guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM In-patient: Complications 83
definite indications of a focus of infection (e.g. example chest x-ray shows staphylococcal abscesses
or TB) broad spectrum antibiotics should be given. Most children with septic shock have enteric, gram
negative bacteria that have translocated from the intestinal tract. Those with haemoglobinopathies
(e.g. sickle cell disease) often have salmonella septicaemia.
The principles of treatment is then to maintain the patient in as stable a condition as possible whilst
the antibiotics start to work, whilst preventing hypothermia and hypoglycaemia, maintaining fluid
balance and giving basic nutrition with F75 to address any major nutritional deficiency.
All patients with septic shock should immediately be:
1. Given broad-spectrum antibiotics 127
•
•
•
• Ceftriaxone by SLOW IV injection once per day (100mg/kg/d on the first day, followed by
50mg/kg/d on subsequent days)
AND
• • Gentamicin 5 mg/kg/day by 1 injection IM
• If there are extensive open skin lesions or signs suggestive of pulmonary abscesses add
Cloxacillin IV: Children: 100mg/kg/d by 3 injections every 8 hours
• If there is no improvement in 24h then:
- add Ciprofloxacin orally 15-30mg/kg/d in 2 doses
- add Fluconazole: orally 3mg/kg/d once daily (in areas of high HIV prevalence, where
there is oral candidiasis or where the prevalence of candidiasis is >20% add at the start of
treatment)
2. Kept warm to prevent or treat hypothermia.
3. Given sugar-water by mouth or naso-gastric tube as soon as the diagnosis is made (to prevent
hypoglycaemia).
4. Physically disturb the patient as little as possible (no washing, excess examination,
investigations in other departments, etc.).
5. Not be transported to another facility unless there are proper facilities to safely transport the
patient. The stress of transport leads to dramatic deterioration and usually death. Even if
the admitting facility has few resources and the staff is relatively unskilled, it is much less
dangerous to treat the child in the admitting facility according to this protocol than to subject the
child to “transport trauma”. In this case it is very important to discuss the situation with the
caretakers realistically and explain that the outlook is not good, but that the worst thing would be
to subject the child to a long journey.
Incipient septic shock: Give the standard F75 diet by NG-tube 128 , if there are gastric residue
aspirated from the NG-tube, start with half the recommended quantity of F75 until there are no gastric
aspirates.
127 The levels of amoxicillin/ampicillin resistance of enteric gram negative bacteria in many countries is over 70% [13,14];
where the child is severely ill with septicaemia/septic shock, it is unwise to wait for 24h or more using amoxicillin to see if
there will be an improvement. It is difficult to retrieve the situation if the child deteriorates over the fist 24h by a change in
antibiotics.