Implications for paediatric shock management in resource-limited settings: a perspective from the FEAST trial

Abstract

BackgroundAlthough the African “Fluid Expansion as Supportive therapy” (FEAST) trial showed fluid resuscitation was harmful in children with severe febrile illness managed in resource-limited hospitals, the most recent evidence reviewed World Health Organization (WHO) guidelines continue to recommend fluid boluses in children with shock according to WHO criteria “WHO shock”, arguing that the numbers included in the FEAST trial were too small to provide reasonable certainty.MethodsWe re-analysed the FEAST trial results for all international definitions for paediatric shock including hypotensive (or decompensated shock) and the WHO criteria. In addition, we examined the clinical relevance of the WHO criteria to published and unpublished observational studies reporting shock in resource-limited settings.ResultsWe established that hypotension was rare in children with severe febrile illness complicating only 29/3170 trial participants (0.9%). We confirmed that fluid boluses were harmful irrespective of the definitions of shock including the very small number with WHO shock (n = 65). In this subgroup 48% of bolus recipients died at 48 h compared to 20% of the non-bolus control group, an increased absolute risk of 28%, but translating to an increased relative risk of 240% (p = 0.07 (two-sided Fisher’s exact test)). Examining studies describing the prevalence of the stringent WHO shock criteria in children presenting to hospital we found this was rare (~ 0.1%) and in these children mortality was very high (41.5–100%).ConclusionsThe updated WHO guidelines continue to recommend boluses for a very limited number of children presenting at hospital with the strict definition of WHO shock. Nevertheless, the 3% increased mortality from boluses seen across FEAST trial participants would also include this subgroup of children receiving boluses. Recommendations aiming to differentiate WHO shock from other definitions will invariably lead to “slippage” at the bedside, with the potential of exposing a wider group of children to the harm of fluid-bolus therapy.Electronic supplementary materialThe online version of this article (10.1186/s13054-018-1966-4) contains supplementary material, which is available to authorized users.

Multidrug resistant and extensively drug resistant Acinetobacter baumannii hospital infection associated with high mortality: A retrospective study in the Pediatric Intensive Care Unit

“…MDR was de ned as acquired non-susceptibility to at least one agent in three or more antimicrobial categories, XDR was de ned as non-susceptibility to at least one agent in all but two or fewer antimicrobial categories (i.e. bacterial isolates remain susceptible to only one or two categories) and PDR (pandrug resistant) was de ned as non-susceptibility to all agents in all antimicrobial categories [16] .According to CLSI criteria, we de ned infection as follow:1) Blood stream infection: Patient has fever and has a recognized pathogen cultured from 1 or more blood cultures and organism cultured from blood is not related to an infection at another site, or had hemodynamic instability.2) Ventilator associated pneumonia (VAP): Patients with new or progressive and persistent in ltrate in X-rays, with new onset of purulent sputum, change in the character of sputum, more suctioning requirements or worsening gas exchange.3) Central line-associated bloodstream infection: A central line-associated bloodstream infection was de ned as a patient who had at least 1 of the following signs or symptoms: hypothermia or hyperthermia, apnea and positive laboratory results not related to an infection at another site that were central venous line-associated with the central venous catheter having been in place at the time of, or within 48 hours before, the onset of bacteremia. 4) Meningitis: Meningitis was de ned as a patient had organisms cultured from cerebrospinal uid (CSF), as well as who had at least 2 of the following signs or symptoms with no other recognized cause: headache, dizziness, fever, localizing neurologic signs, changing level of consciousness, or confusion.…”

Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children

“…It should also be noted that children with gastroenteritis were excluded from FEAST, as ongoing fluid losses should be replaced with IV or oral rehydration as indicated. A recent analysis of children with "moderate" hypotension who were randomized to either fluid bolus or maintenance fluid in the FEAST trial was published after completion of our initial systematic review but considered by the panel to be potentially influential [188]. In this analysis, only children with moderate hypotension were included because children with severe hypotension were not allocated to the control (no bolus) arm.…”

Emergency fluid bolus therapy studies: first do no harm

“…In such paediatric patients, a conservative 10 mL/kg FBT (and not 20 mL/kg) can be used and repeated up to three times 3. However, in our post hoc analysis of the FEAST trial data, we found a general 3% increase in mortality from FBT across all FEAST trial subgroups, including the 65 cases meeting the WHO ‘strict shock’ criteria FBT 4. Second, in the 2014 American College of Critical Care Medicine (ACCM) clinical guidelines for haemodynamic support of neonates and children with septic shock,5 there have been no changes since the 2007 guidelines 6.…”