Implications for paediatric shock management in resource-limited settings: a perspective from the FEAST trial

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Title: Implications for paediatric shock management in resource-limited settings: a perspective from the FEAST trial
Author(s): Houston, KA
George, EC
Maitland, K
Item Type: Journal Article
Abstract: Background Although the African “Fluid Expansion as Supportive therapy” (FEAST) trial showed fluid resuscitation was harmful in children with severe febrile illness managed in resource-limited hospitals, the most recent evidence reviewed World Health Organization (WHO) guidelines continue to recommend fluid boluses in children with shock according to WHO criteria “WHO shock”, arguing that the numbers included in the FEAST trial were too small to provide reasonable certainty. Methods We re-analysed the FEAST trial results for all international definitions for paediatric shock including hypotensive (or decompensated shock) and the WHO criteria. In addition, we examined the clinical relevance of the WHO criteria to published and unpublished observational studies reporting shock in resource-limited settings. Results We established that hypotension was rare in children with severe febrile illness complicating only 29/3170 trial participants (0.9%). We confirmed that fluid boluses were harmful irrespective of the definitions of shock including the very small number with WHO shock (n = 65). In this subgroup 48% of bolus recipients died at 48 h compared to 20% of the non-bolus control group, an increased absolute risk of 28%, but translating to an increased relative risk of 240% (p = 0.07 (two-sided Fisher’s exact test)). Examining studies describing the prevalence of the stringent WHO shock criteria in children presenting to hospital we found this was rare (~ 0.1%) and in these children mortality was very high (41.5–100%). Conclusions The updated WHO guidelines continue to recommend boluses for a very limited number of children presenting at hospital with the strict definition of WHO shock. Nevertheless, the 3% increased mortality from boluses seen across FEAST trial participants would also include this subgroup of children receiving boluses. Recommendations aiming to differentiate WHO shock from other definitions will invariably lead to “slippage” at the bedside, with the potential of exposing a wider group of children to the harm of fluid-bolus therapy.
Publication Date: 4-May-2018
Date of Acceptance: 25-Jan-2018
ISSN: 1364-8535
Publisher: BioMed Central
Journal / Book Title: Critical Care
Volume: 22
Sponsor/Funder: Medical Research Council (MRC)
Wellcome Trust
Wellcome Trust
Funder's Grant Number: G0801439
Copyright Statement: © The Author(s). 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( ) applies to the data made available in this article, unless otherwise state
Keywords: Hypotension
Intravenous fluids
World Health Organization (WHO)
11 Medical And Health Sciences
Emergency & Critical Care Medicine
Publication Status: Published
Article Number: 119
Appears in Collections:Department of Medicine
Faculty of Medicine

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