nine indices of autonomic nervous system control, and their performance was assessed by using leave-one-subject-out cross-validation. An overall accuracy of mild dehydration detection was 91.2% when using the cubic SE-KNN and indices obtained only at rest, and the accuracy was 91.2% when using the cubic SVM classifiers and indices obtained only at test. Accuracy was 86.8% when rest-to-test increments in the autonomic indices were used along with the KNN and QDA classifiers. In summary, measures of autonomic function based on EDA and PRV are suitable for detecting mild dehydration and could potentially be used for the noninvasive testing of dehydration.

Emergency department management of gastro-enteritis in Australia and New Zealand.

OBJECTIVE: Comparison of clinical practice guideline (CPG) recommendations and reported physician management of gastro-enteritis at Paediatric Research in Emergency Departments International Collaborative (PREDICT) network sites as a baseline for further randomised controlled trials. METHODS: Two part survey comprising: (i) review of CPGs from PREDICT sites for gastro-enteritis; and (ii) survey of senior emergency department physicians regarding the management of gastro-enteritis. RESULTS: All 11 PREDICT sites participated. Nine CPGs were available with three sites using a common CPG. For moderate dehydration, eight CPGs advocated nasogastric (NG) rehydration in preference to intravenous (IV) rehydration. The IV route was reserved for severe dehydration or failed NG rehydration. In the second component of the survey, 78 of 83 (94%) physicians responded. In moderate dehydration, 82% of respondents used NG rehydration. In severe dehydration, 86% used IV fluids; 12% used NG and 3% an initial IV bolus followed by NG fluid. Serum electrolytes were measured universally with IV fluid use and by 22% using NG rehydration. The IV fluid bolus was with normal saline (86%). Fifty-four per cent used anti-emetics 'rarely' or 'sometimes'. The commonest agents were ondansetron (60%) and metoclopramide (29%). CONCLUSIONS: CPG recommendations and physician practice for the management of gastro-enteritis were similar across PREDICT sites with a focus on NG for moderate dehydration and IV for severe dehydration. A variety of fluids and administration rates were used. Anti-emetics were used infrequently. The efficacy and safety of newer anti-emetics should be explored in collaborative studies. Collaborative development of new CPGs should be considered to simplify fluid regimens.

Use of a single solution for oral rehydration and maintenance therapy of infants with diarrhea and mild to moderate dehydration.

OBJECTIVE: To compare the efficacy of two commonly used solutions in the rehydration of infants with mild to moderate dehydration caused by acute diarrhea in the United States. DESIGN AND SETTING: Double-blind, parallel-group, randomized study performed at Children's Hospital Medical Center. PATIENTS: Sixty infant boys (< or = 2 years old), with mild (< or = 5%) or moderate (6 to 9%) dehydration caused by acute diarrhea of less than 1 week's duration were included in the study. INTERVENTIONS: Infants were randomly assigned to receive treatment with either a glucose-based oral rehydration solution (ORS) (Pedialyte, Ross Laboratories, Columbus, OH) or a rice syrup solids-based ORS (Infalyte, Mead Johnson Nutritional Group, Evansville, IN). After rehydration was achieved, patients entered a maintenance phase during which, in addition to a maintenance ORS, breast milk or a soy-based formula was offered; infants older than 1 year were also given a lactose-free diet. OUTCOME MEASURES: Rehydration was judged clinically. Infants remained on a metabolic bed during the study in to separate and quantitate urine and stool output. Therefore, in addition to clinical outcome, we compared intake, output and apparent absorption and retention of fluid, sodium, and potassium between groups. RESULTS: All patients were successfully rehydrated using an ORS without the use of intravenous fluids. No differences were detected between treatment groups in time to rehydration, percentage of weight gain after rehydration, consumption of ORS to achieve rehydration, or stool output. However, the apparent sodium absorption (net intake less fecal output) was greater in the Infalyte group than the Pedialyte group during the first 24 hours. CONCLUSION: The two maintenance oral electrolyte solutions (Pedialyte and Infalyte) most commonly used in the United States are effective as rehydration solutions for infants with mild to moderate dehydration. We speculate that a strategy for oral rehydration therapy in the United States, based on the use of a single solution during the rehydration and maintenance phase, might gain additional acceptance by practicing pediatricians and family physicians.

Value of laboratory studies in assessment of dehydration in children.

BACKGROUND: Due to the lack of a reliable way of clinically measuring dehydration, laboratory tests are usually used to improve the accuracy of clinical assessment of dehydration in children. The purpose of this study was to compare the relationship between clinical and laboratory parameters in the assessment of dehydration and to evaluate the improvement of those parameters over time. METHODS: We conducted a retrospective study to assess the relationship between clinical assessment of dehydration and laboratory findings. RESULTS: Three hundred children were eligible for the study. Twenty-six per cent of those with mild dehydration had serum urea concentrations greater than 14.3 mmol/L, compared with 38% and 5% of those with moderate or no dehydration, respectively. Urea concentration showed a good specificity, 95%. Creatinine concentrations and mean pH were similar whether or not dehydration was present. Bicarbonate and base excess concentrations decreased with the increasing severity of dehydration and were significantly greater in subjects with moderate dehydration than in those without. The sensitivity (71%) and specificity (74%) of both tests were rather poor. All groups had an abnormal anion gap, which was significantly greater in those with mild or moderate dehydration. CONCLUSION: This study confirms that there is a discrepancy between clinical assessment and laboratory parameters of dehydration. Urea showed good specificity, and anion gap was the most sensitive laboratory parameter for assessment of dehydration. These findings need further validation.

Predictors of weight loss during radiation therapy.

OBJECTIVE: To define risk factors for weight loss or dehydration during radiation therapy (RT). STUDY DESIGN AND SETTING: Retrospective chart review, academic tertiary care center. RESULTS: The incidence of severe weight loss during RT was 32.7%, the incidence of dehydration was 10.9%, and the rate of prophylactic feeding gastrostomy tube placement was 32%. The patients most likely to suffer severe weight loss included patients with tumor sites of nasopharynx and base of tongue, those treated with chemoradiation, and patients with severe pretreatment weight loss. Prophylactic feeding gastrostomy tube placement before RT significantly reduced the incidence of severe weight loss and hospitalization during RT. CONCLUSION: Severe weight loss and dehydration during RT for head and neck cancer is common. Prophylactic feeding gastrostomy tubes significantly reduce the incidence of severe weight loss and hospitalization for dehydration during RT when placed before onset of RT. Patients at risk for severe weight loss include those with severe pretreatment weight loss, tumors of the nasopharynx and base of tongue, or treatment with chemoradiation.

Dehydration and fluid therapy.

In the clinical setting, dehydration implies loss of both water and electrolytes. This is indeed what occurs in diarrhea, which is the most common cause of dehydration in children. The treatment of diarrhea is detailed first, followed by consideration of several less common conditions leading to dehydration in early infancy, including acute adrenal insufficiency and pyloric stenosis.

Physician misdiagnosis of dehydration in older adults.

INTRODUCTION: Dehydration is a difficult clinical diagnosis in older adults because the physical signs of dehydration are often confusing. The clinical consequences of a diagnosis of dehydration are critical, since dehydration implies increased morbidity and mortality and aggressive rehydration can improve clinical outcome. The diagnosis is a sentinel event for nursing homes, and often is made at transfer to a hospital. OBJECTIVE: To define the accuracy of the clinical diagnosis of dehydration during hospital admission, and to observe persons admitted from long-term care. METHODS: A total of 102 consecutive medical admissions in persons older than 65 years with a diagnostic coding for dehydration either on admission or during the course of hospitalization over a 3-month period at a university teaching hospital were reviewed. The diagnosis of dehydration was considered confirmed if the calculated serum osmolarity was greater than 295 milliosmols (mOsmol). Subjects were considered to have intravascular volume depletion if the ratio of blood urea nitrogen (BUN) to serum creatinine was greater than 20 or the serum sodium was greater than 145 milligrams per deciliter. Subjects were considered to have hypovolemia if the serum osmolarity was greater than 295 and the BUN/creatinine ratio was greater than 20. RESULTS: Among subjects with a clinical diagnosis of dehydration, only 17% had a serum osmolarity >295 mOsm, and only 11% had a serum sodium greater than 145. A BUN/creatinine ratio greater than 20 was present in 68% of the subjects. Clinicians appear to be using the term dehydration synonymously with intravascular volume depletion. Even so, at least a third of the diagnoses of intravascular volume depletion in older adults were incorrect based on laboratory data. CONCLUSION: Physicians who diagnose dehydration during hospital admission may be relying more on physical signs than laboratory data. Little change in laboratory markers for hydration status occurs from the time of diagnosis to hospital discharge, suggesting that the clinical diagnosis does not affect fluid management. The data suggest a need for improvement in the differential diagnosis and management of volume changes in older persons.

The dehydrated child: a management approach.

Dehydration in the child requires urgent attention to fluid replacement. Management must focus on an understanding of the physiology of fluid loss and clinical and laboratory assessment. Fluid therapy must combine correction of fluid deficits with concurrent administration of maintenance fluids.

Laboratory predictors of fluid deficit in acutely dehydrated children.

To determine which laboratory studies are most predictive of the fluid deficit in acutely dehydrated children, we studied a convenience sample of 40 children requiring intravenous fluid resuscitation. Nine laboratory studies (serum BUN/cr, total serum CO2, serum uric acid, serum anion gap, urine anion gap, venous pH, venous base deficit, urine specific gravity, and fractional excretion of sodium) were individually assessed in simple linear regression models with fluid deficit as the dependent variable. Only the serum BUN/cr and serum uric acid were significantly associated with increasing fluid deficit (r = 0.52, P = 0.0005 and r = 0.35, P = 0.03, respectively). The sensitivities and specificities of these two laboratory studies for the detection of > 5% fluid deficit were poor. Conventional laboratory studies used to assess dehydration in children are poorly predictive of fluid deficits.

The intraosseous route is a suitable alternative to intravenous route for fluid resuscitation in severely dehydrated children.

It is sometimes difficult to gain a rapid intravenous access in hypovolemic states. The suitability of intraosseous (IO) route for fluid infusion as an effective, safe and reliable alternative to intravenous (IV) route was explored. Sixty children (age range 3 months to 2 years) with severe dehydration were assigned alternately to receive resuscitating fluid through either IO or IV routes. The IO route was successfully secured in all cases within the first 5 minutes of attempt. On the other hand, the IV line could not be secured in 33% (10 out of 30) patients within 5 minutes. The time taken for IV cannulation when it was successful (129 +/- 13 seconds, 95% confidence interval 103-156 seconds) was significantly longer than the time taken for IO cannulation (67 +/- 7 seconds, 95% confidence interval 55-80 seconds). Fluid infusion through either routes was equally effective in stabilizing vital signs and normalizing laboratory abnormalities. No significant complication of IO route was noted on short term follow-up. We conclude that IO route is a safe, effective alternative for emergency fluid administration in severe dehydration when intravenous line cannot be secured rapidly.

The nutrient content and effectiveness of rice flour and maize flour based oral rehydration solutions.

The effectiveness of rice flour and maize flour based oral rehydration solution (ORS) in treating mild and moderate dehydration was studied among 88 children aged to 6 to 42 months at the Oni Memorial Children Hospital, Ibadan. In this randomized clinical trial, fifty children were treated with rice-based ORS while fifty-three received the maize-based ORS, over a four hour period. There was clinical improvement in the signs of dehydration with a significant increase in body weights and a significant fall in the packed cell volume following the administration of the two preparations. The maize-ORS contains 4.3 g protein, 179.3 Kilocalories and rice-ORS contains 3.6 g protein and 152.1 Kilocalories per litre of the preparation, respectively. It is concluded that rice and maize based ORS were acceptable and effective in oral rehydration of diarrhoea patients. They may also contribute to the nutrient intake of patients with (mild to moderate) 'some' dehydration. However other sources of energy, protein and mineral intake should be continued in these patients.

Preventing and managing dehydration.

Sufficient body water and electrolyte homeostasis are essential for healthy physiologic functioning. Nurses are key to preventing, detecting early, and treating fluid and electrolyte imbalances. Dehydration significantly alters both physical and psychological functioning, and older adults are at increased risk. Identifying fluid disorders early can prevent complications and reduce hospital stays. Understanding the mechanisms of fluid homeostasis enables nurses to assess, prevent, and collaborate in managing isotonic, hypertonic, and hypotonic dehydration.

Mild to moderate dehydration combined with moderate alcohol consumption has no influence on simulated driving performance.

OBJECTIVE: Many people consume alcoholic beverages following a period of physical activity that results in fluid loss through sweating (e.g., after sports, work). Adequate rehydration following physical activity may not occur, consequently resulting in the consumption of alcohol in a dehydrated state. This may have serious implications for the safety of individuals operating motor vehicles. Therefore, this study investigated the impact of mild-moderate dehydration in combination with moderate alcohol consumption on simulated driving performance. METHODS: Fourteen healthy males participated in a placebo-controlled crossover design study involving 4 experimental trials (separated by 4 days or more). In each trial, participants were dehydrated by ∼2 percent body mass through exercise. After a 30-min recovery, participants completed a 15-min computerized simulated driving task (drive 1). In 2 of the trials, participants were provided with water equivalent to either 50 or 150 percent body mass loss and also received salt capsules (NaCl, 50 mmol/L). A set volume of alcohol or placebo was then consumed in each trial, incorporating the conditions: dehydration-placebo (DP), dehydration-alcohol (DA), partial rehydration-alcohol (PA), and full rehydration-alcohol (FA). The volume of the alcoholic beverage was individually calculated and intended to raise the blood alcohol content (BAC) to ∼0.05 percent. The same driving task was then readministered (drive 2). Primary outcome measures of driving consisted of standard deviation of lateral position (SDLP), number of side and center line crossings (LC), number of failures to stop at red traffic signals (FTS), number of impacts/collisions with other vehicles or objects (IMP), and time to collision with a specified lead vehicle (TTC). In addition, reaction time (RT) and incorrect inhibition response (IIR) behavior to critical events were collected throughout each experimental drive. Subjective ratings of mood and estimates of alcohol intoxication and driving impairment were also recorded in each trial. RESULTS: No effects of trial condition were observed on any of the driving performance measures or on subjective ratings of mood, alcohol intoxication, and driving impairment. SDLP was higher following the consumption of alcohol compared to the placebo trial. However, no differences in SDLP were recorded between the alcohol trials, indicating that hydration level had no observable interaction with alcohol to influence SDLP performance. CONCLUSIONS: Overall, it appears that dehydration does not exacerbate impairment in driving performance caused by mild-moderate alcohol intoxication. Further research is required to clarify the effects of alcohol and dehydration at various alcohol doses.

Evaluation of a clinical dehydration scale in children requiring intravenous rehydration.

OBJECTIVES: To evaluate the reliability and validity of a previously derived clinical dehydration scale (CDS) in a cohort of children with gastroenteritis and evidence of dehydration. METHODS: Participants were 226 children older than 3 months who presented to a tertiary care emergency department and required intravenous rehydration. Reliability was assessed at treatment initiation, by comparing the scores assigned independently by a trained research nurse and a physician. Validity was assessed by using parameters reflective of disease severity: weight gain, baseline laboratory results, willingness of the physician to discharge the patient, hospitalization, and length of stay. RESULTS: Interobserver reliability was moderate, with a weighted κ of 0.52 (95% confidence interval [CI] 0.41, 0.63). There was no correlation between CDS score and percent weight gain, a proxy measure of fluid deficit (Spearman correlation coefficient = -0.03; 95% CI -0.18, 0.12). There were, however, modest and statistically significant correlations between CDS score and several other parameters, including serum bicarbonate (Pearson correlation coefficient = -0.35; 95% CI -0.46, -0.22) and length of stay (Pearson correlation coefficient = 0.24; 95% CI 0.11, 0.36). The scale's discriminative ability was assessed for the outcome of hospitalization, yielding an area under the receiver operating characteristic curve of 0.65 (95% CI 0.57, 0.73). CONCLUSIONS: In children administered intravenous rehydration, the CDS was characterized by moderate interobserver reliability and weak associations with objective measures of disease severity. These data do not support its use as a tool to dictate the need for intravenous rehydration or to predict clinical course.