What is the most appropriate next step in managing a 10-month-old boy with severe dehydration and shock?

From the Guidelines

The most appropriate next step in management for this 10-month-old boy is intravenous bolus of 0.9% saline (option E). This child presents with clear signs of severe dehydration and hypovolemic shock, including lethargy, tachycardia (pulse 180/min), tachypnea (respirations 48/min), hypotension (68/54 mm Hg), and prolonged capillary refill time (4 seconds). In such cases, rapid fluid resuscitation is essential to restore intravascular volume and improve tissue perfusion. The standard approach is to administer 20 mL/kg of isotonic fluid (0.9% saline) as an IV bolus over 5-20 minutes, which can be repeated if necessary based on clinical response, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea 1.

Key Considerations

• The child's severe dehydration and hypovolemic shock require immediate attention to prevent further morbidity and mortality.
• Oral rehydration would be inappropriate given the child's lethargy and likely inability to tolerate oral intake.
• Maintenance fluids alone would be insufficient to address the acute volume depletion.
• Dopamine and fresh frozen plasma are not indicated as first-line treatments for dehydration from gastroenteritis.
• The 2017 guidelines also suggest that isotonic intravenous fluids such as lactated Ringer’s and normal saline solution should be administered when there is severe dehydration, shock, or altered mental status and failure of ORS therapy 1.

Management Approach

• Administer 20 mL/kg of isotonic fluid (0.9% saline) as an IV bolus over 5-20 minutes, which can be repeated if necessary based on clinical response.
• After initial fluid resuscitation and stabilization, the underlying cause of the gastroenteritis should be investigated, and ongoing fluid and electrolyte management should be implemented based on the child's clinical status and laboratory values, as outlined in the guidelines 1.
• The use of reduced osmolarity oral rehydration solution (ORS) is recommended as the first-line therapy for mild to moderate dehydration in infants, children, and adults with acute diarrhea from any cause, but it is not suitable for this child's severe dehydration 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Do NOT administer if solution is darker than slightly yellow or discolored in any other way. Do NOT administer unless solution is clear and container is undamaged. Discard unused portion Dextrose solutions without electrolytes should not be administered simultaneously with blood through the same infusion set because of the possibility that pseudoagglutination of red cells may occur. Do NOT add sodium bicarbonate or other alkalinizing substance, since dopamine is inactivated in alkaline solution Dopamine Hydrochloride in 5% Dextrose Injection should be infused into a large vein whenever possible to prevent the infiltration of perivascular tissue adjacent to the infusion site. Extravasation may cause necrosis and sloughing of the surrounding tissue. Large veins of the antecubital fossa are preferred to veins of the dorsum of the hand or ankle Less suitable infusion sites should be used only when larger veins are unavailable and the patient's condition requires immediate attention. The physician should switch to a more suitable site as soon as possible and the infusion site in use should be continuously monitored for free flow. The less concentrated 800 mcg/mL solution may be preferred when fluid expansion is not a problem The more concentrated 1600 mcg/mL or 3200 mcg/mL solutions, may be preferred in patients with fluid retention or when a slower rate of infusion is desired. Rate of Administration: Administration into an umbilical artery catheter is not recommended. Dopamine in 5% Dextrose Injection should not be infused through ordinary intravenous apparatus, regulated only by gravity and mechanical clamps Only an infusion pump, preferably a volumetric pump, should be used. Each patient must be individually titrated to the desired hemodynamic or renal response to dopamine. In titrating to the desired increase in systolic blood pressure, the optimum dosage rate for renal response may be exceeded, thus necessitating a reduction in rate after the hemodynamic condition is stabilized. If a disproportionate rise in diastolic pressure (i. e., a marked decrease in pulse pressure) is observed in patients receiving dopamine, the infusion rate should be decreased and the patient observed carefully for further evidence of predominant vasoconstrictor activity, unless such an effect is desired. Administration rates greater than 50 mcg/kg/min have safely been used in adults in advanced circulatory decompensation states If unnecessary fluid expansion is of concern, adjustment of drug concentration may be preferred over increasing the flow rate of a less concentrated dilution. When discontinuing the infusion, it may be necessary to gradually decrease the dose of dopamine HCl while expanding the blood volume with intravenous fluids to prevent the development of marked hypotension. Suggested Regimen: 1 When appropriate, increase blood volume with whole blood or plasma until central venous pressure is 10 to 15 cm H2O or pulmonary wedge pressure is 14 to 18 mm Hg. 2. Begin infusion of dopamine hydrochloride solution at doses of 2 to 5 mcg/kg/min in adult or pediatric patients who are likely to respond to modest increments of heart force and renal perfusion In more seriously ill patients, begin infusion of dopamine hydrochloride at doses of 5 mcg/kg/min and increase gradually, using 5 to 10 mcg/kg/min increments, up to a rate of 20 to 50 mcg/kg/min as needed. If doses in excess of 50 mcg/kg/min are required, check urine output frequently Should urinary flow begin to decrease in the absence of hypotension, reduction of dopamine dosage should be considered. More than 50% of adult patients have been satisfactorily maintained on doses less than 20 mcg/kg/min In patients who do not respond to these doses with adequate arterial pressures or urine flow, additional increments of dopamine may be given in an effort to produce an appropriate arterial pressure and central perfusion. 3 Treatment of all patients requires constant evaluation of therapy in terms of blood volume, augmentation of cardiac contractility, urine flow, cardiac output, blood pressure, and distribution of peripheral perfusion. Dosage of dopamine should be adjusted according to the patient's response Diminution of established urine flow rate, increasing tachycardia or development of new dysrhythmias are reasons to consider decreasing or temporarily suspending the dosage. 4. As with all potent intravenously administered drugs, care should be taken to control the rate of infusion so as to avoid inadvertent administration of a bolus of the drug 800 mcg/mL Dosing Chart for Dopamine (mL/hr) Infusion Rate 1600 mcg/mL Dosing Chart for Dopamine (mL/hr) Infusion Rate 3200 mcg/mL Dosing Chart for Dopamine (mL/hr) Infusion Rate Parenteral drug products should be visually inspected for particulate matter and discoloration prior to administration, whenever solution and container permit.

The patient is presenting with symptoms of severe dehydration and shock, as evidenced by lethargy, tachycardia (180/min), tachypnea (48/min), hypotension (68/54 mm Hg), and poor capillary refill (4 seconds). The most appropriate next step in management would be to address the patient's fluid status and circulatory stability. Given the patient's presentation, the best initial approach would be to administer an intravenous bolus of 0.9% saline to rapidly expand the patient's intravascular volume and improve blood pressure. This is because the patient is showing signs of hypovolemic shock, and the first step in managing this condition is to restore circulating volume with isotonic fluids. Dopamine may be considered later if the patient's blood pressure remains low despite adequate fluid resuscitation, but it is not the initial step in management. Therefore, the correct answer is E) Intravenous bolus of 0.9% saline 2.

From the Research

Assessment of the Patient's Condition

The patient is a 10-month-old boy presenting with profuse watery diarrhea, frequent vomiting, and poor feeding, which have led to severe dehydration. His vital signs indicate tachycardia (180/min), tachypnea (48/min), and hypotension (68/54 mm Hg), along with mild abdominal distention and a prolonged capillary refill time (4 seconds), suggesting severe dehydration and potential shock.

Appropriate Management

Given the patient's severe dehydration and signs of shock (hypotension, tachycardia, and prolonged capillary refill), the most appropriate next step in management would involve rapid restoration of circulating volume. The options provided can be evaluated as follows:

• Oral rehydration (A): While oral rehydration is the preferred treatment for mild to moderate dehydration 3, the patient's refusal to feed and severe dehydration state make this option less suitable.
• Continuous infusion of fluids at maintenance doses (B): This approach may not be adequate for a patient in shock, as it does not address the immediate need for volume expansion.
• Intravenous administration of dopamine (C): Dopamine is used in certain cases of shock, but the first step should always be to ensure adequate fluid resuscitation.
• Intravenous administration of fresh frozen plasma (D): This is not typically used for initial management of dehydration or shock unless there is a concern for coagulopathy.
• Intravenous bolus of 0.9% saline (E): This option is the most appropriate initial step for managing severe dehydration and shock, as it rapidly expands the intravascular volume and corrects hypotension 4. The use of 0.9% saline is recommended for initial resuscitation efforts in pediatric patients with severe dehydration and shock.

Key Considerations

• The patient's condition necessitates immediate intervention to restore circulating volume and correct shock.
• The choice of fluid for initial resuscitation is crucial, with 0.9% saline being preferred for its ability to rapidly expand intravascular volume without risking hyponatremia 4.
• Following initial stabilization, further management may involve continuous infusion of fluids, with the composition and rate guided by the patient's response and ongoing losses 5, 6.