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Published on: November 9, 2016
Mortality after emergency unit fluid bolus in febrile Ugandan children
Brian Rice1,2, Jessica Hawkins3, Serena Nakato2,4
1Department of Emergency Medicine, Stanford University, Palo Alto, California, United States of America.
Insights
Pediatric fluid resuscitation in Uganda emergency units did not significantly impact mortality for febrile children. Individualized fluid management is recommended over universal protocols for better patient outcomes.
Area of Science:
- Pediatric Emergency Medicine
- Global Health
- Clinical Trials
Background:
- Pediatric fluid resuscitation in sub-Saharan Africa traditionally occurs in inpatient settings.
- The Fluid Expansion as Supportive Therapy (FEAST) trial indicated increased mortality with fluid boluses in febrile inpatients.
- Emergency care expansion in sub-Saharan Africa shifts fluid resuscitation to emergency units.
Purpose of the Study:
- To determine the mortality impact of emergency unit fluid resuscitation on febrile pediatric patients in Uganda.
- To evaluate if fluid resuscitation in the emergency setting affects outcomes differently than in inpatient settings.
- To inform best practices for fluid management in pediatric emergency care in resource-limited settings.
Main Methods:
- Retrospective cohort study of 3087 febrile pediatric patients (2 months-12 years) in a Ugandan emergency unit (2012-2019).
- Propensity score matching created matched cohorts to compare mortality between patients receiving and not receiving fluids.
- Logistic regression and sensitivity analyses were performed, including subgroup analysis for FEAST trial criteria.
Main Results:
- Overall mortality was 4.0% with no significant difference in three-day mortality between fluid resuscitation and non-fluid groups in matched or unmatched cohorts.
- Adjusted analyses and sensitivity analyses for FEAST criteria also showed no significant mortality benefit or harm.
- The study was powered to detect absolute harm similar to FEAST but lacked power to detect relative risk increases.
Conclusions:
- Fluid resuscitation in Ugandan emergency units did not significantly alter three-day mortality for febrile children.
- Aggressive or fluid-sparing universal protocols are likely not optimal; individualized fluid resuscitation is recommended.
- Further research may be needed to clarify optimal fluid strategies in diverse pediatric emergency populations.
Objectives:
Pediatric fluid resuscitation in sub-Saharan Africa has traditionally occurred in inpatients. The landmark Fluid Expansion as Supportive Therapy (FEAST) trial showed fluid boluses for febrile children in this inpatient setting increased mortality. As emergency care expands in sub-Saharan Africa, fluid resuscitation increasingly occurs in the emergency unit. The objective of this study was to determine the mortality impact of emergency unit fluid resuscitation on febrile pediatric patients in Uganda.
Methods:
This retrospective cohort study used data from 2012-2019 from a single emergency unit in rural Western Uganda to compare three-day mortality for febrile patients that did and did not receive fluids in the emergency unit. Propensity score matching was used to create matched cohorts. Crude and multivariable logistic regression analysis (using both complete case analysis and multiple imputation) were performed on matched and unmatched cohorts. Sensitivity analysis was done separately for patients meeting FEAST inclusion and exclusion criteria.
Results:
The analysis included 3087 febrile patients aged 2 months to 12 years with 1,526 patients receiving fluids and 1,561 not receiving fluids. The matched cohorts each had 1,180 patients. Overall mortality was 4.0%. No significant mortality benefit or harm was shown in the crude unmatched (Odds Ratio [95% Confidence Interval] = 0.88 [0.61-1.26] or crude matched (1.00 [0.66-1.50]) cohorts. Adjusted cohort analysis (including both complete case analysis and multiple imputation) and sensitivity analysis of patients meeting FEAST inclusion and exclusion criteria all also failed to show benefit or harm. Post-hoc power calculations showed the study was powered to detect the absolute harm seen in FEAST but not the relative risk increase.
Conclusions:
This study's primary finding is that fluid resuscitation in the emergency unit did not significantly increase or decrease three-day mortality for febrile children in Uganda. Universally aggressive or fluid-sparing emergency unit protocols are unlikely to be best practices, and choices about fluid resuscitation should be individualized.
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