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Causes of death after fluid bolus resuscitation: new insights from FEAST
1St George Clinical School, University of New South Wales, The George Institute for Global Health, L13, 321 Kent Street, Sydney 2000, Australia. jmyburgh@georgeinstitute.org.au
Insights
Febrile children with impaired perfusion in low-income countries receiving intravenous fluid boluses had higher mortality. This excess death was due to refractory shock, not fluid overload, suggesting potential cardiotoxicity.
Area of Science:
- Pediatric critical care medicine
- Resuscitation science
- Global health
Background:
- The Fluid Expansion as Supportive Therapy (FEAST) trial investigated fluid resuscitation in febrile children in low-income countries.
- Previous findings indicated increased mortality with albumin or saline boluses in children with impaired perfusion.
Purpose of the Study:
- To analyze secondary outcomes of the FEAST trial, focusing on causes of increased mortality after fluid bolus resuscitation.
- To investigate the clinical presentation and underlying mechanisms of excess deaths in critically ill children.
Main Methods:
- Secondary analysis of the FEAST trial data.
- Examination of clinical features associated with increased mortality in children receiving fluid boluses.
- Assessment of the primary cause of death, distinguishing between refractory shock and fluid overload.
Main Results:
- Increased mortality was observed in children with severe shock, particularly when accompanied by respiratory or neurological failure.
- The primary cause of excess deaths was refractory shock, not fluid overload.
- Findings suggest potential cardiotoxicity or ischemia-reperfusion injury as mechanisms, possibly exacerbated by limited intensive care resources.
Conclusions:
- Intravenous fluid bolus resuscitation in specific pediatric populations may lead to adverse outcomes beyond the initial resuscitation phase.
- These findings challenge current resuscitation guidelines and highlight the need for careful consideration of fluid administration in resource-limited settings.
- Further research is warranted to understand the long-term effects and underlying pathophysiology of fluid resuscitation in critically ill children.
Abstract:
The Fluid Expansion as Supportive Therapy (FEAST study) was an extremely well conducted study that gave unexpected results. The investigators had reported that febrile children with impaired perfusion treated in low-income countries without access to intensive care are more likely to die if they receive bolus resuscitation with albumin or saline compared with no bolus resuscitation at all. In a secondary analysis of the trial, published in BMC Medicine, the authors found that increased mortality was evident in patients who presented with clinical features of severe shock in isolation or in conjunction with features of respiratory or neurological failure. The cause of excess deaths was primarily refractory shock and not fluid overload. These features are consistent with a potential cardiotoxic or ischemia-reperfusion injury following resuscitation with boluses of intravenous fluid. Although these effects may have been amplified by the absence of invasive monitoring, mechanical ventilation or vasopressors, the results provide compelling insights into the effects of intravenous fluid resuscitation and potential adverse effects that extend beyond the initial resuscitation period. These data add to the increasing body of literature about the safety and efficacy of intravenous resuscitation fluids, which may be applicable to management of other populations of critically ill patients.
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