You are called to assist with the management of a 5-month-old, 6 kg female infant who has been brought into the Emergency Department of your small rural hospital with a 4-day history of diarrhoea and vomiting.
On review, she is drowsy, mottled and cold with a heart rate of 155 beats/min and blood pressure 72/37 mmHg.
Her arterial blood results are as follows:
Parameter |
Patient Value |
Normal Adult Range |
Fi02 |
0.5 |
|
pH |
6.90* |
7.35 - 7.45 |
PC02 |
44 mmHg (5.8 kPa) |
35 - 50 (4.9 - 6.6) |
P02 |
41 mmHq (5.4 kPa) |
|
Bicarbonate |
8.5 mmol/L* |
22.0 - 28.0 |
Base Excess |
-20 mmol/L* |
-2 - +2 |
Sodium |
146 mmol/L* |
135 - 145 |
Potassium |
6.2 mmol/L* |
3.5 - 5.0 |
Chloride |
110 mmol/L |
100 - 110 |
Glucose |
2.2 mmol/L* |
3.0 - 5.4 |
Calcium ionised |
1.13 mmol/L |
1.12 - 1.32 |
Urea |
31.0 mmol/L* |
3.0 - 8.0 |
Creatinine |
305 umol/L* |
45 - 90 |
Outline the principles of management for this infant.
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
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.
"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:
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,
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)
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.
Holliday, Malcolm A., and William E. Segar. "The maintenance need for water in parenteral fluid therapy." Pediatrics 19.5 (1957): 823-832.
Meyers, Rachel S. "Pediatric fluid and electrolyte therapy." The Journal of Pediatric Pharmacology and Therapeutics 14.4 (2009): 204-211.
Wang, Jingjing, Erdi Xu, and Yanfeng Xiao. "Isotonic versus hypotonic maintenance IV fluids in hospitalized children: a meta-analysis." Pediatrics (2013): peds-2013.
Neilson, Julie, et al. "Intravenous fluids in children and young people: summary of NICE guidance." BMJ: British Medical Journal (Online) 351 (2015).