Management of SAM Patient in Shock

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Algorithm

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graph TD
    %% Base style definitions
    classDef action fill:#FFF0F2,stroke:#990011,stroke-width:3px,color:#990011;
    classDef decision fill:#FFF5E6,stroke:#B35900,stroke-width:3px,color:#B35900;
    classDef improve fill:#EAF4F1,stroke:#196F3D,stroke-width:3px,color:#196F3D;

    A["A child with SAM with cold extremities with CRT > 3 seconds and weak & fast pulse"]:::action --> B
    
    B["Immediate Interventions:
• Give oxygen to keep SpO2 > 94%
• Insert an IV line (draw blood for emergency laboratory investigations)
• Weigh the child (or estimate the weight) to calculate the volume of fluid
• Give 5 ml/kg 10% Glucose IV
• Give IV fluid 15 ml/kg over 1 hour of either half-normal saline with 5% glucose or Ringer's lactate in 5% glucose*"]:::action --> C

    C["Measure the pulse, respiratory rate, temperature and CRT at the start and every 10 min"]:::action --> D
    C --> E
    C --> F

    D{"Signs of improvement
(PR and RR fall)
"}:::improve --> G["Switch to oral or nasogastric rehydration with ORS, 10 ml/kg/h up to 10 hours in alternate hour with starter diet (F-75)"]:::improve
    
    E{"If the child fails to improve after the first 15 ml/kg IV over 60 minutes"}:::decision --> H
    
    F{"If the child deteriorates, during the IV rehydration (RR increases by 5 /min or PR by 15 beats/min)
"}:::decision --> I["Stop the infusion and reassess"]:::decision --> H

    H["Assume: The child has septic shock"]:::action --> J

    J["Septic Shock Management:
• Add broad spectrum antibiotics
• Start Epinephrine infusion (0.1 to 1 mcg/kg/min). Use dopamine infusion at 10 mcg/kg/min if epinephrine not available
• If no response, give IV hydrocortisone if adrenal insufficiency is a possibility (1-2 mg/kg)
• If still poor response/prolonged or high dose of vasopressors required, consider transfer to facility with ICU settings, if available"]:::action --> K

    K["As soon as child is stabilized start feeding
"]:::action

Identification Of Shock In Severe Acute Malnutrition

A child with Severe Acute Malnutrition (SAM) is considered to be in shock if specific clinical signs are present.
Look for cold extremities.
Check for a Capillary Refill Time (CRT) that is longer than 3 seconds.
Palpate for a weak and fast pulse.

Initial Stabilization And Resuscitation

Provide oxygen immediately to maintain oxygen saturation (SpO2) above 94%.
Insert an intravenous (IV) line promptly.
Draw blood for emergency laboratory investigations at the time of IV insertion.
Weigh the child accurately.
Estimate the weight if the child cannot be weighed to calculate fluid volume.
Administer 5 ml/kg of 10% Glucose IV to prevent or treat hypoglycemia.

Intravenous Fluid Therapy Protocol

Do not use standard rapid fluid resuscitation protocols in SAM patients.
Administer IV fluids slowly and cautiously.

Fluid Parameter	Recommendation
Volume	15 ml/kg.
Duration	Administer over 1 hour.
Fluid Choice 1	Half-normal saline with 5% glucose.
Fluid Choice 2	Ringer's lactate in 5% glucose.
Special Condition	If profuse diarrhoea is present (more than 10 loose watery stools in the last 24 hours), repeat 15 ml/kg of fluid over 1 hour.

Monitoring During Fluid Resuscitation

Continuous monitoring is critical to prevent fluid overload.
Record baseline parameters at the start of the infusion.
Measure the pulse rate, respiratory rate, temperature, and CRT every 10 minutes.

Assessment Of Response To Fluid Therapy

Signs Of Improvement

Improvement is indicated by a fall in pulse rate and respiratory rate.

Action Upon Improvement	Details
Switch To Oral Route	Stop IV fluids and switch to oral or nasogastric rehydration.
Rehydration Fluid	Use Oral Rehydration Salt (ORS) solution.
Volume And Rate	Give 10 ml/kg/hour for up to 10 hours.
Diet Integration	Provide ORS in alternate hours with starter diet (F-75).
Feeding	Start feeding as soon as the child is stabilized.

Signs Of Deterioration

Deterioration during IV rehydration is a critical emergency.
It is indicated if the respiratory rate increases by 5 breaths per minute.
It is also indicated if the pulse rate increases by 15 beats per minute.
Stop the IV infusion immediately.
Reassess the patient thoroughly.

Failure To Improve

If the child fails to improve after the first 15 ml/kg IV fluid over 60 minutes, assume the child has septic shock.

Management Of Septic Shock In Severe Acute Malnutrition

Initiate aggressive management for septic shock if fluid resuscitation fails.

Antimicrobial Therapy

Add broad-spectrum antibiotics immediately.
Give third-generation cephalosporins.
Use Injection Cefotaxime 150 mg/kg/day in 3 divided doses.
Alternatively, use Injection Ceftriaxone 100 mg/kg/day in 2 divided doses.
Combine with Injection Gentamicin 7.5 mg as a single dose.
Do not administer the second dose of Gentamicin until the child has passed urine.
Continue the antibiotic course for 10-14 days.

Vasoactive Support

Start Epinephrine infusion at a dose of 0.1 to 1 mcg/kg/min.
Use Dopamine infusion at 10 mcg/kg/min if Epinephrine is not available.

Additional Interventions

Consider adrenal insufficiency if the shock is unresponsive.
Administer IV hydrocortisone at a dose of 1-2 mg/kg if no response to vasoactive drugs is seen.
Consider transferring the patient to a facility with Intensive Care Unit (ICU) settings.
Transfer is indicated if there is a persistently poor response.
Transfer is also indicated if prolonged or high doses of vasopressors are required.