guidelines for the integrated management of severe acute malnutrition

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ACF-In Guidelines for the integrated management of SAM In-patient: Complications 84 Developed septic shock: If the patient is unconscious because of poor brain perfusion then a slow IV infusion of one of the following can be given (do not give if there is a possibility of cardiogenic shock) 129 : � Whole blood of 10ml/kg over at least 3 hours – nothing should be given orally during the blood transfusion or for 3 hours after the transfusion. Or 10ml/kg/h for 2 hours of one of the following: � Half-strength Darrow’s solution with 5% glucose � Ringer’s lactate solution with 5% glucose � Half-normal (0.45%) saline with 5% glucose Monitor every 10 minutes for signs of deterioration, especially over-hydration and heart failure. • Increasing respiratory rate, • Development of grunting respiration, • Increasing liver size, • Vein engorgement. As soon as the patient improves (stronger radial pulse, regain of consciousness) stop all IV intake - continue with F75 diet by NG-tube. 4. ABSENT BOWEL SOUNDS, GASTRIC DILATATION AND INTESTINAL SPLASH WITH ABDOMINAL DISTENSION. There is a functional ileus with bacterial overgrowth similar to that with intestinal obstruction. The stomach is not emptying, there is no peristalsis and fluid is gathering in the intestinal lumen. These are very grave signs and the mother should be warned that the prognosis is not good. The following measures should be taken: � Give first and second line antibiotic treatment by intra-muscular injection. � Consider adding third line antibiotics � If metronidazole is given then do not exceed a dose of 10mg/kg/d. � STOP all other drugs that may be causing toxicity � Give a single IM injection of magnesium sulphate (2ml of 50% solution) and repeat twice daily until stool is passed and gastric aspirated drop. � Pass an NG-tube and aspirate the contents of the stomach, then: 1. “Irrigate” the stomach with isotonic clear fluid (5% dextrose or 10% sucrose –the solution does not need to be sterile). Do this by introducing 50ml of solution into the stomach and then gently aspirating all the fluid back again. This should be repeated until the fluid that returns from the stomach is clear. 128 It may seem that “aggressive” treatment is warranted to prevent further deterioration, this is unwise. These patients are very fragile and do not tolerate sudden changes – the treatment has to be gentle and gradual. The idea is to “hold” the patient stable with minimum stress to their “milieu interior” until the antibiotics and nutrients start to work. 129 There is no evidence that albumin infusion lowers morality (relative risk of death with albumin 1.04 (0.95-1.13)) in neonates or adults [66,67]. Very conservative fluid therapy is advised for septic patients who are not in shock [68] and slow cautious fluid therapy for those who are in severe shock; there is nearly always an element of compromised cardiac function in severely septic children. If blood pressure is being measured it should only be raised to 65mm/hg.
ACF-In Guidelines for the integrated management of SAM In-patient: Complications 85 2. Put 5 ml/kg of sugar-water (10% sucrose solution) into the stomach and leave it there for one hour. Then aspirate the stomach and measure the volume that is retrieved. If the volume is less than the amount that was introduced then either a further dose of sugar-water should be given or the fluid returned to the stomach. � There is frequently gastric and oesophageal candidiasis: put oral nystatin suspension or fluconazole down the NG-tube. � Keep the child warm. � These children are usually unconsciousness, semiconscious or delirious: give intravenous glucose (see section on hypoglycaemia). Monitoring: • Do not put up a drip at this stage. Monitor the child carefully for 6 hours, without giving any other treatment. • Improvement is measured first by a change in intestinal function - decrease in the distension of the abdomen, visible peristalsis seen through the abdominal wall, return of bowel sounds, decreasing size of gastric aspirates – and second by improvement in the general condition of the child. - If there is intestinal improvement then start to give small amounts of F75 by NG tube (half the quantities given in the F75 – table. Aspirate the stomach before each feed. If the volume of residual feed remaining is large, then decrease the amount of F75. If the amount of aspirate is small then the amount can be gradually increased. - If there is no improvement after 6 hours then: � Consider putting up an IV drip. It is very important that the fluid given contains adequate amounts of potassium. Sterile Potassium Chloride (20mmol/l) should be added to all solutions that do not contain potassium. If it is available use one-fifth normal saline in 5% dextrose, otherwise use Ringer-Lactate in 5% dextrose or half-strength saline in 5% dextrose. The drip should be run VERY SLOWLY – the amount of fluid that is given should be NO MORE THAN 2 to 4 ml/kg/h. � Start to give the first and second line antibiotics intravenously. � When the gastric aspirates decrease so that one half of the fluid given to the stomach is absorbed, discontinue the IV treatment and continue with oral treatment only. 5. HEART FAILURE Signs and symptoms Heart failure should be diagnosed when there is: � Physical deterioration with a gain in weight 130 • this is the most common way of making the diagnosis and does not require any equipment or particular clinical skill � An increase in respiration rate with weight gain 130 As heart failure is rare on admission there should be an admission weight, so that weight change can be determined Weight gain in this context is almost always due to fluid retention – the ill child does not ingest sufficient food for the weight gain to be normal tissue gain, and the amount of weight gained is normally more than expected from the energy intake. Even if the full amount of prescribed F75 is taken there should not be any weight gained because of new tissue synthesis so that weight gain is NOT expected in the acute phase of treatment.
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Cover photography: © ACF, Anne-Dom
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guidelines for the integrated management of severe acute malnutrition

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