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Darren A. DeWalt, MD, MPH
Department of Medicine
Julie S. Byerley, MD, MPH
Department of Pediatrics
University of North Carolina
Chapel Hill, NC 27599
To the Editor.—
Wathen et al1 studied the use of serum electrolyte panels (SEPs) for children needing intravenous fluid (IVF) for gastroenteritis. All children enrolled had obligatory SEPs drawn, and the results were presented to the attending physician. They then documented evaluation, management, and disposition plans. Because the SEPs changed decisions about clinical care and disposition, the authors concluded that SEPs are useful in all children receiving IVFs for gastroenteritis. We feel that the results are overstated because of a limited study design.
Two of the study endpoints were whether attending physicians could accurately predict SEP abnormalities and whether those SEP results would alter clinical management. The authors indicate that the attending physicians would have ordered tests for only 58% of children for whom clinical management changed because of SEP results. Asking physicians to retrospectively document whether SEP results changed their management may introduce bias into the results. Furthermore, the authors fail to point out that in the 121 patients for whom the attending physician did not plan to order an SEP, only 8 (6.6%) had test results that changed management (see Table 4 in ref 1). In other words, the attending physicians were correct 93% of the times that they chose not to order the test. The authors did not comment on the importance of the management changes for that 6.6% of patients. The abnormalities in that select group should be the key finding for the study.
A more direct question should be addressed before the SEP is promoted as a screening test to be checked in all children with gastroenteritis receiving IVFs. Does this intervention result in an important benefit to patients? Previous studies demonstrate that appropriate rehydration in children with gastroenteritis will cause many electrolyte abnormalities to resolve quickly and safely.2,3 Mild or moderate electrolyte derangements, such as many of those labeled "clinically significant" in this study, do not automatically necessitate changes from currently accepted gastroenteritis management strategies.4 We argue that the primary endpoint of physician management changes is a poor surrogate for a clinically important outcome.
Children in American emergency departments with mild to moderate dehydration caused by gastroenteritis almost always have a good clinical outcome.4 This study does not demonstrate that ordering SEPs on all patients who receive IVFs improves those outcomes. Rather, it seems to demonstrate that the attending physician judgment was correct almost all, if not all, of the time. We applaud Wathen et al for trying to understand the role of electrolyte testing in patients with gastroenteritis, but we disagree with their conclusions. Previously well children with mild to moderate gastroenteritis do not routinely need additional assessment with SEPs.4,5
REFERENCES
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