[display_podcast]
Date: May 31st, 2015
Guest Skeptic: Dr. Anthony Crocco. Anthony is the Medical Director & Division Head of Pediatric Emergency at McMaster’s Children’s Hospital. He is known on YouTube for his RANThonys and has recently developed a novel website to teach evidence based medicine called SketchyEBM.
Case: Four year-old girl presents with diarrhea and three episodes of vomiting in the last 24 hours. The child has signs of mild dehydration. A diagnosis of gastroenteritis is made but you are concerned about ensuring the child takes enough fluids and wonder whether ondansetron is a good choice.
Background: Dehydration in children is a common presentation to the emergency department. A main cause of dehydration in this age group is gastroenteritis that is characterized by acute onset diarrhea with or without nausea, vomiting, fever and abdominal pain.
The scope of the problem was quantified by Glass et al:
* 20-40 million episodes of diarrhea in children each year in the USA
* 2-4 million physician visits per year
* 10% of all hospital admissions of children < 5 yrs old
In the last few years there have been two systematic reviews on the use of ondansetron in children with vomiting from gastroenteritis.
The first was by DeCamp et al. in 2008 and the second was by Fedorowicz et al in 2011. We covered DeCamp in SGEM#12 that showed impressive results:
* NNT of 5 to stop vomiting
* NNT of 5 to prevent one IV insertion
* NNT of 14 to prevent one admission
Given the prevalence of gastroenteritis in the pediatric population, the concerns around preventing dehydration and the desire to avoid unnecessary invasive procedures or admissions, these results were very important.
Clinical Questions: What has been the trend in ondansetron use in the last 10 years, and how has this related to intravenous rates and admission rates?
Reference: Freedman SB et al. Impact of increasing ondansetron use on clinical outcomes in children with gastroenteritis. JAMA Pediatr 2014
* Population: Children <18 years old presenting to the emergency department with gastroenteritis
* Intervention: Oral ondansetron use
* Comparison: Time-trend retrospective analysis
* Outcome:
* Primary Outcome: Rates of intravenous insertion.
* Secondary Outcomes: Hospital admission rates, representation to the emergency department within three days, alternative diagnose within three days, cost analysis over time.
Authors’ Conclusions: “Ondansetron use in children with AGE (acute gastroenteritis) has increased dramatically in pediatric centres during the past decade without a concomitant reduction in IV rehydration or hospitalizations.”
Quality Checklist for Observational Trials:
* Did the study address a clearly focused issue? Yes
* Did the authors use an appropriate method to answer their question? Yes
* Was the cohort recruited in an acceptable way? Unsure
* Was the exposure accurately measured to minimize bias? Yes
* Was the outcome accurately measured to minimize bias? Yes
* Have the authors identified all important confounding factors? Yes
