Fluid Boluses Might Not Benefit All Children in Shock

Clinical question: What is the effect of fluid resuscitation on mortality in children with shock in resource-limited settings?

Background: Rapid fluid resuscitation is typically recommended for children who present with shock. In resource-limited settings, particularly in Africa, this practice is not commonplace. The exact role of early fluid resuscitation, in addition to the optimal type of fluid (saline or albumin), is unknown.

Study design: Multicenter, randomized, controlled trial.

Setting: Six clinical centers in Africa.

Synopsis: This study was stopped after data for 3,141 of a projected 3,600 enrolled children demonstrated increased mortality in the bolus groups vs. control. Children aged 60 days to 12 years who presented with a severe febrile illness and impaired perfusion without severe hypotension were randomized openly to three groups: saline bolus, albumin bolus, or no bolus (control). Baseline characteristics of the groups were similar. After 48 hours, mortality in the albumin, saline, and control groups was 10.6%, 10.5%, and 7.3% respectively. The relative risk for any bolus vs. control was 1.45 (95% CI, 1.13-1.86; P=.003).

The results of this study are strengthened by the large number of children enrolled and the solid study design. However, it is difficult to immediately generalize the findings due to the unique nature of the study population and environment, which included a high proportion of patients with malaria and notable constraints on resources. Nonetheless, questions are raised regarding the routine practice of rapid and early fluid resuscitation in patients with shock and without clear hypovolemia.

Bottom line: Fluid resuscitation is not beneficial in resource-limited settings for children in shock who are not hypotensive.

Citation: Matiland K, Kiguli S, Opoka RO, et. al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364:2483-2495.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the effect of fluid resuscitation on mortality in children with shock in resource-limited settings?

Background: Rapid fluid resuscitation is typically recommended for children who present with shock. In resource-limited settings, particularly in Africa, this practice is not commonplace. The exact role of early fluid resuscitation, in addition to the optimal type of fluid (saline or albumin), is unknown.

Study design: Multicenter, randomized, controlled trial.

Setting: Six clinical centers in Africa.

Synopsis: This study was stopped after data for 3,141 of a projected 3,600 enrolled children demonstrated increased mortality in the bolus groups vs. control. Children aged 60 days to 12 years who presented with a severe febrile illness and impaired perfusion without severe hypotension were randomized openly to three groups: saline bolus, albumin bolus, or no bolus (control). Baseline characteristics of the groups were similar. After 48 hours, mortality in the albumin, saline, and control groups was 10.6%, 10.5%, and 7.3% respectively. The relative risk for any bolus vs. control was 1.45 (95% CI, 1.13-1.86; P=.003).

The results of this study are strengthened by the large number of children enrolled and the solid study design. However, it is difficult to immediately generalize the findings due to the unique nature of the study population and environment, which included a high proportion of patients with malaria and notable constraints on resources. Nonetheless, questions are raised regarding the routine practice of rapid and early fluid resuscitation in patients with shock and without clear hypovolemia.

Bottom line: Fluid resuscitation is not beneficial in resource-limited settings for children in shock who are not hypotensive.

Citation: Matiland K, Kiguli S, Opoka RO, et. al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364:2483-2495.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the effect of fluid resuscitation on mortality in children with shock in resource-limited settings?

Background: Rapid fluid resuscitation is typically recommended for children who present with shock. In resource-limited settings, particularly in Africa, this practice is not commonplace. The exact role of early fluid resuscitation, in addition to the optimal type of fluid (saline or albumin), is unknown.

Study design: Multicenter, randomized, controlled trial.

Setting: Six clinical centers in Africa.

Synopsis: This study was stopped after data for 3,141 of a projected 3,600 enrolled children demonstrated increased mortality in the bolus groups vs. control. Children aged 60 days to 12 years who presented with a severe febrile illness and impaired perfusion without severe hypotension were randomized openly to three groups: saline bolus, albumin bolus, or no bolus (control). Baseline characteristics of the groups were similar. After 48 hours, mortality in the albumin, saline, and control groups was 10.6%, 10.5%, and 7.3% respectively. The relative risk for any bolus vs. control was 1.45 (95% CI, 1.13-1.86; P=.003).

The results of this study are strengthened by the large number of children enrolled and the solid study design. However, it is difficult to immediately generalize the findings due to the unique nature of the study population and environment, which included a high proportion of patients with malaria and notable constraints on resources. Nonetheless, questions are raised regarding the routine practice of rapid and early fluid resuscitation in patients with shock and without clear hypovolemia.

Bottom line: Fluid resuscitation is not beneficial in resource-limited settings for children in shock who are not hypotensive.

Citation: Matiland K, Kiguli S, Opoka RO, et. al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364:2483-2495.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.