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Deaths among children in shock treated with fluids were caused by cardiovascular collapse

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1671 (Published 14 March 2013) Cite this as: BMJ 2013;346:f1671
  1. Zosia Kmietowicz
  1. 1BMJ

A detailed examination of a study which showed that giving fluids to children in shock increased the chances of them dying has found that their deaths were mostly caused by cardiovascular shock.

The Fluid Expansion as Supportive Therapy (FEAST) trial took place in six centres in Kenya, Tanzania, and Uganda in 2009-2011, and involved more than 3000 children with shock caused by conditions including sepsis and malaria. The trial excluded children with gastroenteritis, burns, and severe malnutrition. All the children were treated for their underlying illness and were randomly assigned to receive fluid resuscitation or to a control group without fluid resuscitation.

This study found that treating children with fluid increased absolute risk of death at 48 hours by 3.3%, compared with controls.1 To try to explain this “surprising result,” the researchers analysed the data further according to patients’ signs and symptoms at enrolment, their predominant clinical syndrome before death, and changes in their vital signs.

The researchers hypothesised that boluses could cause excess deaths from neurological or respiratory events, particularly those relating to fluid overload.

However, they found that more children died of cardiogenic events or shock (n=123; 4.6% of children who had fluids v 2.6% of controls, P=0.008) than respiratory (n=61; 2.2% v 1.3%, P=0.09) or neurological events (n=63, 2.1% v 1.8%, P=0.6). The results are published in BMC Medicine.2

Kathryn Maitland, from the Wellcome Trust Centre for Clinical Tropical Medicine at Imperial College London, who led the secondary analysis, explained: “The children who were given this treatment (boluses) initially responded well compared to the control group. However, this did not translate into a better recovery at 48 hours—more children died in the group receiving boluses. The main cause of death, rather than fluid overload, was cardiovascular collapse.”

The research team behind the trial believes that in settings where there is a lack of intensive care facilities, “standard” procedures—such as fluid resuscitation—should not necessarily be used, especially when they have not been properly tested in clinical trials.

In a commentary on the study, John Myburgh, from the University of New South Wales and the George Institute for Global Health, interpreted the findings further and recommended that fluid resuscitation should be used with the same care as any potentially lethal drug.3

“Studies are beginning to show cracks in fluid resuscitation therapy and that careful monitoring is needed as well as a better understanding of dose and the way the therapy is given. The compelling results of this study from Africa question the wisdom of fluid bolus as therapy not only in paediatric patients but also in all critically ill patients,” he said.

Notes

Cite this as: BMJ 2013;346:f1671

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