KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya.
Department of Paediatrics, Mbale Regional Referral Hospital, Mbale, Uganda.
Crit Care. 2017 May 3;21(1):103. doi: 10.1186/s13054-017-1679-0.
Fluid therapy in severely malnourished children is hypothesized to be deleterious owing to compromised cardiac function. We evaluated World Health Organization (WHO) fluid resuscitation guidelines for hypovolaemic shock using myocardial and haemodynamic function and safety endpoints.
A prospective observational study of two sequential fluid management strategies was conducted at two East African hospitals. Eligible participants were severely malnourished children, aged 6-60 months, with hypovolaemic shock secondary to gastroenteritis. Group 1 received up to two boluses of 15 ml/kg/h of Ringer's lactate (RL) prior to rehydration as per WHO guidelines. Group 2 received rehydration only (10 ml/kg/h of RL) up to a maximum of 5 h. Comprehensive clinical, haemodynamic and echocardiographic data were collected from admission to day 28.
Twenty children were enrolled (11 in group 1 and 9 in group 2), including 15 children (75%) with kwashiorkor, 8 (40%) with elevated brain natriuretic peptide >300 pg/ml, and 9 (45%) with markedly elevated median systemic vascular resistance index (SVRI) >1600 dscm-/m indicative of severe hypovolaemia. Echocardiographic evidence of fluid-responsiveness (FR) was heterogeneous in group 1, with both increased and decreased stroke volume and myocardial fractional shortening. In group 2, these variables were more homogenous and typical of FR. Median SVRI marginally decreased post fluid administration (both groups) but remained high at 24 h. Mortality at 48 h and to day 28, respectively, was 36% (4 deaths) and 81.8% (9 deaths) in group 1 and 44% (4 deaths) and 55.6% (5 deaths) in group 2. We observed no pulmonary oedema or congestive cardiac failure on or during admission; most deaths were unrelated to fluid interventions or echocardiographic findings of response to fluids.
Baseline and cardiac response to fluid resuscitation do not indicate an effect of compromised cardiac function on response to fluid loading or that fluid overload is common in severely malnourished children with hypovolaemic shock. Endocrine response to shock and persistently high SVRI post fluid-therapy resuscitation may indicate a need for further research investigating enhanced fluid volumes to adequately correct volume deficit. The adverse outcomes are concerning, but appear to be unrelated to immediate fluid management.
由于心脏功能受损，人们推测严重营养不良的儿童进行液体疗法会产生不良影响。我们使用心肌和血液动力学功能及安全性终点评估了世界卫生组织（WHO）针对低血容量性休克的液体复苏指南。
在东非的两家医院进行了一项前瞻性观察性研究，纳入了患有低血容量性休克的严重营养不良儿童（6-60 月龄），休克由胃肠炎引起。第 1 组按 WHO 指南给予 15ml/kg/h 的林格氏乳酸盐（RL），最多 2 个负荷剂量，随后开始补液。第 2 组仅进行补液（10ml/kg/h 的 RL），最多 5 小时。从入院到第 28 天，收集了全面的临床、血液动力学和超声心动图数据。
共纳入 20 名患儿（第 1 组 11 名，第 2 组 9 名），其中 15 名患儿（75%）患有夸希奥科营养不良，8 名患儿（40%）脑利钠肽升高>300pg/ml，9 名患儿（45%）中值全身血管阻力指数（SVRI）显著升高>1600dscm-/m，提示严重低血容量。第 1 组的超声心动图液体反应性（FR）证据存在异质性，表现为每搏量和心肌缩短分数增加和减少。第 2 组的这些变量更为一致，更符合 FR 的特征。两组液体给药后 SVRI 略有下降，但 24 小时仍较高。第 1 组的 48 小时和 28 天病死率分别为 36%（4 例死亡）和 81.8%（9 例死亡），第 2 组的 44%（4 例死亡）和 55.6%（5 例死亡）。入院时或入院期间均未见肺水肿或充血性心力衰竭；大多数死亡与液体干预或对液体反应的超声心动图发现无关。
基线和心脏对液体复苏的反应并不能表明心脏功能受损对液体负荷的反应有影响，也不能表明低血容量性休克的严重营养不良儿童中液体超负荷很常见。对休克的内分泌反应和液体复苏后持续高 SVRI 可能表明需要进一步研究增加液体量以充分纠正容量不足。不良结局令人担忧，但似乎与即时液体管理无关。
