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Doctors have urged hospitals around the world to reconsider the type of fluids used to treat children with severe sepsis.
In a new study, researchers at Imperial College London found that saline fluids commonly used to help stabilize critically ill children could cause blood acidification and organ failure.
The team, which published its work in Lancet respiratory medicine, urge hospitals in the UK – and around the world – to consider the exchange of saline fluids for a different type of so-called buffered solution, which helps prevent the blood from becoming too acidic.
Although research has studied data from more than 3,000 children with malaria or sepsis (intoxication caused by a serious infection) in Africa, the research team said the findings could apply to all children and adults who are seriously ill.
When a critically ill patient is brought to the hospital, medical teams often administer very large amounts of fluid quickly through the vein through a drip. This is called a liquid "bolus", which helps to increase blood pressure and heart rate, and ensures that the blood is still flowing through the body.
The most commonly used fluids in hospitals around the world are called saline solutions (a type of salt water) or 5% albumin (saline solutions containing albumin proteins).
It has always been badumed that these fluids were the most effective in stabilizing a patient until a 2011 Imperial College trial of 3,000 children, called the FEAST trial, suggests the opposite. The trial, conducted in Kenya, Uganda and Tanzania, compared the rapid administration of a bolus of saline or albumin at 5% to that obtained with fluid quantities well. more reduced over a longer period.
The research team hoped that the trial would reduce the number of child deaths due to infection, but they were shocked to find that giving a large bolus was badociated with higher mortality. An independent panel decided to end the trial earlier, while stressing that children participating in the trial still had a better chance of survival than in Africa, thanks in part to additional training for hospital staff.
In the latest study, scientists wanted to study why saline fluids were badociated with a higher risk of death and whether these results could apply to other children in the world.
By badyzing the FEAST trial data and comparing it to data from more than 18,000 children who attended a British hospital and other hospitals in Malawi and South Africa, the team found that the use of a saline solution or a 5% albumin had many adverse effects. .
The research, funded by the Medical Research Council, the Department of International Development and the Center for Biomedical Research of the National Institute of Health Research, Imperial College, revealed that while the fluid bolus improved the heart rate and blood pressure, the solution also impaired lung function increased brain swelling and acidity of the blood – which together contributed to the increase in mortality observed in the l 39; FEAST test.
The researchers point out that fluids are still a vital part of resuscitation, and these results apply primarily to critically ill patients. They say that a saline solution and a 5% albumin may have less adverse effects in moderately ill patients, but suggest solutions containing buffering components and fewer chlorides (which can make the blood acidic) should be used in critically ill people.
The team added that much of the FEAST data came from children who did not have access to an intensive care unit – and that, as a result, the risk a fluid bolus increases the risk of death is much lower in facilities with comprehensive medical services. But they add that even under these conditions, the use of a bolus of saline or 5% albumin could further aggravate the condition of the child.
According to them, new tests are now urgently needed to study the use of alternative fluids containing buffers and less chloride, as well as the amount of fluid to use.
Professor Michael Levin, from the Department of Medicine at Imperial College London, who led the study, explained: "This study suggests rethinking the way we resuscitate patients – how much liquid we are give patients, and the type of fluid we give to patients.
"The FEAST trial provided the first clear evidence that administering a rapid" bolus "of normal saline or albumin to critically ill patients was harmful if intensive intensive care support was not available. new badysis has identified the mechanisms by which a fluid bolus causes damage Although bolus fluids have had the desired effect of improving cardiovascular function, this has resulted in a series of unintended side effects, including deterioration of lung function. , increased brain swelling and, more importantly, increased acidification of the blood.
"The effect of high chloride fluids such as normal saline and 5% albumin on blood acidity can be avoided by using alternative fluids with lower chloride concentrations." beneficial effects on cardiovascular function without the adverse effects on the acidity of the lungs, brain and blood. "
Dr. Aubrey Cunnington, co-author of the study of the Department of Medicine at Imperial Oil:
The findings and implications of the FEAST trial have puzzled the medical community. The uncertainty surrounding the mechanisms by which increased fluid bolus mortality in FEAST is probably one of the main reasons why the test results did not result in as many changes as expected international guidelines. We have found evidence that boluses of normal saline or fluids containing 5% albumin have worsened the function of several organs in the body. "
Professor Simon Nadel, another co-author of the Imperial Department of Medicine and pediatric intensive care consultant at the Imperial College Healthcare NHS, said: "The FEAST study clearly showed for the first time that a rapid administration of fluids resulted in higher mortality in children who were already seriously ill, than the slower administration of fluid.It should be emphasized that this discovery occurred in an environment where there was no access to advanced intensive care support.
It is now clear that we need to be aware of the rate and type of fluid resuscitation in critically ill patients, and it is essential that properly conducted studies on the most appropriate fluid resuscitation in the critically ill patient be conducted as soon as possible. "
Source:
Imperial College London
Journal reference:
Levin, M. et al. (2019) Effects of a bolus of saline or albumin on resuscitation: evidence from the new badysis of the FEAST trial. Lancet Respiratory Medicine. doi.org/10.1016/S2213-2600(19)30114-6.
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