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Choice of fluids for resuscitation in children with severe infection and shock: systematic review

BMJ 2010; 341 doi: (Published 02 September 2010) Cite this as: BMJ 2010;341:c4416

Human serum albumin used in paediatric resuscitation poses a negligible, but still existent, infection transmission risk

Whilst human albumin solution (HSA) shows promise in the fluid
resuscitation of children with severe malaria and late or severe septic
shock in resource poor settings, 1, 2 HSA remains expensive and difficult
to access in Africa.3 Blood services in sub-Saharan Africa continue to
experience supply shortages and low retention of voluntary non-remunerated
donors. 4 Economic modelling in sub-Saharan Africa demonstrated improved
health care cost and the prevention of blood borne infections such as HIV,
HBV and HCV when a non-blood haemostatic agent such as tranexamic acid is
used to reduce blood product use in surgical bleeding, even when there is
no blood shortage.5 Despite the availability of nucleic acid testing for
difficult to detect window seroconversions for donated blood, the
seroprevalence of blood-borne viruses among apparently healthy prospective
adult blood donors remains relatively high.6 In resource limited settings,
optimal viral screening strategies of donors or donated blood remains
unclear.7Although improving, pre-donation infection transmission risk
determination for donors in Africa continues to be suboptimal.8 For
instance, HIV seroprevalence was potentially higher than 14% for
"occasional" donors in Mali in 2001, 8 with the cumulative seroprevalence
of HCV and HBV being 12 and 1.3% respectively among nearly 56 000 healthy
potential blood donors in Egypt.9 High prevalence of transfusion-
transmitted infections in Africa are compounded by blood product
(including HSA) shortage, inadequately regulated blood product processing
as well as suboptimal organisation of transfusion services (donor and
blood screening, collection, processing, distribution, storage, safety and
staff training).10-13 Cultural barriers to donating or receiving blood
products including HSA remains.13 Donor blood continues to be discarded
due to being infected or of unacceptable quality,11 pre-donation
screening continues to be problematic12 and blood transfusion remain an
important route for paediatric HIV infection. 14

Even in the developed world, few countries are self-sufficient in
plasma as plasma fractionation relies on donor blood supply and its
quality, which can vary over time.15 Although HSA has an excellent
worldwide adverse effect profile, 16 being relatively safe from infection
transmission risk in developed countries17 and newly emerging countries,
18 this is not absolutely so for HIV, HBV and HCV, let along prions and
still to be identified viruses. 17

The cost of HSA ranges from 2-20 fold that of synthetic colloids.19
In the context of high cost of HSA in Africa, its short supply,
inadequately developed blood product procurement, processing and
regulation as well as relatively high infection transmission risk, the
focus of the crystalloid versus colloid debate in poor resource settings
could be shifted from HSA to synthetic affordable colloids, such as that
in a recent clinical study comparing Dextran 70 with hydroxyethyl starch
in the treatment of severe childhood malaria in Kenya.3 Any future
paediatric resuscitation study could do well to mention the paucity of
data for relatively rare events such as blood borne infection acquisition
related to receipt of cellular and non cellular blood products, or include
transfusion related infection risk in modelling studies. 5


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infection and shock. BMJ 2010; 341: c4546 doi: 10.1136/bmj.c4546.

2. Akech S, Ledermann H, Maitland K. Choice of fluids for resuscitation in
children with severe infection and shock: systematic review. BMJ 2010;
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Competing interests: No competing interests
20 September 2010
Joseph Y Ting
Clinical Senior Lecturer
Division of Anaesthesiology and Critical Care, University of Queensland, Brisbane, Australia
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