Impact of resuscitation with 20% versus 5% albumin in outcome of severe dengue: A prospective observational study

Abstract

Background : Severe dengue is characterized by severe vascular leakage and abnormal haemostasis which can lead to mortality. As per exciting guidelines fluid resuscitation is recognised as the critical therapeutic intervention; however these guidelines are more empirical than evidence based. Methods : This was a prospective observational study (June 2016 to august 2017), conducted in a tertiary care intensive care unit. Children aged between one month and 18 years with diagnosis of severe dengue were categorized to receive either 20%A or 5%A, in addition to routine fluid resuscitation with crystalloids as per WHO guidelines. Children admitted between June 2016 to August2017, were allocated to receive 20%A (group A) during first 6 month (June 2016 to December 2016) and 5%A (group B) during next 6 month. Arterial blood lactates were measured before and after albumin transfusion and lactate clearance were calculated using the formula (Lactate before - lactate after)/lactate before (%)(mill moles/ liter) . Children were followed up to recovery or mortality. The primary outcome was lactate clearance and the secondary outcome variables were length of hospital stay, duration of mechanical ventilation, fluid overload, mortality and inotrope requirement, which were compared between the two groups. Results : A total of 90 children with 45 in each group were enrolled in the study. The mean lactate clearance in 20%A group was 43.3±17.75% (95% CI: 33.5-53.17) and 5%A group was 19.46±19.0% (95% CI: 8.8 -30.0). This difference was found to be statistically significant (p value=0.001).The mean hospital stay was 129.5±42.1 hours (95%CI: 106.1-152.9) and 162.73±57.2 (95%CI: 131-194.4) in the 20%A and 5%A groups respectively (p value=0.081),and the net fluid overload in 20%A was 133.6±119.8ml/kg (95%CI: 67.2 -199.9) and in the 5%A group was 162.3±96.8ml/kg (95%CI: 108.7-215.9) (p value=0.47), but both were statistically not significant. The need of inotrope requirement between two groups was statistically not significant (p value=0.5). The need of ventilation and mortality (n=1) could not be statistically determined because of inadequate data. Conclusion : Children treated with 20%A had better lactate clearance and relatively lesser fluid overload when compared to 5%A. Since lactate clearance is a viable surrogate marker of resuscitation adequacy 20%A can be considered superior to 5%A as per our study for resuscitation of severe dengue cases. However, randomised control trials with larger sample size are warranted to confirm the advantage of 20%A over 5%A.