FEAST or Famine

Matthew O’MearaDirector Emergency

Sydney Children’s Hospital Randwick

FEAST

Fever + impaired perfusion

No bolusAlbumin20mL/kg

Saline20mL/kg

Saline40mL/kg

Albumin40mL/kg

Severe Hypotension

48 hour mortality 28 day mortality

Sick?

• Fever +

• Decreased level of consciousness• 62% can’t sit, 15%

unresponsive

• and/or

• respiratory distress (83%)

Poor perfusion

Shocked?

• FEAST

• cap refill 3 sec, or

• leg temp gradient, or

• weak radial pulse volume, or

• tachycardia

• CRT or 3 seconds or more, or a lower limb temperature gradient, or a weak radial pulse volume (21%) or severe tachycardia, based on age – over 180 for infants, over 160 for 1-5 years and over 140 for children over 5 years of age. (i

WHO

Cold hands and feet and

cap refill 4 sec and

fast weak pulse

Inclusion Benefit?

So FEAST hasn’t changed my practice,

tell me something new

• Hyponatraemia and death or permanent brain damage in healthy children. Arieff BMJ 1992

• Fatal Hyponatraemic brain oedema... Sjoblom ICM 1997

• Fatal Iatrogenic Hyponatraemia. Playfor ADC 2003

• Acute Hyponatraemia in children admitted to hospital. Halberthal BMJ 2001

• Prevention of Hospital acquired hyponatraemia. Moritz Pediatrics 2003

“From three to 120 inpatient hours after hypotonic fuid administration patients developed progressive lethargy, headache, nausea and emesis with explosive onset of respiratory arrest”.

Moritz Pediatrics 2003

Too much fuidor

Not enough salt?

The fuid type, not the rate, determines the

risk of hyponatraemia

Hyponatraemia is less likely when isotonic

saline is used

Relationship between IV fuid type and development of hyponatraemia.

Is saline the best fuid?

How much Sugar?

What’s being done?

What should you do differently?

• Resuscitate with saline/colloid/blood

• Maintenance with more salt and enough glucose at usual rate

• Check your patient