Kenya Medical Research Institute, Clinical Sciences Department, Wellcome Trust Research Programme, Kilifi, Kenya.
Initiative to Develop African Research Leaders, Kilifi, Kenya.
Pediatr Crit Care Med. 2022 Jul 1;23(7):502-513. doi: 10.1097/PCC.0000000000002968. Epub 2022 Apr 21.
Fluid bolus resuscitation in African children is harmful. Little research has evaluated physiologic effects of maintenance-only fluid strategy.
We describe the efficacy of fluid-conservative resuscitation of septic shock using case-fatality, hemodynamic, and myocardial function endpoints.
Pediatric wards of Mbale Regional Referral Hospital, Uganda, and Kilifi County Hospital, Kenya, conducted between October 2013 and July 2015. Data were analysed from August 2016 to July 2019.
Children (≥ 60 d to ≤ 12 yr) with severe febrile illness and clinical signs of impaired perfusion.
IV maintenance fluid (4 mL/kg/hr) unless children had World Health Organization (WHO) defined shock (≥ 3 signs) where they received two fluid boluses (20 mL/kg) and transfusion if shock persisted. Clinical, electrocardiographic, echocardiographic, and laboratory data were collected at presentation, during resuscitation and on day 28. Outcome measures were 48-hour mortality, normalization of hemodynamics, and cardiac biomarkers.
Thirty children (70% males) were recruited, six had WHO shock, all of whom died (6/6) versus three of 24 deaths in the non-WHO shock. Median fluid volume received by survivors and nonsurvivors were similar (13 [interquartile range (IQR), 9-32] vs 30 mL/kg [28-61 mL/kg], z = 1.62, p = 0.23). By 24 hours, we observed increases in median (IQR) stroke volume index (39 mL/m 2 [32-42 mL/m 2 ] to 47 mL/m 2 [41-49 mL/m 2 ]) and a measure of systolic function: fractional shortening from 30 (27-33) to 34 (31-38) from baseline including children managed with no-bolus. Children with WHO shock had a higher mean level of cardiac troponin ( t = 3.58; 95% CI, 1.24-1.43; p = 0.02) and alpha-atrial natriuretic peptide ( t = 16.5; 95% CI, 2.80-67.5; p < 0.01) at admission compared with non-WHO shock. Elevated troponin (> 0.1 μg/mL) and hyperlactatemia (> 4 mmol/L) were putative makers predicting outcome.
Maintenance-only fluid therapy normalized clinical and myocardial perturbations in shock without compromising cardiac or hemodynamic function whereas fluid-bolus management of WHO shock resulted in high fatality. Troponin and lactate biomarkers of cardiac dysfunction could be promising outcome predictors in pediatric septic shock in resource-limited settings.
在非洲儿童中，液体冲击复苏是有害的。很少有研究评估维持性液体策略的生理效应。
我们描述了使用病死率、血液动力学和心肌功能终点来进行脓毒性休克的液体保守复苏的疗效。
乌干达姆巴莱地区转诊医院和肯尼亚基利菲县医院的儿科病房，于 2013 年 10 月至 2015 年 7 月进行。数据分析于 2016 年 8 月至 2019 年 7 月进行。
患有严重发热性疾病和灌注受损临床体征的儿童（≥ 60 d 至≤ 12 岁）。
静脉维持液（4 mL/kg/hr），除非儿童符合世界卫生组织（WHO）定义的休克（≥ 3 个体征），此时他们接受两个液体冲击（20 mL/kg），如果休克持续存在则进行输血。在就诊时、复苏期间和第 28 天采集临床、心电图、超声心动图和实验室数据。主要终点为 48 小时死亡率、血液动力学正常化和心脏生物标志物。
共招募了 30 名儿童（70%为男性），6 名儿童符合 WHO 休克标准，所有符合 WHO 休克标准的儿童均死亡（6/6），而非 WHO 休克的 24 名死亡儿童中有 3 名死亡。幸存者和非幸存者接受的中位液体量相似（13 [四分位距（IQR），9-32] vs 30 mL/kg [28-61 mL/kg]，z = 1.62，p = 0.23）。到 24 小时，我们观察到中位（IQR）心排量指数（39 mL/m 2 [32-42 mL/m 2 ] 增加到 47 mL/m 2 [41-49 mL/m 2 ]）和收缩功能的一项测量：射血分数从基线时的 30（27-33）增加到 34（31-38），包括接受无冲击治疗的儿童。与非 WHO 休克相比，符合 WHO 休克的儿童在入院时具有更高的心肌肌钙蛋白（ t = 3.58；95%置信区间，1.24-1.43；p = 0.02）和α-心房利钠肽（ t = 16.5；95%置信区间，2.80-67.5；p < 0.01）水平。肌钙蛋白升高（> 0.1 μg/mL）和乳酸升高（> 4 mmol/L）是预测预后的潜在标志物。
在不影响心脏或血液动力学功能的情况下，仅维持性液体疗法可使休克患者的临床和心肌紊乱正常化，而对 WHO 休克进行液体冲击管理则导致高死亡率。心肌功能障碍的肌钙蛋白和乳酸生物标志物可能是资源有限环境中儿科脓毒性休克有前途的预后预测指标。
