How is pediatric dehydration and shock managed?

Management of Pediatric Dehydration and Shock

Rapid fluid resuscitation is the cornerstone of managing pediatric dehydration and shock, with up to 40-60 mL/kg of isotonic crystalloid administered in the first hour for children with septic shock or significant dehydration, titrated to clinical markers of cardiac output and discontinued if signs of fluid overload develop. 1

Assessment of Dehydration

The most useful clinical signs for identifying dehydration in children include:

• Prolonged capillary refill time (>2 seconds)
• Abnormal skin turgor
• Abnormal respiratory pattern
• Heart rate changes
• Mental status changes
• Urine output (<1 mL/kg/h indicates significant dehydration)

Clinical dehydration scales combining multiple physical examination findings are better predictors than individual signs 2.

Management Algorithm

1. Initial Fluid Resuscitation

For Mild to Moderate Dehydration:

• First-line: Oral Rehydration Therapy (ORT)
  • Use low-osmolarity ORS (preparation: 3.5g NaCl, 2.5g NaHCO₃, 1.5g KCl, and 20g glucose per liter of clean water) 3
  • Commercial options include Pedialyte, CeraLyte, and Enfalac Lytren
  • Consider ondansetron to prevent vomiting and improve ORS tolerance 3
  • If unable to tolerate oral intake, consider nasogastric administration

For Severe Dehydration or Shock:

• Rapid IV Fluid Boluses:

  • Administer 20 mL/kg isotonic crystalloid (normal saline or Ringer's lactate) rapidly
  • Can repeat to total of 40-60 mL/kg in first hour if needed 1
  • Push fluid with goal of attaining normal perfusion and blood pressure 1
  • Children commonly require 40-60 mL/kg in first hour 1
  • In healthcare systems without ICU availability but with hypotension present, administer up to 40 mL/kg (10-20 mL/kg per bolus) 1

• Fluid Selection:

  • Prefer balanced/buffered crystalloids over 0.9% saline 1
  • Avoid starches (strong recommendation) 1
  • Avoid gelatins 1
  • Consider crystalloid over albumin (although outcomes are similar, crystalloid is more cost-effective) 1

2. Monitoring During Resuscitation

• Continuously assess for signs of fluid overload:

  • Increased work of breathing
  • Rales
  • Gallop rhythm
  • Hepatomegaly 1

• Monitor:

  • Pulse oximetry
  • Continuous ECG
  • Blood pressure (arterial if possible)
  • Core temperature
  • Urine output (target >1 mL/kg/h)
  • Central venous pressure/O₂ saturation when available
  • Blood glucose and calcium
  • INR, lactate, and anion gap 1, 3

• Use trends in blood lactate levels to guide resuscitation 1

3. Hemodynamic Support for Shock

If shock is fluid-refractory (persists after 40-60 mL/kg fluid):

• Peripheral Inotrope Administration:

  • Begin peripheral inotrope (low-dose dopamine or epinephrine) if second peripheral IV/IO access is available while establishing central venous access 1
  • When administering through peripheral IV/IO, use dilute solution or with carrier solution 1

• Central Inotrope Administration:

  • For cold shock: Central epinephrine (0.05-0.3 μg/kg/min) 1
  • For warm shock: Norepinephrine 1
  • Central dopamine may be titrated through central venous access 1

4. Hydrocortisone Therapy

• Consider hydrocortisone for children at risk of adrenal insufficiency who remain in shock despite inotrope therapy
• Dosage ranges from 1-2 mg/kg/day for stress coverage to 50 mg/kg/day titrated to shock reversal
• Ideally obtain baseline cortisol level before administration 1

5. Nutrition and Feeding

• Continue breastfeeding throughout diarrheal episodes
• Resume regular age-appropriate diet during or immediately after rehydration
• Early feeding reduces stool output and duration of diarrhea by approximately 50%
• Recommend bland diet (BRAT: bananas, rice, applesauce, toast)
• Avoid foods high in simple sugars and high-fat foods 3

Therapeutic Endpoints

Treatment should continue until achieving:

• Capillary refill ≤2 seconds
• Normal heart rate for age
• Normal pulses with no differential between peripheral and central pulses
• Warm extremities
• Urine output >1 mL/kg/h
• Normal mental status
• Cardiac index >3.3 and <6.0 L/min/m² with normal perfusion pressure
• ScvO₂ >70%
• Normal INR, anion gap, and lactate 1

Common Pitfalls and Caveats

1. Fluid Overload Risk: While aggressive fluid resuscitation is beneficial, monitor closely for signs of fluid overload, especially in children with underlying cardiac or renal disease.

2. Rales Interpretation: Rales may be heard in children with pneumonia as a cause of sepsis and don't always indicate fluid overload. If pneumonia is suspected, continue fluid resuscitation with careful monitoring of work of breathing and oxygen saturation 1.

3. Peripheral Inotrope Administration: When using peripheral IV/IO for inotropes, reduce dosage if evidence of peripheral infiltration/ischemia occurs, as alpha-adrenergic effects are more pronounced at higher concentrations 1.

4. Inappropriate Medication Use: Avoid antimotility drugs like loperamide in children under 18 years with acute diarrhea 3.

5. Antibiotics Overuse: Antibiotics are generally not indicated for most cases of acute gastroenteritis in children 3.

6. Warning Signs Requiring Immediate Attention: Persistent vomiting preventing ORS intake, high stool output (>10 mL/kg/hour), bloody diarrhea, worsening dehydration despite treatment, and lethargy or altered mental status 3.

Early, aggressive fluid resuscitation is crucial in pediatric shock management, with studies showing that rapid fluid resuscitation in excess of 40 mL/kg in the first hour was associated with improved survival and decreased occurrence of persistent hypovolemia 4.