Level 1: Likely reliable evidence
Early fluid resuscitation is recommended for hemodynamic support in critically ill children (Crit Care Med. 2008;36:296-327), but there has been little evidence to guide the type, timing, and volume of fluids to use, especially in children who are not severely hypotensive or dehydrated.
The FEAST trial evaluated the use of fluid boluses (saline or albumin) in severely ill children in Uganda, Kenya, and Tanzania (N Engl J Med. 2011;364:2483-2495). A total of 3,141 children (57% positive for malaria parasitemia) without severe hypotension (moderate hypotension in 6%, dehydration in 7%) were randomized to one of three fluid bolus strategies for initial fluid resuscitation:
- 0.9% saline solution 20 mL/kg IV over one hour
- 5% albumin solution 20 mL/kg IV over one hour
- No bolus (the initial bolus in the saline and albumin groups was increased to 40 mL/kg after a trial protocol amendment
All children had severe febrile illness, impaired consciousness and/or respiratory distress and impaired perfusion. Children were excluded for severe malnutrition, gastroenteritis, noninfectious causes of shock or contraindication to fluid expansion.
At 48 hours, mortality was increased for both saline (10.5%, P=0.01, NNH 31) and albumin (10.6%, P=0.008, NNH=30) compared with placebo (7.3%). There were no significant differences in the rates of pulmonary edema or increased intracranial pressure. Mortality was also increased in the saline and albumin groups at 4 months (14.6% vs. 15.2% vs. 11.1%, P=0.01), with an NNH of 30 for saline and 28 for albumin. There were no significant differences between saline and albumin, and subgroup analyses did not find any subgroup demonstrating benefit for fluid bolus.
An additional group of 29 severely hypotensive children, for whom it was considered unethical to withhold fluids, were randomized to saline vs. albumin and showed no significant differences in mortality between the two bolus strategies (69% vs. 56%). This trial has immediate implications for care in low-resource settings but also raises questions about the standard practice of fluid resuscitation in other settings where benefits have yet to be proven.