Reduction of unnecessary transfusion and intravenous fluids in severely malnourished children is not enough to reduce mortality
Reduction of unnecessary transfusion and intravenous fluids in severely malnourished children is not enough to reduce mortality
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DOI：
10.1179/146532808x270644
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发表时间：
2008-03-01
影响因子：
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通讯作者：
Tylleskar, Thorkild
中科院分区：
文献类型：
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作者：
Bachou, Hanifa;Tumwine, James K.;Tylleskar, Thorkild
目的：测试输血和静脉输液的标准化使用是否可以降低坎帕拉穆拉戈医院收治的严重营养不良儿童的死亡率。方法：通过持续的医学教育，提高对严重营养不良患者输血和静脉输液的遵守情况。采用“前后对比”设计对450名60个月以下的严重营养不良儿童（体重与身高比值< -3 Z-score或存在水肿）进行研究。在2003年9月至11月和2004年9月至12月期间，共有220名“改进实践”前和230名“改进实践”后患者连续入组。患者随访至出院或死亡。Kaplan-Meier生存曲线和Cox回归风险模型分别用于单因素和多因素分析。结果：术前病死率为23.6%(52/220)，术后病死率为24.8% (57/230)（p=0.78）。大多数死亡发生在入院第一周（73%（38/52）在入院前，61%（35/57）在入院后），并且是在入院前接受输血或静脉输液或两者兼有的儿童。输血和/或输注儿童的死亡率在治疗后显著降低（治疗前为82%，31/38，治疗后为23%，8/35,p=0.008）。术后不适当输血次数（18%，34/194比3.5%,8/230,p=0.01）和静脉输液次数（27%，52/194比9%，20/230,p < 0.001）显著减少。术后接受输血的儿童生存率提高[危险比（HR） 0.22, 95% CI 0.30-1.67 vs危险比4.80,95% CI 1.71-13.51]，接受静脉输液的儿童生存率也提高（HR 2.10, 95% CI 0.84-5.23 vs危险比3.91,95% CI 1.10-14.04）。结论：按照世界卫生组织方案对严重营养不良患者进行管理，可减少血液和静脉输液的需要。然而，还需要进一步的研究来验证全面实施世卫组织议定书是否能降低撒哈拉以南地区医院的高病死率。
Aim: To test whether standardising the use of blood transfusions and intravenous (IV) infusions could reduce fatality in severely malnourished children admitted to Mulago Hospital, Kampala.Methods: Improved adherence to the WHO protocol for blood transfusion and IV fluids was effected in patients with severe malnutrition by continuous medical education. A 'before and after' design was used to study 450 severely malnourished children (weight-for-height < -3 Z-score or presence of oedema) under 60 months of age. A total of 220 pre- and 230 post-'improved practice' patients were enrolled consecutively during the periods September to November 2003 and September to December 2004, respectively. Patients were followed up until discharge or death. The Kaplan-Meier survival curve and the Cox regression hazard model were used for univariate and multivariate analyses, respectively.Results: Overall case fatality was 23.6% (52/220) in the pre-period and 24.8% (57/230) in the post-period (p=0.78). Most of the deaths occurred in the 1st week of admission (73%, 38/52 in the pre-period and 61%, 35/57 in the post-period) and were of children who had received blood transfusion or IV infusion or both in the pre-period. Mortality in children transfused and/or infused was significantly reduced in the post-period (82%, 31/38 in the preperiod vs 23%, 8/35 in the post-period, p=0.008). In the post-period, there was a significant reduction in the number of inappropriate blood transfusions (18%, 34/194 vs 3.5%, 8/230, p=0.01) and IV fluid infusions (27%, 52/194 vs 9%, 20/230,p < 0.001). Survival improved in children who received blood transfusions in the post-period [hazards ratio (HR) 0.22, 95% CI 0.30-1.67 vs HR 4.80, 95% CI 1.71-13.51], as did that of children who received IV infusions (HR 2.10, 95% CI 0.84-5.23 vs HR 3.91, 95% CI 1.10-14.04).Conclusion: Management according to the WHO protocol for severe malnutrition can reduce the need for blood and IV infusions. However, further studies are required to verify whether full implementation of the WHO protocol reduces the high case fatality in sub-Saharan hospitals.