guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM In-patient: Complications 82
� If the child is unconscious then the same volumes of fluid (5% dextrose if there is no diarrhoea
and one fifth normal saline in 5% dextrose if there is diarrhoea) can be given by intravenous
infusion. There should be a peristaltic pump or accurate paediatric burette in order to ensure
that that the rate of administration of fluid is not exceeded during treatment.
� When the child is awake and alert, then recommence feeding with F75.
3. SEPTIC (OR TOXIC) SHOCK
Septic shock presents with some of the signs of true dehydration but also of cardiogenic shock and
frequently of liver dysfunction; the differential diagnosis is often very difficult.
Children that appear “very ill”, may have septic shock 126 , hypernatraemic dehydration, cardiogenic
shock, liver failure, or toxic shock from poisoning with traditional medicines or overdose of therapeutic
drugs, aspirin poisoning, malaria, acute viral infection or other severe conditions. All “very ill” children
should not be automatically diagnosed as having septic shock; the true reason for the condition should
be sought.
Children with septic shock normally present with very severe illness, if the condition develops after
admission then it is more likely to be cardiogenic shock, or an adverse reaction to the treatment that
is being given.
If the child deteriorates after admission to the in-patient facility, then:
� Review the treatment given to the child to determine if the treatment is the cause of the
clinical deterioration.
� Review the fluid (sodium) intake, particularly any treatment given in the emergency ward
during admission
� Examine the daily weight changes as this may indicate cardiogenic shock; do not diagnose
septic shock in a very ill child if there has been weight gain during the preceding 24h.
� Stop any drugs being given that are not included in the protocol
� Check the dose of drugs given to ensure that they have been adjusted for the malnourished
state.
Diagnosis of septic shock
To make a diagnosis of developed septic shock requires the signs of hypovolaemic shock to be
present
• A fast weak pulse with
• Cold peripheries
• Slow capillary refill in the nail beds
• Disturbed consciousness
• Absence of signs of heart failure
Treatment of septic shock
The main treatment of septic shock is to give antibiotics active against the infecting organism. This is
normally unknown; there are rarely any localising signs in the severely malnourished child, indeed
autopsy studies show that they normally have up to 4 different systemic pathogens. Unless there are
126 Disseminated viral infections that will not respond to antibiotics are often present in the children who die despite
optimum treatment [11,64,65]. Trials of modern anti-viral agents have not been assessed in complicated severe malnutrition.
The facilities to make the diagnosis ante-mortem are not normally present.