I have spent my entire professional career giving boluses of fluid to patients with septic shock, from the very first paediatric patient I met on call (“You’re the paed? We need you, this lad’s sick.”) through imprints of 50ml syringes squeezed into infants to over-the-phone requests to run another 500 ml of saline in while I scrabbled for a clean shirt and car keys.
I didn’t really use much albumin, or starches, or blood product for the purpose. (Which was probably good for quite a few reasons … A B C.) But I did, and probably will next week, do fluid resuscitation.
Which is why the FEAST trial of the treatment of septic shock in African children unnerved me a little, but a reassuring analysis of the differences settled me down. Now a specific reanalysis of the data in BioMedCentral has asked those questions of the trial; was it that the deaths were in the severely anaemic, or those with respiratory illnesses (in the setting of no ventilators) leading to the excess death. No. It seems not.
Indeed the group with with worse volume depletion (high lactates etc) seemed to fare worse. Is this a reperfusion injury issue? Is this, like oxygen for acute MI, a case of ‘nature knows better’?
I don’t know. I cannot bring myself to not give fluid to the shocked. But I do feel extremely uncertain if I’m doing more good than harm.