Question 4

College Answer

a) Initial management

• •  ABCDEFG approach.
• •   Oxygen
• •   Venous access (IO if required)
• •   Secure airway if needed
• Fluid bolus (20ml/kg early boluses ; aim for reversal of immediately life-threatening shock; post FEAST more controversial but remains key management)
• Keep warm
• Check BSL as an early priority
• Early administration of empiric antibiotics

• Investigations- blood gas essential mentioned essential for full marks; others may be mentioned as delayed (arterial, venous or capillary all reasonable; venous quick and useful)

• Investigations: blood culture, FBC, ELFT, formal BSL as early keys, stool culture and viral screen, urine culture, nasopharyngeal aspirate for respiratory viruses, CXR

b) Assessment of dehydration

• Clinical assessment of dehydration can be difficult, especially in young infants, and rarely predicts the exact degree of dehydration accurately. 
• The most useful individual signs for predicting 5% dehydration in children are an abnormal capillary refill time, abnormal skin turgor and abnormal respiratory pattern. Combinations of examination signs provide a much better method than any individual signs in assessing the degree of dehydration.
• Clinical assessment therefore comprises some of the following indicators of dehydration:

Loss of body weight:

• Normal: no loss of body weight.
• Mild dehydration: 5-6% loss of body weight.

• Moderate: 7-10% loss of body weight.
• Severe: over 10% loss of body weight.

Clinical features of mild-to-moderate dehydration; 2 or more of:

• Restlessness or irritability.

• Sunken eyes (also ask the parent).

• Thirsty and drinks eagerly.

Clinical features of severe dehydration; 2 or more of:

• Abnormally sleepy or lethargic.

• Sunken eyes.

• Drinking poorly or not at all.

• Pinch test (skin turgor): the sign is unreliable in obese or severely malnourished children.

• Normal: skin fold retracts immediately.

• Mild or moderate dehydration: slow; skin fold visible for less than 2 seconds.

• Severe dehydration: very slow; skin fold visible for longer than 2 seconds.

• Other features of dehydration include dry mucous membranes, reduced tears and decreased urine output.

• Additional signs of severe dehydration include circulatory collapse (e.g. weak rapid pulse, cool or blue extremities, hypotension), rapid breathing, sunken anterior fontanelle.

Discussion

1) Initial management of the non-specifically shocked child can consist of the following generic steps, copied and pasted from the chapter on paediatric shock:

1. Assess the need for intubation.
   - At this stage, senior assistance from somebody expert in paediatric critical care is required, as the intubation may be difficult.
2. Administer 100% oxygen.
3. Establish venous access.
   - Give a 20ml/kg bolus, FEAST be damned.
   - Inotropes and vasopressors if no longer fluid-responsive
   - Parameters guiding resuscitation (eg. lactate, haemodynamic variables, urine output) differ little from adult standards
4. Sedation and analgesia to support tolerance of invasive therapies
   (also decreases demands on the cardiac output)
5. Electrolyte correction
6. Maintenance fluid:  As per college answer, "add 100 ml of 50% dextrose to 900 ml 0.9% NaCl and infuse this at 2/3 maintenance rate (16 ml/hr in this case) (accept 24 ml/hr for 1^st 48 hours)". 
   - A urinary catheter will also be required.
7. No protein in diet until metabolic screen is cleared
   - Maintain normoglycaemia with infusion of 10% dextrose of dextrose-rich maintenance fluid
8. Blood transfusion may not be warranted
9. Empiric antibiotics if sepsis is suspected, within 1 hour.
   - Cultures of blood and urine.
   - Consider antivirals if there is suspicion of viral meningitis or encephalitis

2) Assessment of dehydration offered by the college is based on Gorelick et al (1997). Here it is, interpreted as a table:

Mild (5-6% loss of body weight)	Moderate (7-10% loss of body weight)	Severe (over 10% loss of body weight)
2 or more of: Restlessness or irritability. Sunken eyes (also ask the parent). Thirsty and drinks eagerly. Poor skin turgor; after pinch test the skin fold is visible for less than 2 seconds.		2 or more of: Abnormally sleepy or lethargic. Sunken eyes. Drinking poorly or not at all. Very poor skin turgor; after pinch test the skin fold is visible for longer than 2 seconds. Weak rapid pulse Cool or blue extremities Hypotension Rapid breathing Sunken anterior fontanelle.

That whole "two or more" thing also comes from Gorelick (1997). "A subset of four factors—capillary refill >2 seconds, absent tears, dry mucous membranes, and ill general appearance—predicted dehydration as well as the entire set, with the presence of any two or more of these signs indicating a deficit of at least 5%".  In general, when it comes to assessing dehydration, Gorelick et al recommend using a combination of three signs (this is also mentioned in the college answer) - a combination of three signs had a sensitivity of 87% and specificity of 82% for detecting a water deficit of 5% or more.

The FEAST trial earns a mention because mortality was found to be increased in the group of severely ill febrile African children who received fluid boluses. It was published in the previous year, and caused something of a moral panic ("What? No fluids for our sick children?"). It seems cardiovascular collapse rather than fluid overload is the cause of death among these children. It has brought into question the administration of early 20-40ml/kg boluses to these kids.

However, the college still seems to support this practice, though they acknowledge it as "controversial". In fact, even the WHO has persisted with its recommendations to give fluid boluses in septic children, which has prompted some authors to question the degree of its attachment to evidence.

Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, Nyeko R, Mtove G, Reyburn H, Lang T, Brent B, Evans JA, Tibenderana JK, Crawley J, Russell EC, Levin M, Babiker AG, Gibb DM: Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011, 364:2483-2495

Kiguli, Sarah, et al. "WHO guidelines on fluid resuscitation in children: missing the FEAST data." BMJ: British Medical Journal 348 (2014).

Steiner, Michael J., Darren A. DeWalt, and Julie S. Byerley. "Is this child dehydrated?." Jama 291.22 (2004): 2746-2754.

Levine, Adam C., et al. "Empirically Derived Dehydration Scoring and Decision Tree Models for Children With Diarrhea: Assessment and Internal Validation in a Prospective Cohort Study in Dhaka, Bangladesh." Global Health: Science and Practice 3.3 (2015): 405-418.

Freedman, Stephen B., et al. "Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis." The Journal of pediatrics 166.4 (2015): 908-916.

Friedman, Jeremy N., et al. "Development of a clinical dehydration scale for use in children between 1 and 36 months of age." The Journal of pediatrics 145.2 (2004): 201-207.

Gorelick, Marc H., Kathy N. Shaw, and Kathleen O. Murphy. "Validity and reliability of clinical signs in the diagnosis of dehydration in children." Pediatrics 99.5 (1997): e6-e6.