Glassford N J, Gelbart B, Bellomo R
Registrar and Clinical Research Fellow, Department of Intensive Care, Austin Hospital, PhD Candidate, Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Melbourne, Victoria.
Staff Specialist, Department of Intensive Care, Royal Children's Hospital, Honorary Fellow, Murdoch Childrens Research Institute, Melbourne, Victoria.
Anaesth Intensive Care. 2017 May;45(3):308-319. doi: 10.1177/0310057X1704500306.
Fluid bolus therapy (FBT) is a cornerstone of the management of the septic child, but clinical research in this field is challenging to perform, and hard to interpret. The evidence base for independent benefit from liberal FBT in the developed world is limited, and the Fluid Expansion as Supportive Therapy (FEAST) trial has led to conservative changes in the World Health Organization-recommended approach to FBT in resource-poor settings. Trials in the intensive care unit (ICU) and emergency department settings post-FEAST have continued to explore liberal FBT strategies as the norm, despite a strong signal associating fluid accumulation with pulmonary pathology in the paediatric population. Modern clinical trial methodology may ameliorate the traditional challenges of performing randomised interventional trials in critically ill children. Such trials could examine differing strategies of fluid resuscitation, or compare early FBT to early vasoactive agent use. Given the ubiquity of FBT and the potential for harm, appropriately powered examinations of the efficacy of FBT compared to alternative interventions in the paediatric emergency and ICU settings in the developed world appear justified and warranted.
液体冲击疗法（FBT）是脓毒症患儿治疗的基石，但该领域的临床研究实施具有挑战性且难以解读。在发达国家，关于大量FBT能带来独立益处的证据基础有限，而液体扩容作为支持性治疗（FEAST）试验已导致世界卫生组织在资源匮乏地区推荐的FBT方法出现保守性变化。尽管有强烈信号表明在儿科人群中液体蓄积与肺部病变相关，但在FEAST试验后，重症监护病房（ICU）和急诊科环境中的试验仍继续将大量FBT策略作为常规进行探索。现代临床试验方法可能会改善在危重症儿童中进行随机干预试验的传统挑战。此类试验可以研究不同的液体复苏策略，或者比较早期FBT与早期使用血管活性药物的效果。鉴于FBT的普遍性以及潜在危害，在发达国家对儿科急诊和ICU环境中FBT与替代干预措施的疗效进行有足够效力的研究似乎是合理且必要的。
