Letters from Maine

'...Up his nose?'


 

Gastroenteritis continues to be one of the primary presenting illnesses for children in North America and the rest of the world.

Rotavirus vaccine has diminished the disease burden from one virus, but I don’t think anyone is surprised that another infective agent has taken up the slack. A recent study provides a window into the behavior of clinicians when they are called to the bedside of a child who seems unable to keep up with his gastrointestinal fluid losses (Pediatrics 2012;130:e1504-11 [doi: 10.1542/peds.2012-1012]).

The researchers, from the Hospital for Sick Children in Toronto, looked at the emergency department experience of 435 children who presented with symptoms of gastroenteritis. They found that 10% of the caregivers and 14% of the clinicians would choose nasogastric rehydration if oral rehydration failed. Eighty percent of the caregivers were more familiar with the intravenous route. Fifteen percent of the children ended up having an IV. Zero had a nasogastric tube placed.

When the nurses tasked with intervention were surveyed, the researchers found that in the previous 6 months, the nurses had inserted 90 IVs and only 4 nasogastric tubes. "It appears that current practice begets current practice," the authors wrote.

We are all traveling in the ruts of the wagon wheels that have rolled ahead of us. And obviously, habituation stifles innovation. But in this case, is commitment to ritual causing any harm? The authors cite references that report a low complication rate of 3%-6% (intrapulmonary infusion) for nasogastric use. I haven’t been able to find a complication rate for intravenous rehydration, but I suspect it is in a comparable range.

These Canadian investigators raise an interesting concern. In a teaching hospital whose house staff has a strong international flavor, is the current practice of intravenous rehydration propagating an intervention that may not be the better choice in less developed countries?

I think they make a valid point, but for those of us who practice in communities without a teaching hospital, does nasogastric tube rehydration have a place?

In Australia and New Zealand, 82% of ED physicians prefer nasogastric tube placement. They must be good at it. But in our hospital, and I suspect in yours, the nurses are like those in Toronto: Most are much more comfortable with an intravenous needle than with a nasogastric tube. Having been a recipient of both interventions several times in my career as a patient, I can tell you that I am much more comfortable with an IV than a tube up my nose. But you can argue that my experience reflects the inexperience of my assailants, and not a discomfort inherent to the procedure itself.

What I do know is that if one of our nurses were to approach a parent and tell him the next thing she was going to do was to put a tube up his child’s nose, that parent’s response would more than likely be a negative one. Some of that response would be generated by surprise. In our community, even parents whose children have never been in the ED would be expecting an IV for dehydration that has failed oral rehydration, because "that’s just the way they do it. "

In the short term, I think the wagon wheel ruts here in Brunswick are just too deep. However, these Canadian authors report that after a brief educational intervention, they could create a shift in both caregiver and clinician attitudes toward nasogastric rehydration. I’m interested to hear whether your community leans toward IV or NG.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine.

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