Fluid Controversies

11 August, 2011 by: colinparker

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A recent paper about fluid boluses in sick African children has raised a few eyebrows around the world of pediatric emergency medicine, and the world of medicine in general…

We thought we’d get in on the discussion, before everyone goes throwing the baby out with the bathwater. ┬áIn this PEMcast we try to appraise the Maitland paper in a rational, unemotional way… and almost manage!


Fluid Controversies PEMcast

[cp] Introduction, disclaimer

[kb] IntraVenous fluid can be for:

  • resuscitation – replacing intravascular volume
  • maintenance – replacing insensible losses and metabolic requirements
  • rehydration – rehydrating dessicated tissues (interstitial and intracellular fluid)
  • ongoing losses (large loose stools or large vomits)

[rr] Controversies regarding type, rates and volumes of fluids, for resuscitation and maintenance/rehydration.
Crystalloid vs Colloid (essentially dead debate, but Albumin still a bit controversial)
Isotonic vs Hypotonic fluids (see Circulation PEMcast for detailed discussion)
Rapid vs slower rehydration
Low-volume resuscitation in trauma

[kb] Accepted conventional wisdom:
Shock: 10-20mL boluses of Normal Saline
Haemorrhagic Shock: 10mL/kg of blood
Maintenance & Rehydration fluid: Normal Saline + 5% dextrose (esp in younger kids under 5 years)
Slower / more cautious fluids in DKA, meningitis, pneumonia, bronchiolitis, post-operatively, or any other situation where increased ADH secretion is likely (head and chest pathology commonly).

[cp] New data challenging our world view: options are to accept & incorporate, reject outright, accept parts we like, or ‘shelve it’ until more data becomes available…

[cp] NEJM Editorial: Fluid Resuscitation in Acute Illness – Time to Reappraise the Basics

NEJM Original Article May 2011: Mortality after Fluid Bolus in African Children with Severe Infection – Maitland et al for the FEAST Trial Group

[kb] Background: IV fluid boluses reserved for advanced shock; not widely practiced in parts of Africa
[rr] Methods: Robust design; fluid protocol increased to 40 or 60mL/kg; case definition
[cp] Statistical analysis: sample size increased due to lower mortality; subgroups under-powered?
[kb] Results: prostration 62% coma 15% resp distress 83% malaria 57% mean Hb 71; 48hr mortality 10.6 vs 10.5 vs 7.3% in stratum A
[rr] Discussion: extrapolation to other settings? Clinical differentiation of cases
[cp] Discussion (continued): Kaplan-Meier curves; few adverse events identified (?under-reported)

ADC Article June 2011: Treating the wrong children with fluids will cause harm: response to ‘mortality after fluid bolus in African children with severe infection’ – Southall & Samuels

[all] discussion: patient population, signs of shock vs illness, underlying causes, oxygen, clinical signs

[all] Conclusions and closing remarks

References

Myburgh JA.
Fluid resuscitation in acute illness–time to reappraise the basics.
N Engl J Med. 2011 Jun 30;364(26):2543-4. Epub 2011 May 26. PubMed PMID: 21615300.

Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, Nyeko R, Mtove G, Reyburn H, Lang T, Brent B, Evans JA, Tibenderana JK, Crawley J, Russell EC, Levin M, Babiker AG, Gibb DM; FEAST Trial Group.
Mortality after fluid bolus in African children with severe infection.
N Engl J Med. 2011 Jun 30;364(26):2483-95. Epub 2011 May 26. PubMed PMID: 21615299.

Southall DP, Samuels MP.
Treating the wrong children with fluids will cause harm: response to ‘mortality after fluid bolus in African children with severe infection’.
Arch Dis Child. 2011 Jun 28. [Epub ahead of print] PubMed PMID: 21715393.

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Comments

7 Responses to “Fluid Controversies”
  1. Meredith Borland says:

    Great summary guys!!

  2. Rahul says:

    Nice one.
    Keep it going.

  3. colinparker says:

    Thanks Rahul.
    Your support is like the wind beneath my wings… but not in a romantic way.

  4. Anand Senthi says:

    hey guys,
    This re-analysis by the authors
    http://www.ncbi.nlm.nih.gov/pubmed/23496872
    and the associated discussion by Myburgh & Finfer
    http://www.ncbi.nlm.nih.gov/pubmed/23497460
    of the FEAST data is most interesting and refutes some of the previously cited limitations of the study.
    I’ve discussed it here:
    http://www.emergucate.com/the-feast-study/

    Perhaps it might be good to do an update podcast on the topic?

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