Finally a real windmill to tilt at. Yes, you should expect the dextrose to raise their sugar pretty quickly, but it's irrelevant. You want to provide more than they need unless it's a super long starvation such as neglect.
First, if they're starving, they're starving for nutrition, not salt. Yes, they're dehydrated, but they're also ketotic which can cause nausea. That's why WHO fluid and pedialyte both contain sugar. You don't metabolize sodium or chloride.
As far as giving dextrose containing fluids in bolus being dangerous? Laughable. People argue until they're blue in the face that bolusing that fluid as too hyperosmolar will harm vessels, and then turn around and give d50. It's a hyperosmotic solution with an osmolarity of approximately 2,525 mOsm/L and a pH between 3.5 and 6.5.
The NHS does have a contraindication for hypertonic/hypotonic solutions but it specifically points towards hypotonic sodium content, and in general hasn't applied to dextrose containing fluids. The NHS has made policy against hyponatremia, and while it specifically forbids (and removed) .18% NS, they do recommend in the case of fluid loss to "estimate any fluid deficit and replace as sodium chloride 0.9% with glucose 5% (isotonic solution) or sodium chloride 0.9% over a minimum of 24 hours." The NHS isn't being cavalier in their efforts.
This is the important bit. We aren't resuscitating using D5whatever, we are correcting deficits. Always resuscitate with NS or LR. You're not fixing their hypotension using it. You're hydrating them. You can bolus hydrate, there's no "rule" against it.
If you look at a recent actual study, you can see that there was a difference between pediatric gastroenteritis (ie starvation ketosis) groups that received dextrose vs the one getting only crystalloid. 9% more were admitted in the non-dextrose group. And furthermore, 3 times as many in the d5NS group (15 vs 5) were admitted based on family request, which would have doubled the difference between groups and likely showed statistical differences. They did this study because of a
retrospective analysis showing a benefit to giving IV dextrose.
And then, they point out that "Twenty-six children were hypoglycemic (glucose 60 mg/dL) before receiving the study fluid. None of the children who received a 5% dextrose in normal saline solution bolus were hypoglycemic 1 hour after initiation of the study fluid bolus, whereas all of the children in the normal saline solution group remained hypoglycemic at 1 hour, with an additional 12 children becoming hypoglycemic in this treatment arm." Because the physicians weren't sadists, the hypoglycemic children of course received IV dextrose, potentially skewing the results even more. Both groups received some, with the d5 arm getting an average of 1g/kg more during the duration.
More importantly they found "Among dehydrated children requiring intravenous rehydration, administration of a dextrose-containing fluid bolus appears to be safe and led to a greater reduction in serum ketone levels compared with a bolus of normal saline solution" and also "In the subset of patients who were acidotic and discharged, 30% of patients in the normal saline solution group required unscheduled medical care compared with only 11% in the 5% dextrose in normal saline solution group. Although this planned analysis was not subject to hypothesis testing and may have been due to chance alone, our findings may have clinical relevance and warrant further study."
Futhermore, in the first article "The investigators conclude that rapid IV therapy is effective, and that inclusion of dextrose in the treatment fluid may prevent occurrence of hypoglycemia without harmful effects...The results are more mixed with regard to avoidance of hospitalization or relapse. Overall, nearly 20% of subjects in those studies conducted in an ED setting either required hospital admission after treatment or returned for unscheduled care. The one study that reported a high rate of treatment failure (in the form of hospital admission or return for further treatment) had the smallest total volume of fluid administered by the treatment regimen: the “rapid IV hydration” consisted of the administration of 20-30 ml/kg over 1-2 hours, followed by 1-3 ounces of clear fluid. For most patients with mild-moderate dehydration, where the deficit is likely to be 5-10% of body weight, this would not constitute total deficit replacement. Excluding this study, the rate of admission or relapse is 10.1% (95% CI: 5.1%, 17.3%). It is a commonly accepted belief in clinical practice that patients who require more than 2 initial boluses of fluid in the ED require hospital admission.25 These studies, taken as whole, would suggest that patients can be given large volumes of fluid, in excess of 40-50 ml/kg, and still be safely and successfully discharged."
And finally, while not exactly pertinent for AGE in peds, this
blog post from the guys at Kings County/SUNY Downstate discuss dextrose containing fluids in hyperemesis, another ketotic state.
Some argue for NS because of higher chloride content in a relatively chloride depleted state, but again you're fighting metabolic acidosis with an acidotic fluid.
Always remember, the worst reason for doing anything is "because we've always done it that way"
