The Case Files

Welcome to the Case Files!
The Case Files is an anecdotal collection of emergency medicine cases to enable physicians and researchers to find clinically important information on unusual conditions.

Case reports should focus on:

  • Unusual side effects or adverse interactions.
  • Unusual presentations of a disease.
  • Presentations of new and emerging diseases, including new street drugs.
  • Findings that shed new light on a disease or an adverse effect.

Comment on a case or submit your own case following the instructions in the Submissions box to the right.

Tuesday, June 13, 2017

Rethink Fluid Resuscitation in Pediatric Septic Shock


New recommendations on fluid resuscitation in septic children were included in the last pediatric resuscitation guidelines published by the American Heart Association. (Circulation 2015;132[16 Suppl 1]:S177.) Early and rapid intravenous administration of isotonic fluids has been widely accepted as a cornerstone in treating septic shock. A large randomized controlled study revealed that the administration of intravenous fluid boluses in pediatric patients with severe febrile disease in a resource-limited setting might be associated with poor outcomes. (Indian Pediatr 2015;52[11]:965.) The recommendation of administrating 20 to 60 mL/kg fluid boluses in septic shock is based on the observational studies conducted in developed countries (Crit Care Med 2013;41[2]:580; Intensive Care Med 2008;34[6]:1065) and contradicts the results of a prospective randomized controlled study conducted in pediatric patients with severe febrile illness in underdeveloped countries. (N Engl J Med 2011;364[26]:2483.)

case files bicer.jpeg

A total of 3,141 pediatric patients were included in this Fluid Expansion as Supportive Therapy (FEAST) study conducted in Africa. Sixty-two percent were debilitated, 15 percent were comatose, 83 percent had respiratory distress, 52 percent had multiple signs of impaired perfusion (significant tachycardia and cold extremities), 51 percent had moderate to severe lactic acidosis, 39 percent had severe lactic acidosis (≥5 mmol/L), 57 percent had malaria, and four percent were HIV-positive with a mean hemoglobin level of 7.1 g/dL. Patients were divided into two groups to receive fluid loading (group I: 20-40 ml/kg/hour 0.9% NaCl administration or fluid loading with 5% albumin) or maintenance fluids (group II: 2.5-4.0 ml/kg/hour maintenance fluids).

The signs and symptoms were improved at the end of the first hour in more patients who had received bolus fluids compared with those who had received maintenance fluids (43% vs. 32% respectively, P<0.001), but 48 hours later and at the end of the fourth week, the mortality rate was higher among the patients who had received bolus fluids when compared with the patients who had received maintenance fluids, which were 48 percent and 20 percent respectively (RR 2.40; 95% CI 0.84, 6.88). (N Engl J Med 2011;364[26]:2483.) No significant differences were found between the patients who received 5% albumin and those who received normal saline solution in the bolus group in neurological sequelae, pulmonary edema, increased intracranial pressure, and mortality rates.

The new guidelines emphasize that fluid treatment should be tailored to each patient and that frequent clinical assessments are required. This recommendation still emphasizes the importance of intravenous fluid resuscitation in pediatric patients in septic shock, but it states that aggressive fluid boluses may be associated with complications in febrile patients if intensive care support, appropriate equipment, and expert specialists are unavailable. (Circulation 2015;132[16 Suppl 1]:S177.) Individualizing fluid treatment to each patient, frequent clinical assessment before, during, and after fluid treatment, and predicting the need for other treatment options (e.g., inotropic treatment) as well as timely initiation of these treatments are recommended.

In the case of limited access to intensive care unit resources such as mechanical ventilation or inotropic support, intravenous fluid boluses may cause harm in children with febrile disease, and should be administered with caution in these patients. (Pediatr Emerg Care 2008;24[10]:647; BMJ 2014;348:f7003.)

Dr. Biçer is an associate professor in the department of pediatrics at Yeditepe University Faculty of Medicine in Istanbul and a training coordinator in the department of pediatric emergency medicine at Marmara University Faculty of Medicine. Dr. Söğütlü is a pediatric emergency specialist at Marmara University Faculty of Medicine. Mr. Şah is a research assistant in the department of pediatrics at Marmara University.