This is one of the most interesting ideas in (evolutionary) medicine.
Is shock itself a host defense?
Kathryn Maitland conducted the FEAST trial, a landmark study of fluid resuscitation in children with septic shock published in the New England Journal of Medicine, that we have discussed in a previous podcast
The question: do sick kids in African countries have better outcomes when we treat them the same way we treat them in the U.S. or the U.K.? Children in Tanzania, Uganda, and Kenya were randomized to a bolus of normal saline, an alternate fluid, or control (no fluid bolus). Just to be clear, the 20ml per kilogram saline bolus that the African children received is exactly what we do in my hospital.
Maitland describes the results and the reaction in this podcast:
The results stunned the nurses and doctors carrying it out. They saw kids appear to get better when they were given fluids – they pinked up, and all their vital signs improved. But they died more often if they received fluids. The kids who remained hypotensive without getting a fluid bolus (this would be malpractice here in the United States) did better.
“Our theory is that the shock response in severe febrile illness is a defence mechanism, and bringing [children] out of this too soon with a fluid bolus can be counterproductive, resulting in later cardiovascular collapse. It’s better to rehydrate them more slowly”, explains Maitland. Nevertheless, she stresses that rapid fluid infusions are still vital for other conditions such as diarrhoea. When Maitland first presented these findings in 2011, she was met with stunned silence, followed by a standing ovation. However, these findings attracted much controversy. “WHO remained silent and only later modified its guidelines, and even then not adequately”, explains Maitland. “Some tried to explain away our findings as relating to specific diseases or subgroups, or our definition of shock, but our data showed that fluid boluses were causing harm across all subgroups. We calculated that the excess mortality in Africa alone was thousands of children while fluid bolus therapy was still being recommended. The Hippocratic oath ‘first do no harm’ was evident here more than ever.”
This is extraordinary. An evolutionary hypothesis can lead to truly groundbreaking and unanticipated results. We will have more to say about this soon.
Copyright © Joe Alcock MD
Emergency Physician, Educator, Researcher, interested in the microbiome, evolution, and medicine