Abstract
Sepsis is a leading cause of morbidity and mortality in children with a worldwide prevalence in pediatric intensive care units of approximately 8%. Fluid bolus therapy (FBT) is a first line therapy for resuscitation of septic shock and has been a recommendation of international guidelines for nearly two decades. The evidence base supporting these guidelines are based on limited data including animal studies and case control studies. In recent times, evidence suggesting harm from fluid in terms of morbidity and mortality have generated interest in evaluating FBT. In view of this, studies of fluid restrictive strategies in adults and children have emerged. The complexity of studying FBT relates to several points. Firstly, the physiological and haemodynamic response to FBT including magnitude and duration is not well described in children. Secondly, assessment of the circulation is based on non-specific clinical signs and limited haemodynamic monitoring with limited physiological targets. Thirdly, FBT exists in a complex myriad of pathophysiological responses to sepsis and other confounding therapies. Despite this, a greater understanding of the role of FBT in terms of the physiological response and possible harm is warranted. This review outlines current knowledge and future direction for FBT in sepsis.
Highlights
The worldwide burden of sepsis in pediatric intensive care in terms of morbidity and mortality remains high and is a key healthcare priority [1,2,3]
The past two decades has seen large multicentre studies targeting optimal fluid composition [14, 15], goal directed therapy [16,17,18], fluid restrictive protocols [19,20,21,22,23] as well as a pivotal study of Fluid bolus therapy (FBT) vs. no FBT in African children with sepsis [24]; all contributing to the current landscape
The FLUID EXPANSION AS SUPPORTIVE THERAPY (FEAST) study, a RCT of FBT in over 3,000 Sub-Saharan African children with sepsis and impaired perfusion has been a pivotal study in generating interest in the potential harm from FBT
Summary
The worldwide burden of sepsis in pediatric intensive care in terms of morbidity and mortality remains high and is a key healthcare priority [1,2,3]. Three studies have compared a range of interventions such as fluid types, early inotrope and goal directed therapy with measured outcomes such as shock reversal, mortality, and intensive care resources [18, 73, 74] These studies included a total of 309 children and when systematically reviewed, there were no discernible difference in patient-centered outcomes [75]. Alternative interventions may prove to be safe equivalent in reversing shock and may reduce harm in terms of morbidity and mortality related to limiting excessive fluid administration One such strategy is restrictive fluid resuscitation where early vasoactive therapy is initiated rather than repeated FBT. The sample size required to show a 5–10% difference in outcomes have been suggested to be up to 1,500 participants [1] which would be feasibly achieved by a multinational collaboration
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