College answer

Concurrent resuscitation, assessment and treatment of this extremely sick child, addressing the hypotension, acute kidney injury, severe shock and dehydration and profound metabolic derangement.

Stabilisation of the child prior to transfer to a tertiary paediatric institution with close liaison with paediatric team for advice on management. 

Use Broselow tape, guidelines on paediatric drug doses, dedicated paediatric resuscitation equipment etc. to ensure appropriate doses of fluids and drugs, tube sizes, ventilator settings etc. 

Steps in management

• Call for help
• Assess airway and breathing o inadequate ventilation, depressed level of consciousness, profound dehydration and shock
• 100% oxygen and support ventilation with BVM if required. This child will need intubation but need to optimise cardiac output before proceeding with this (consider waiting until transport team arrive for maximum support)
• Establish venous access, IO line or peripheral venous (central venous access only if second person available to perform or if child more stable)
• Immediate treatment of hypoglycaemia with 2 – 5 ml/kg 10% dextrose. Ongoing glucose to maintain blood sugar levels measured hourly at the very least. 
• Ongoing volume resuscitation with 10 – 20 ml/kg boluses of 0.9% sodium chloride, reassess perfusion and repeat as needed. Some children require up to 100 ml/kg fluid resuscitation (caution if cardiogenic shock present) 
• Electrolyte replacement as required
• Ongoing maintenance fluid – e.g. 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)
• Assess % dehydration and replace over 48 hours using maintenance fluid (unless sodium increases > 150 mmol/L) Formula: Vol = % Dehydration x body weight x 10 (in mls)
• Use an inotrope: e.g. adrenaline (other inotropes acceptable)
• IV antibiotics within one hour. These can be stopped after 48 hours if cultures negative
• Treat hyperkalaemia if still present after treatment of shock (usually K⁺ levels drop as shock treated) o IV CaCl₂
  • IV boluses 8.45% NaHCO₃ (Dose in mmol or ml = desired HCO₃ – measured HCO₃ x (weight in kg x 0.6)
  •  Dextrose/insulin
• Urinary catheter to monitor hourly urine output
• Consideration of non-infectious causes 
• Organisation of transfer/retrieval team
• Keep the parents up to date

Exact doses of drugs/fluids not expected but reference to need to look up/check dosing carefully in this instance

Additional Examiners‟ Comments:

Most candidates did well in this question. Failure to immediately treat the hypoglycaemia was a fatal error.

Discussion

"Concurrent resuscitation, assessment and treatment" seems to make the redundant distinction between resuscitation and treatment. Some treatments are resuscitative, and resuscitation is a treatment. But that pedantry aside, this college answer is stereotypic for the management of the child with nonspecific shock.

An example approach is offered below:

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

For maintenance calculation, the following formula is the gold standard, found in this 1957 paper by Holliday and Segar. A good modern revision was performed by Meyers (2009). In short, 

• First 10kg: 4ml/kg/hr
• Second 10kg: 2ml/kg/hr
• All other kgs: 1ml/kg/hr

The reduced  2/3 of the maintenance rate is usually given  to critically ill children because of their propensity to secrete ADH, thereby causing water retention. A full maintenance rate is usually given to the well child fasted for theatre.

Isotonic fluids should be used for maintenance, in contrast to the college answer.  Wang et al (2013) suggest that they are safer than hypotonic fluids. This contrasts slightly with the college answer. NICE guidelines (Neilson et al, 2015) also recommend isotonic crystalloid for maintenance, and make no mention of the dextrose cocktail which the college recommend ("add 100 ml of 50% dextrose to 900 ml 0.9% NaCl"). The RCH guidelines from Melbourne recommend the routine use of Plasmalyte 148 together with 5% dextrose, without offering any references. The 900/100 mixture describe by the college in this case is in any case nearly isotonic (though fairly hyperosmolar, 550mOsm/L or thereabout)