How do you keep Ebola patients hydrated?
Dehydration is a key cause of death in people infected with Ebola. Patients experience severe vomiting and diarrhoea, causing a loss of fluids which are then difficult to replace. The associated fluid loss can be as much as five to 10 litres per day. In fatal cases of Ebola Virus Disease (EVD), blood levels of urea and creatinine increase over time, which may be a consequence of dehydration.
Taking in fluids orally often isn’t enough to compensate for this loss and so health workers need to use other means. The most common way to do this is through the vein (intravenously), but this can be challenging in the context of Ebola: starting intravenous fluids can be difficult in very dehydrated patients and infection control practices (such as the wearing of protective suits) may make it hard to maintain the infusion. Securing access can also present risks to healthcare workers, from needlestick injury or contact with body fluids associated with insertion or dislodgement.
Understanding the advantages and disadvantages of different methods of fluid delivery could help health workers make choices that save lives.
What we did
Prompted by the Ebola crisis in West Africa, NIHR funded a systematic review to compare the reliability, safety, ease of use and speed of insertion of four different access methods: into a vein (intravenously), into bone marrow (intraosseously), into fatty tissue under the skin (subcutaneously) or into the abdominal space (intraperitoneally).
What we found
The evidence suggests that bone marrow access may be achieved faster and with fewer insertion failures than intravenous access.
Subcutaneous access is also associated with fewer insertion failures than intravenous access. This route may be suitable for patients who are not severely dehydrated but where oral intake isn’t enough. Given the ease of insertion of subcutaneous lines, they could be inserted by healthcare workers with minimal medical training.
Taken together, the evidence indicates that intraosseous and subcutaneous access are both viable alternatives to intravenous access when the latter cannot be achieved. However, when done successfully, more fluid can be infused by the intravenous route than by either the intraosseous or subcutaneous route.
The researchers concluded that the choice of method used in clinical practice may depend on site-specific issues, such as the availability and expertise of medical and nursing staff, patient numbers and local infrastructure.
This research met an urgent need for evidence-based guidance on a topic with real treatment uncertainty, offering healthcare staff the means to judge the safest and most effective fluid administration route to use in each case. Despite the intense media focus on anti-viral drugs and vaccines these had little or no impact on death rates in the 2014 Ebola outbreak. Improved management of fluid and electrolytes were probably responsible for the observed reductions in case-fatality.
The findings were disseminated, used and referenced widely during the recent epidemic, and video was created to accessibly share the findings of the review.
The review was also referenced by NICE in its Clinical Pathway ‘Intravenous fluid therapy in adults in hospital overview’ as the research examined parenteral access for in a range of conditions, so the findings apply beyond ebola treatment.