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

Abstract

Objective To systemically review the evidence from clinical trials comparing the use of crystalloids and colloids for fluid resuscitation in children with severe infection.Data sources Medline (1950-2008), PubMed, the Cochrane Library, Embase (1980-2008), and reference lists.Eligibility criteria Published studies comparing fluid resuscitation with crystalloid or colloidal solutions in severe infectious illness in children aged >1 month to ≤12 years. Controlled trials and randomised controlled trials were separately selected by two unblinded investigators who also independently extracted data.Main outcome measures Efficacy in the treatment of shock, mortality, and reported adverse events.Results Nine trials fulfilled criteria, eight of which compared crystalloids with colloids. All trials were conducted in settings with poor resources and predominantly included patients with malaria or dengue haemorrhagic shock. None of the trials had mortality as a primary outcome. Three out of six studies that reported at least one death showed better survival in children resuscitated with colloids compared with crystalloids (Peto fixed odds ratio ranging from 0.18 (95% confidence interval 0.02 to 1.42) to 0.48 (0.06 to 3.99)). Studies contributing data on mortality had some methodological limitations so caution is recommended when interpreting this finding. Studies were heterogeneous so combined estimates were not calculated. The review was limited by inclusion of only published studies.Conclusions The current evidence on choice of fluids for resuscitation in children with infections is weak. While existing trials have provided important evidence in malaria and dengue, resuscitation in children with paediatric sepsis, for which colloids could theoretically be of benefit, has not been studied. The evidence from existing studies is not robust enough to make any definitive recommendations over the choice of resuscitation fluid and a definitive trial is required to address this.

Shock séptico en pediatría II: Enfoque actual en el diagnóstico y tratamiento

“…Una reciente revisión sistemática no demostró evidencia suficiente sobre el uso preferencial de coloides o cristaloides, siendo los diversos tipos de soluciones empleadas igualmente efectivos si se utilizan precozmente y en la cantidad necesaria (20 ml/kg en 10 min.) 56 . En relación al uso masivo de soluciones ricas en cloro, como suero fisiológico 0,9% (154 mEq/L), su uso puede potenciar el desarrollo de acidosis metabólica.…”

Shock séptico en pediatría I: Enfoque actual en el diagnóstico y tratamiento

“…Pueden ser indispensables mayores necesidades de fluidos de reanimación pudiendo llegar hasta 200 ml/kg 84,85 . En relación a la elección del fluido a utilizar, actualmente no existe consenso sobre cuál de los líquidos de reanimación (cristaloides vs coloides) podría ser mejor, siendo los diversos tipos de soluciones empleadas igualmente efectivos si se utilizan precozmente y en la cantidad necesaria (20 ml/ kg < 10 min) 86 . Soporte hemodinámico: El inicio de drogas vasoactivas debe realizarse si persisten signos de shock a pesar de una adecuada resucitación con fluidos.…”

What’s New in the Recognition and Management of Septic Shock in Children: Dos and Don'ts

“…While there is considerable debate about which fluids should be used for volume resuscitation in septic shock, there is no definitive evidence robust enough to make firm recommendations [70]. Currently fluids such as 0.9 % saline and Ringer's lactate are relatively inexpensive and have not been shown to be inferior to colloids.…”