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We appreciate the opportunity to respond to the comments regarding our manuscript and thank the authors for their interest on this topic. We agree that it is important to try and understand the role of the serum electrolyte panel (SEP) in children with gastroenteritis who receive intravenous fluids (IVFs) for rehydration. However, we do disagree with several of the points raised.
The assertion that we concluded that all mild and moderately dehydrated children must have an SEP is not accurate. It must be remembered that our patient population consisted of children in whom attempts at oral rehydration therapy had failed and who the pediatric emergency medicine attending physicians believed required IVF rehydration. Our initial hypothesis was that obtaining routine SEPs on these children would not be beneficial. However, after looking at the results, we did not believe this was the proper conclusion, and as stated, we feel that an SEP can provide useful information for the treatment of some children receiving IVFs for dehydration.
We recognize that there are limitations in our study design, such as not blinding the treating physician to the SEP results. However, as stated in our article, that approach was determined by our institution to be an unethical design component. Treating physicians were asked, before seeing the results of the SEP, if they would have ordered this test in the first place and for what reason. After the SEP results were reviewed, the physicians were then asked how the results changed their management. Indeed, some treatment bias can exist with this study model.
The SEP abnormality was felt by the physicians to change management in 10.4% of the patients, with reasons outlined in our Table 3. Several responders, in looking at our Table 4, correctly note that in patients for whom the treating physicians would not have ordered an SEP, they made a correct determination in 93% of the cases. However, they would have missed 6.6% of the patients in whom management changes did occur. Each physician, when treating these types of children, will have to decide if this is an acceptable risk. In regard to the claim that all severe, significant SEP abnormalities could be detected clinically and that those that were not severely abnormal would not affect clinical management, there are several important points to consider. First, our study shows the inability of pediatric emergency medicine physicians to predict SEP abnormalities. This predictive ability will depend significantly on the clinical acumen of the physician. There are a variety of environments and care providers who take care of dehydrated children. The seasoned clinician may indeed be able to predict for all children the most significant SEP abnormalities. This, however, remains unproven. Second, the notion that less severe abnormalities shown in the SEP do not play a factor in the outcome of those particular children is not known.
Steiner et al suggest that there is evidence and accepted management strategy that previously well children with mild to moderate gastroenteritis do not routinely need additional assessment with an SEP and that SEP abnormalities quickly and safely resolve with rehydration. The references provided in their letter are not controlled studies that evaluated the effect of rehydration on abnormal electrolytes, although several were comprehensive reviews of the management of pediatric dehydration. In fact, only the weakest form of evidence D and 5A (opinions and consensus statements) were cited in the article (Armon et al1) when recommending which children require serum electrolyte testing. Another reference cited, Yurdakok et al,2 was a retrospective report in the Journal of Tropical Medicine on dehydrated children receiving rehydration. Although a change in management did not occur with alterations of sodium and potassium values, there was evidence that time of rehydration correlated with the degree of acidosis. This finding lends additional support to a similar finding in our study, which was that children with lower serum bicarbonate values received rehydration for a longer duration.
We find little evidence to substantiate the concern that obtaining an SEP may have a negative impact or actually cause harm to these children. We totally support the concept that unnecessary testing needs to be avoided. We also do no attempt to recommend management based on SEP results. In fact, we offer several benefits to the care of these children using the SEP, including the importance of identifying at-risk groups such as children <1 year old who are more likely to be acidotic and those children with hypoglycemia who had a higher rate of unscheduled return visits. In addition, evidence indicates that children with a low serum bicarbonate level can be treated successfully in an observation unit, instead of being admitted, which would actually lower the perceived iatrogenic harm that may occur with hospitalization.
There are many acceptable strategies when evaluating pediatric patients with dehydration. Physicians, based on their experience and the patient's presentation, can decide if they will order no tests, a D-stick only, or the full SEP. The purpose of our article was to look at the incidence of electrolyte abnormalities in children receiving IVFs, to determine how accurate physicians are in determining, a priori, if electrolyte abnormalities exist, and to determine how these abnormalities correlated or affected clinical management.
We cannot argue, nor do we suggest, that subtle SEP abnormalities necessitate a change in clinical management. However, more evidence is needed before it can be stated definitively that children with SEP abnormalities respond to generic therapy in exactly the same manner as those without them and that therefore knowing the results of an SEP has no value. The opinion of the American Academy of Pediatrics' Subcommittee on Acute Gastroenteritis3 recommends an SEP in children receiving IVFs. Our study results do not refute this recommendation. We thank Steiner et al, Rhee and Silverstein, and Tarini and Mendoza for adding to this interesting discussion.
REFERENCES
Related articles in Pediatrics:
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