Sample EBM Paper
A 16 month old boy presents with vomiting and diarrhea and is noted on exam to be
moderately dehydrated. He is refusing to drink any fluids. You feel that rehydration is
necessary and the parents ask you if there is any way to rehydrate him without placing an
IV for IV fluids. You think of placing a nasogastric tube for rehydration but are unsure
of whether there is any evidence that this is an effective a method of rehydration.
Clinical Question: In young children with dehydration (Population), has NG
rehydration (Intervention) been shown to be as efficacious (Outcome) as IV rehydration
(Comparison)?
Search: PubMed  Clinical Queries using Research Methodology  Category:
Therapy  Emphasis: Sensitivity  Search term: Nasogastric hydration (Yields 34
articles)  Limit Search to infants birth – 23 months (Yields 12 articles)
Scan the 12 titles for relevance. Titles #3, 4, 6, 8, 10 and 12 seem relevant. I chose to
review more recent abstracts so eliminated 10 and 12.
Title #3: Addresses all aspects of my clinical question and is published in Pediatrics,
which I know is a good peer-reviewed journal.
Title #4: This is a review of the evidence not a controlled study.
Title #6: This study addresses all aspects of my clinical question but the numbers of
patients are much smaller than those studied in Title #3. Also, I don’t know much about
the Journal of Pediatric Gastroenterology and Nutrition.
Title #8: This study addresses my clinical question to some degree although patients are
randomized into an oral group in which they received either oral fluids or nasogastric
fluids.
Select Title #3 for appraisal. Nager AL, Wang VJ. “Comparison of Nasogastric and
Intravenous Methods of Rehydration in Pediatric Patients with Acute Dehydration”.
Pediatrics 2002; Apr 109(4):566-72.
Appraisal: The study methods provide clear definitions of inclusion and exclusion
criteria. The patients are in the same age range as my patient (3 – 36 months.) Exclusion
criteria included severe dehydration and significant chronic disease. My patient fits the
author’s criteria for dehydration and is otherwise healthy as are the children in this study.
Patients were randomized into IV (gold standard) or NG rehydration groups only after
they failed oral rehydration. A clear definition of treatment failures is also given. The
authors describe the statistical analysis they used to determine their sample size and have
a sample size large enough to detect a 20% difference in efficacy between the groups.
The results show that it takes fewer attempts to place an NG tube than an IV. There were
no serious complications to NG placement (1 nose bleed). Although patients are
randomized into the 2 groups, Table 2 demonstrates a higher range of BUN in the RIV
group than the NG group. I do not find this difference addressed in the text nor is there a
good description of the randomization process that assures there was no bias in selection
of patients occurred. Overall, the study shows NG rehydration to be as efficacious as IV
rehydration even in children who are vomiting. Of note, this article also shows NG
rehydration to be more cost-effective than IV rehydration. All of these results have been
analyzed to show statistical significance and therefore appear to be valid. The results are
important and applicable to my current clinical question.
Apply: Although in my clinical experience, I have almost always used IV rehydration in
for cases like this patient, the evidence indicates that NG rehydration is as efficacious as
IV rehydration. My patient’s parents have indicated their desire to forego an IV stick so I
will discuss the option of NG rehydration with them. With their approval, I will attempt
rehydration of this infant with NG fluids.