What is the management for a child presenting with abdominal distension, semiconsciousness, moderate hepatomegaly, elevated Serum Glutamic-Pyruvic Transaminase (SGPT) levels, and anemia, with a history of fever for 3 days?

Management of a Child with Abdominal Distension, Semiconsciousness, Hepatomegaly, Elevated SGPT, and Anemia with Fever

This child is presenting with septic shock and requires immediate fluid resuscitation, empiric antibiotics within 1 hour, and supportive care according to the Surviving Sepsis Campaign guidelines. 1

Initial Assessment and Stabilization (First 5 Minutes)

• Secure airway, provide high-flow oxygen, and assess breathing and circulation 1
• Obtain vascular access (intravenous or intraosseous) immediately 1
• Check blood glucose and correct hypoglycemia if present 1
• Begin fluid resuscitation with isotonic crystalloids at 20 mL/kg boluses (preferably balanced/buffered solutions rather than 0.9% saline) 1
• Continue fluid boluses up to 40-60 mL/kg in the first hour unless signs of fluid overload develop (rales or worsening hepatomegaly) 1
• Obtain blood cultures before starting antibiotics, but do not delay antibiotic administration 1

Antibiotic Therapy (Within First Hour)

• Administer broad-spectrum empiric antibiotics within 1 hour of presentation 1
• Recommended regimen:
  • Ceftriaxone 100 mg/kg/day IV (covers gram-negative and gram-positive bacteria) 1
  • PLUS Vancomycin 15 mg/kg IV q6h (if MRSA is suspected) 1
  • Consider adding metronidazole 10 mg/kg IV q8h if intra-abdominal infection is suspected 1

Hemodynamic Management (First 15-60 Minutes)

• If shock persists after 40-60 mL/kg fluid resuscitation (fluid-refractory shock), begin inotropic support 1
• For cold shock (cool extremities, prolonged capillary refill):
  • Start dopamine 5-10 mcg/kg/min; if resistant, switch to epinephrine 0.05-0.3 mcg/kg/min 1
• For warm shock (flash capillary refill, bounding pulses):
  • Start norepinephrine 0.05-0.3 mcg/kg/min 1
• Target hemoglobin level of 10 g/dL during resuscitation phase (patient currently has 9.9 g/dL) 1
• Consider hydrocortisone 2 mg/kg IV if catecholamine-resistant shock develops 1

Management of Hepatic Dysfunction

• The markedly elevated SGPT (1000 IU/L) with hepatomegaly suggests ischemic hepatitis secondary to shock or severe sepsis 2, 3
• Monitor coagulation parameters (PT/INR) as coagulopathy commonly develops 2, 3
• Check serum bilirubin and alkaline phosphatase 3
• Avoid hepatotoxic medications 4
• Consider viral hepatitis in differential diagnosis, but sepsis with ischemic hepatitis is more likely given the clinical presentation 5, 3

Neurological Management

• Assess level of consciousness using AVPU scale or Glasgow Coma Scale 1
• If the child remains unconscious (Glasgow Coma Score ≤8), consider elective intubation and ventilation 1
• Treat seizures if present:
  • Lorazepam 0.1 mg/kg IV/IO 1
  • Repeat dose if seizures persist after 10 minutes 1

Ongoing Monitoring and Support

• Monitor vital signs, urine output (target >1 mL/kg/hour), mental status, and capillary refill 1
• Serial blood lactate measurements to guide resuscitation 1
• Monitor blood glucose regularly and maintain <180 mg/dL; provide glucose infusion if insulin therapy is required 1
• Monitor drug toxicity labs as drug metabolism is reduced during severe sepsis 1
• Consider advanced hemodynamic monitoring if available (central venous oxygen saturation, cardiac output) 1

Source Control

• Identify and control source of infection as soon as possible 1
• Consider abdominal ultrasound to evaluate for intra-abdominal abscess or other sources of infection 1
• Surgical consultation may be needed if intra-abdominal source is identified 1

Nutritional Support

• Begin enteral nutrition as soon as hemodynamically stable 1
• If enteral feeding is not possible, provide parenteral nutrition 1

Prescription for This Child

1. IV Fluids:

   • Resuscitation: Balanced crystalloid solution 20 mL/kg boluses up to 40-60 mL/kg 1
   • Maintenance: D5 1/2NS at 4 mL/kg/hr after resuscitation 1

2. Antibiotics:

   • Ceftriaxone 100 mg/kg/day IV divided q24h 1
   • Vancomycin 15 mg/kg IV q6h 1

3. Vasopressors/Inotropes (if needed):

   • Dopamine 5-10 mcg/kg/min IV (titrate to effect) 1
   • OR Epinephrine 0.05-0.3 mcg/kg/min IV for cold shock 1
   • OR Norepinephrine 0.05-0.3 mcg/kg/min IV for warm shock 1

4. Supportive medications:

   • Hydrocortisone 2 mg/kg IV q6h if catecholamine-resistant shock 1
   • Packed red blood cells to maintain Hb >10 g/dL during resuscitation 1
   • Acetaminophen 15 mg/kg/dose q6h PRN for fever 1

5. Monitoring:

   • Continuous cardiorespiratory monitoring 1
   • Hourly vital signs and urine output 1
   • Serial blood glucose, electrolytes, liver function tests, and coagulation studies q6h 1, 2
   • Serial lactate measurements q4-6h 1