Study raises questions about fluid resuscitation in patients with shock

Investigators conducted a comparative examination of the practice of early resuscitation with saline or albumin fluid boluses in children with shock and life-threatening infections living in settings with limited resources. At admission to clinical centers in Kenya, Tanzania, and Uganda, more than 3,000 such children (median age, 24 months) were randomly assigned to receive boluses of 20 mL to 40 mL per kilogram of body weight of either 5% albumin solution (albumin-bolus group) or 0.9% saline solution (saline-bolus group) or no bolus (control group). All the children were given appropriate antimicrobial treatment, intravenous maintenance fluids, and supportive care.

The risk of death 1 hour after randomization was similar in the 3 groups (1.1%-1.3%). Beyond 1 hour, a persistent trend to higher mortality in the bolus groups compared with the control group was seen. By 48 hours, the primary end point for the study, 111 of the children in the albumin-bolus group (10.6%), 110 children in the saline-bolus group (10.5%), and 76 children in the control group (7.3%) had died. The relative risk of death with a saline bolus versus no bolus was 1.44; with an albumin bolus versus a saline bolus, 1.01; and with bolus therapy (combined albumin bolus and saline bolus) versus no bolus, 1.45. The 4-week mortality in the 3 groups was 12.2%, 12.0%, and 8.7%, respectively.

At 4 weeks, neurologic sequelae were noted in 22 children (2.2%) in the albumin-bolus group, 19 (1.9%) in the saline-bolus group, and 20 (2.0%) in the control group. Pulmonary edema or increased intracranial pressure developed in 2.6%, 2.2%, and 1.6% of the groups, respectively. Overall, bolus fluid resuscitation with either albumin or saline compared with no bolus increased the absolute risk of death at 48 hours by 3.3 percentage points and the risk of death, neurologic sequelae, or both at 4 weeks by nearly 4 percentage points.

Commentary

It remains to be seen how this study, done in resource-poor settings in which 57% of children included had malaria and 4% were HIV positive, will be translated for use in your emergency department. However, it serves as a reminder that what we have held as fundamentals always can be challenged as new evidence appears. Look for further study of fluid resuscitation closer to home. This sense of movement, that what we did in practice yesterday may not be what we do tomorrow, is one of the things that keeps life in medicine interesting.
-Michael Burke, MD