Shock in children in resource-limited settings: Initial management

INTRODUCTION — The initial management of shock in children treated in resource-limited settings is provided here. The recognition of shock in children in resource-limited settings is discussed separately. (See "Shock in children in resource-limited settings: Recognition".)

TERMINOLOGY

Shock versus circulatory impairment — Shock is a life-threatening condition that occurs when the circulatory system fails to provide adequate oxygenation and perfusion to the body and, as a result, vital organs become hypoxic [1]. For resource-limited settings, The World Health Organization Emergency Triage, Assessment and Treatment Guidelines (WHO ETAT) have established a common definition for circulatory impairment and shock for low- and middle-income countries (LMICs) that uses the following physical findings [1]:

●Cold extremities

●Prolonged capillary refill >3 seconds

●Weak/fast pulse

One or two of these findings is consistent with circulatory impairment; all three findings are needed to diagnose shock. This phased definition acknowledges that the physiology of shock exists on a spectrum and is similar in principle to the definitions of compensated versus hypotensive shock used by the Pediatric Advanced Life Support Course [2].

Resource-limited settings — For the purposes of this topic, resource-limited settings describe regions where access to advanced pediatric critical care and trained critical care personnel are variable or not available, and the therapies essential to successful treatment of shock cannot be reliably performed including:

●Advanced airway management and respiratory support (eg, high-flow nasal cannula oxygen therapy, bilevel positive airway pressure (BiPAP), and mechanical ventilation)

●Central venous and arterial blood pressure monitoring

●Continuous infusions of inotropic medications

Low- and low middle-income countries (LICs and LMICs) — The World Bank classifies countries for the purposes of economic and financial development services based upon national income per person or gross national income per capita as [3]:

●Low-income

●Low-middle income

●High-middle income

●High-income

From the standpoint of health care capability, resource-limited settings with no available intensive care are most common in low-income countries (LICs) and low-middle-income countries (LMICs). Resource-limited health care may also exist in certain parts of high-middle income countries (HMICs) and high-income countries (HICs) because of maldistribution of health care capability relative to population. Nevertheless, access to resource-abundant health care settings still remains much greater for individuals living in HMICs or HICs compared with LICs or LMICs.

APPROACH TO INITIAL STABILIZATION — For children with shock in resource-limited settings, the priorities in care are the same as in resource-abundant settings. Interventions should target improvement in tissue perfusion, as demonstrated by (see 'Monitoring' below):

●Central and peripheral pulses

●Capillary refill time

●Mental status

●Blood pressure

●Urine output

Many resource-limited settings do not have critical care capability with respect to monitoring, mechanical ventilation, and administration of vasopressors [1]. In these facilities, fluid administration should be tailored to the specific cause of shock, the child's clinical features (table 1 and table 2), and whether the child has severe anemia, severe malnutrition, or malaria. (See 'Fluid resuscitation' below.)

Institution-specific guidelines — Clinical practice guidelines for the treatment of pediatric shock at an institution-specific level can decrease variation in care patterns and minimize the harms of alternative care pathways. Given the variation in resources available as well as regional differences in the epidemiology of common comorbid conditions, establishing institutional clinical practice guidelines for the assessment and treatment of pediatric shock can improve the care of children with shock in resource-limited settings. (See 'Guidelines' below.)

Physicians from high-income countries providing health care in resource-limited settings in low- or low-middle income countries must become familiar with local guidelines for the treatment of shock. Awareness of available resources is also critical to a practitioner's approach to shock in resource-limited settings. Research has demonstrated the importance of developing guidelines and best practices for the care of children who are cared for in resource-limited settings from evidence obtained locally [4-8].

Airway and breathing — Children with signs of shock should receive supplemental oxygen to maximize oxygen delivery and avoid hypoxemia (table 3). In clinical settings where patients cannot be intubated and mechanically ventilated, clinicians should provide supplemental oxygen when available to maintain an oxygen saturation of 94 to 98 percent.

For infants and children with respiratory distress, the clinician should perform suctioning and basic airway maneuvers to reestablish or maintain the airway as needed. Once the airway is open and maintained, patients with inadequate breathing require assisted ventilation using bag-mask ventilation. For patients with clinical suspicion of a highly contagious infectious disease, a HEPA filter should be used with bag-mask ventilation whenever available. (See "Basic airway management in children".)

Circulation

Establish venous access — Peripheral venous access is adequate for initial resuscitation of children in shock and should be obtained rapidly. When resources allow, the clinician should place two peripheral intravenous (IV) lines. The most common type of peripheral venous access used in children is the over-the-needle cannula. (See "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies", section on 'Peripheral access'.)

If peripheral venous access cannot be obtained in a timely fashion, then the clinician should place an intraosseous cannula. (See "Intraosseous infusion".)

Obtain laboratory studies — Whenever available, the following laboratory studies in resource-limited settings in low- and low-middle income countries are helpful in the categorization and management of shock:

●Rapid blood glucose

●Malaria Rapid Diagnostic Testing and/or thick and thin blood smear

●Hemoglobin and/or hematocrit

●Lactate

●Blood culture

●Rapid HIV testing in high prevalence areas

●Urine dipstick/microscopy and culture

Obtaining blood for laboratory studies should not delay securing peripheral venous access for fluid resuscitation.

Recommendations for laboratory assessment of shock in resource-abundant settings are provided separately. (See "Initial evaluation of shock in children", section on 'Ancillary studies'.)

Treat hypoglycemia — Children in resource-limited settings with shock are at significant risk for hypoglycemia; rapid blood glucose should be measured as intravenous (IV) access is obtained. If present, hypoglycemia should be corrected by rapid IV infusion of dextrose, as described in the rapid overview (table 4). After initial hypoglycemia is reversed, the clinician should continue to monitor blood glucose. Maintaining normoglycemia is desirable (eg, between 140 and 180 mg/dL [7.8 and 10 mmol/L]). Once normoglycemic, young children should receive continuous maintenance infusion of dextrose 5 to 10 percent in addition to resuscitation fluids as a reasonable option to prevent the occurrence of hypoglycemia [9]. (See "Glycemic control in critically ill adult and pediatric patients".)

Hypoglycemia may also be an indicator of adrenal insufficiency in predisposed children and those with refractory septic shock. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Patients at risk for adrenal insufficiency' and "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Patients with catecholamine-resistant shock'.)

Fluid resuscitation — In resource-limited settings, fluid resuscitation must be tailored to the type of shock identified by clinical findings and is often modified due to comorbidities such as malnutrition, severe anemia, and malaria. The approach below is largely consistent with the 2016 emergency triage assessment and treatment guidelines developed by the World Health Organization (WHO).

Monitoring — Restoration of tissue perfusion and reversal of shock is identified by the following therapeutic endpoints (goals in parentheses):

●Heart rate (within the normal range for age (table 5))

●Respiratory rate

●Quality of central and peripheral pulses (strong, distal pulses equal to central pulses)

●Skin perfusion (capillary refill <2 seconds with warm skin)

●Mental status (awake and alert)

●Urine output (≥1 mL/kg per hour, once effective circulating volume is restored)

●Blood pressure (above the WHO definitions for hypotension (table 2))

●Serum lactate (<2 mmol/L, when available)

Most health facilities in low- and middle-income countries use the WHO thresholds for hypotension given above. Pediatric Advanced Life Support provides the 5^th percentile for systolic blood pressure as an alternative target and estimated as follows:

●Term neonates (0 to 28 days): >60 mmHg

●Infants (1 to 12 months): >70 mmHg

●Children (1 to 10 years): >70 mmHg + (child's age in years x 2)

●Children >10 years: >90 mmHg

Because excess fluid causes an increased risk of death in children with shock in resource-limited settings, monitoring for fluid overload should occur frequently during rapid fluid administration (eg, every 15 minutes) and then no less than every hour until the patient is no longer in shock.

Signs of fluid overload include:

●Tachypnea or increased work of breathing with crackles on lung examination

●Hypoxemia (if pulse oximetry available)

●In infants, periorbital puffiness or edema

●Cardiac gallop

●Hepatomegaly

●Jugular venous distension

●Lethargy or coma

●Enlarged heart on imaging (if available)

Once shock is reversed and tissue perfusion is restored, the patient continues to require regular assessment (eg, every 2 to 4 hours during IV fluid therapy) during the first 24 hours.

Type of fluid — For children with shock in resource-limited settings and without severe anemia, we suggest lactated Ringer's (LR) or other balanced crystalloid solutions (table 6), rather than colloid because clinical outcomes are similar and LR is more widely available and less expensive. For these patients, we also suggest LR rather than normal saline. Normal saline is an option if LR or another balanced crystalloid solution is not available.

Reanalysis of patient level data from a large trial in east Africa (FEAST trial) confirms findings in other settings that rapid infusion of normal saline results in a hyperchloremic metabolic acidosis [10]. This metabolic acidosis has been associated inconsistently with adverse clinical outcomes such as acute kidney injury in pediatric patients with septic shock. The magnitude of this effect appears to be small, as discussed separately. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Fluid resuscitation'.)

Children with severe anemia and shock require blood as described below. (See 'Nonhemorrhagic shock and severe anemia (blood transfusion)' below.)

Volume and rate — In children with shock in resource-limited settings, the volume and rate of fluid administration varies by the type of shock and may also be modified due to comorbidities such as malnutrition, severe anemia, and malaria, as described below.

TREATMENT BY TYPE OF SHOCK

Severe sepsis and septic shock — In resource-limited settings, the clinician should modify treatment of severe sepsis and septic shock compared with resource-abundant settings because of the risk of harm that can occur when administering high fluid volumes at rapid rates during fluid repletion. (See 'Risk of harm' below.)

Children who have a suspected infection (eg, febrile) with circulatory impairment are similar to children with severe sepsis with compensated shock in resource-abundant settings [1,11,12]. Children with suspected infection and shock by the WHO definition according to clinical findings (table 1) or systolic blood pressure (table 2) are similar to children with hypotensive septic shock in resource-abundant settings.

Fluid therapy — Fluid management for children with a severe febrile illness depends upon the patient's circulatory status according to the WHO definition of circulatory impairment and shock, as shown in the table (table 1). While measurement of blood pressure can be helpful in defining compensated or hypotensive shock (table 2), the reliability of this measurement can be difficult in resource-limited settings and is not required for initial classification and treatment of severe sepsis and septic shock (algorithm 1):

●Septic shock (hypotensive shock) – For patients in resource-limited settings with hypotensive septic shock and without severe anemia or severe acute malnutrition (table 7), we suggest careful fluid administration with close monitoring for any signs of fluid overload (see 'Risk of harm' below). Initial fluid therapy typically consists of 10 to 20 mL/kg of lactated Ringer's (LR) over 30 to 60 minutes; normal saline is an acceptable alternative if LR or another balanced crystalloid solution is not available. For children who remain in shock, give an additional 10 mL/kg of LR over 30 minutes [1].

The approach in the first hour should be modified for those with severe anemia or severe malnutrition as follows:

•Severe anemia – Patients with septic shock accompanied by severe anemia should receive blood transfusion, as described separately. (See 'Nonhemorrhagic shock and severe anemia (blood transfusion)' below.)

•Severe malnutrition – Patients with septic shock and severe acute malnutrition (table 7) typically receive fluid resuscitation that is at the lower end of the recommended volume and rate described above (eg, 10 to 15 mL/kg of BCS over 60 minutes).

Because excess fluid causes an increased risk of death in children with shock in resource-limited settings, monitoring for fluid overload should occur frequently during rapid fluid administration (eg, every 5 to 15 minutes). (See 'Monitoring' above.)

Fluid resuscitation should be discontinued if the patient develops clinical signs of fluid overload [11,12].

●Severe sepsis (severe febrile illness with compensated shock) – For children in resource-limited settings with severe sepsis (fever and one or two signs of circulatory impairment (table 1) but without hypotensive shock according to WHO criteria), we recommend maintenance fluid administration rather than rapid fluid resuscitation. Fluids typically consist of lactated Ringer's with 5 percent dextrose (D5LR) or, in infants, lactated Ringer's with 10 percent dextrose (D10LR). In addition to maintenance fluids, replace estimated and ongoing losses (eg, diarrhea, vomiting, or poor oral intake). (See "Maintenance intravenous fluid therapy in children" and "Approach to the child with acute diarrhea in resource-limited settings", section on 'Fluid and electrolytes'.)

These patients should also receive antipyretics (eg, acetaminophen) for fever control to decrease insensible fluid losses.

Patients with severe anemia (hemoglobin <6 g/dL [plasma cell volume/hematocrit <18 percent] or, in malaria-endemic settings <5g/dL [plasma cell volume or hematocrit <15 percent) require blood, as described separately. (See 'Nonhemorrhagic shock and severe anemia (blood transfusion)' below.)

In children with severe sepsis but without hypovolemia (ie, significant fluid or blood losses in addition to sepsis), rapid infusions of isotonic fluids or colloid increases mortality. (See 'Risk of harm' below.)

Risk of harm — In children with severe sepsis and septic shock who are managed in resource-limited settings with unavailable pediatric intensive care resources, evidence indicates that rapid infusions of fluids and excessive fluid volumes increase mortality [1,4,7,13-15]. This risk of harm has been best demonstrated in febrile children with severe sepsis who meet the WHO definition of circulatory impairment (table 1). For example, in the Fluid Expansion as Supportive Therapy (FEAST) study, a randomized trial of over 3,100 children (60 days to 12 years old) with severe sepsis who were treated in clinical centers located in Uganda, Kenya, and Tanzania, children were randomly assigned to receive rapid fluid infusion ("boluses" of either normal saline or 5 percent human albumen over one hour) versus no bolus; the vast majority of these children had severe sepsis [7]. All patients received maintenance fluids; patients with a hemoglobin <5 g/dL received a whole blood transfusion of 20 mL/kg over four hours. Individuals assigned to normal saline or 5 percent albumen bolus had higher mortality compared with the no bolus group (10.6 and 10.5 versus 7.3 percent, respectively; relative risk (RR) 1.44, 95% CI 1.09 to 1.90).

In a pre-specified subgroup analysis, increased mortality also occurred in patients who received fluid bolus regardless of malaria status (57 percent of patients), severe anemia (32 percent of patients), hypotension, or malnutrition. More children in the no-fluid bolus group received blood transfusions in the first hour compared with the fluid bolus groups (22 versus 2 to 4 percent) [7]. However, the overall amount of blood delivered after eight hours was not significantly different among the groups. Of note, none of the patients in the FEAST trial had hypovolemic dehydration or trauma as the primary cause of their illness. In addition, patients with severe hypotension by the WHO definition (table 1) all received 40 mL/kg of normal saline or albumin.

On re-analysis of the FEAST data using all international definitions of pediatric shock, mortality was still increased in patients with severe sepsis who received bolus fluid therapy [4]. The analysis also evaluated mortality among children who met the more stringent WHO definition of shock (all three clinical signs of circulatory impairment). However, only 65 children met these strict criteria, a sample size too small to provide conclusions regarding mortality due to fluid therapy in this group. Furthermore, some experienced clinicians in resource-limited settings may still give an initial, cautious fluid bolus of 10 mL/kg over 30-60 minutes to children with severe sepsis and closely monitor the clinical response. This approach applies if there is a clinical suspicion of moderate dehydration, and the child is unable to drink or drinks poorly.

Additional analysis of the FEAST cohort identified cardiovascular collapse as the primary contributor to excess deaths among children receiving fluid boluses rather than fluid overload [13,16]. The excessive impact on mortality due to fluid bolus extended as long as four days after initial treatment [14].

Furthermore, in a small trial performed in India, children with septic shock who were largely underweight for their age were more likely to be intubated in the first 24 hours if they were randomized to rapid fluid administration ("boluses") over 5 to 10 versus 15 to 20 minutes. However, resolution of shock and mortality were the same in both groups, and a definitive conclusion regarding the role of rapid fluid resuscitation in causing a greater need for mechanical ventilation was limited by the small sample size, lack of central randomization, and lack of blinding [17,18]. Still, in light of evidence regarding potential harm from rapid fluid resuscitation in patients with severe febrile illness in resource-limited settings, we advise caution with both volume and rate of fluid administration whenever capacity for mechanical ventilation is limited, and life-threatening shock is not present.

There is no evidence that these findings can be generalized to resource-abundant settings where the baseline characteristics of the patients are significantly different and intensive monitoring, mechanical ventilation, and vasopressor support are routinely available. However, limited observational evidence suggests that even in clinical facilities with these capabilities, early fluid resuscitation should be carefully guided by the response to bolus therapy as well as the degree and type of shock present. (See "Shock in children in resource-abundant settings: Initial management", section on 'Clinical and physiologic targets' and 'Severe sepsis and septic shock' above and "Shock in children in resource-abundant settings: Initial management", section on 'Volume and rate'.)

Empiric antimicrobial therapy — As in resource-abundant settings, children with severe febrile illness or septic shock should receive prompt administration of broad-spectrum antimicrobial agents within an hour of presentation (algorithm 2). In malaria-endemic regions, empiric antimicrobial therapy should also include anti-malarial agents (table 8) [19]. (See "Treatment of severe malaria".)

Empiric antimicrobial therapy should also be informed by other endemic infections found in the region and in accordance with hospital and national guidelines. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Empiric regimens' and "Sepsis in children: Definitions, epidemiology, clinical manifestations, and diagnosis", section on 'Epidemiology'.)

Rapid initiation of antimicrobial agents in septic shock is associated with decreased mortality and lower multisystem organ dysfunction, as discussed in detail separately. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Timing'.)

Whenever possible, blood cultures or other body fluid analysis should be obtained prior to initiation of antibiotics. However, in most resource-limited settings, accurate blood cultures are not available, and in these facilities, initiation of broad-spectrum antibiotics should not be delayed.

Fluid refractory shock — Children with fluid refractory septic shock require vasoactive agents. In resource-limited settings, epinephrine is typically the most available drug and is appropriate for treatment of septic, cardiogenic, and anaphylactic shock. It can be safely administered through a peripheral IV access site or intraosseous (IO) but requires an IV pump and frequent reassessment for of the IV for patency. For peripheral administration of epinephrine, the concentration should be no greater than 0.1 mg/mL. The starting dose is 0.02 to 0.05 mcg/kg per minute. The author's approach is to start with 0.02 mcg/kg per minute. The infusion is then titrated, as needed, up to 1 mcg/kg per minute. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Central versus peripheral venous access'.)

If epinephrine is not available, norepinephrine has similar efficacy. Dopamine is another option but may not be as efficacious as epinephrine. (See "Septic shock in children in resource-abundant settings: Ongoing management after resuscitation", section on 'Vasoactive drug therapy'.)

Hypovolemic shock — Hypovolemic shock is the most common type of shock in resource-limited settings. Severe dehydration due to infectious diarrhea and hemorrhagic shock due to trauma are leading causes. (See "Shock in children in resource-limited settings: Recognition", section on 'Epidemiology'.)

As in resource-abundant settings, third space losses (capillary leakage) in children with abdominal surgical emergencies (eg, malrotation with small bowel obstruction, intussusception, or perforated appendicitis), increased insensible losses in children with burns or fever, inadequate fluid intake (especially in young infants and children) or osmotic diuresis are other potential sources of intravascular volume loss.

It is important to differentiate between hypovolemic shock and severe sepsis in children with fever and circulatory impairment because rapid infusion of fluids to children with severe sepsis can be harmful (table 9). (See "Shock in children in resource-limited settings: Recognition", section on 'Clinical classification of shock'.)

Nonhemorrhagic hypovolemic shock — Severe dehydration and hypovolemic shock lie upon a continuum. Hypovolemic shock is defined by WHO as evidence of fluid loss with all three clinical signs of circulatory impairment (table 1) and/or hypotension (table 2). Children with severe anemia (eg, hemoglobin <6 g/dL [PCV/HCT <18 percent] or, in malaria endemic regions, ≤5 g/dL [PCV/HCT <15 percent]) require blood instead of crystalloid. (See 'Nonhemorrhagic shock and severe anemia (blood transfusion)' below.)

According to the WHO guidelines, children with hypovolemic shock and without severe anemia should receive fluid resuscitation with lactated Ringer's (LR) or other balanced crystalloid solution (algorithm 3) [1]:

●Give 10 to 20 mL/kg of LR over 30 to 60 minutes (isotonic normal saline is acceptable if LR or other balance crystalloid fluid is not available). For children with severe acute malnutrition, give 10 to 15 mL/kg of LR over 60 minutes.

●Evaluate for the source of fluid loss

●Carefully monitor vital signs and for signs of fluid overload (eg, every 5 to 15 minutes during rapid infusion of fluids) (see 'Monitoring' above)

Further fluid therapy is determined by the clinical response:

●Clinical improvement – Patients with clinical improvement should receive additional fluid therapy according to the WHO plan C for severe dehydration (algorithm 4). (See 'Severe dehydration (The WHO plan C)' below.)

●Persistent shock – Children with persistence of hypotension or shock and no signs of fluid overload after the initial resuscitation should receive an additional 10 mL/kg of LR over 30 minutes. If shock still persists, the WHO guidelines suggest transfusion (10 mL/kg of whole blood or 5 mL/kg packed red blood cells) given over three hours.

Once the child has improved from shock, the WHO suggests giving fluids per guidelines for severe dehydration (plan C) [1]. (See 'Severe dehydration (The WHO plan C)' below.)

●Signs of fluid overload – Fluid infusion should be stopped immediately if the child develops any signs of fluid overload, cardiac failure, or neurologic deterioration and reassessed to see if they remain in hypovolemic shock. If shock has resolved, then additional fluids may be given under close monitoring as IV D5LR, or D10LR in infants at maintenance with replacement of any ongoing fluid losses. If the child can drink adequately, then oral rehydration solution may be used instead of IV fluids. (See "Maintenance intravenous fluid therapy in children" and "Approach to the child with acute diarrhea in resource-limited settings".)

Patients with signs of fluid overload and persistent shock should be reevaluated for signs of cardiogenic and/or septic shock. If either type of shock is present, give peripheral IV or IO continuous infusion of epinephrine (concentration 0.1 mg/mL) starting at 0.02 to 0.05 mcg/kg per minute with titration up to 1 mcg/kg per minute as needed using an IV pump. (See 'Fluid refractory shock' above.)

Intravenous fluid therapy in children with severe malnutrition and signs of shock is controversial. Traditionally, guidelines have emphasized that IV fluid resuscitation should be given over a longer duration and at lower volumes in these patients to avoid causing fluid overload and increased mortality [20-22]. However, evidence from two observational studies and two small randomized trials have not shown higher rates of heart failure in children with severe acute malnutrition who receive higher volumes and rates of IV fluids and suggest that the WHO guidelines may be too restrictive [23-25]. Some experts suggest that severely malnourished children with shock receive fluid resuscitation according to the WHO guidelines for children with shock and no signs of malnutrition.

Severe dehydration (The WHO plan C) — The WHO defines severe dehydration as two or more of the following signs (table 10):

●Lethargic or unconscious

●Sunken eyes

●Decreased turgor (skin pinch goes back very slowly)

●Not able to drink or drinking poorly

According to the WHO, severe dehydration is an emergency sign that requires treatment with IV fluids even though the patient does not meet the WHO clinical or systolic blood pressure criteria for shock [1]. The WHO plan C provides recommendations for fluid repletion of severe dehydration for these patients that vary by the degree of anemia and malnutrition:

●No severe anemia or malnutrition – For fluid resuscitation of children in resource-limited settings who do not have severe anemia and severe acute malnutrition (table 7), we suggest IV fluid administration according to the WHO plan C guidelines (algorithm 4) [1,26]. The WHO plan C also provides guidance on fluid management and transfer to a higher level of care for children with severe dehydration in settings where IV or IO access is not available (algorithm 5).

During initial IV fluid resuscitation with balanced crystalloid solution or normal saline, the clinician must monitor blood glucose and provide maintenance dextrose infusion (either 5 or 10 percent dextrose depending on patient age) to avoid hypoglycemia. Patients who develop seizures during fluid repletion and for whom rapid glucose testing is unavailable should receive a rapid infusion of intravenous dextrose followed by dextrose containing IV fluids, as described in the rapid overview (table 4).

Emerging evidence suggests that a slower, constant rate of fluid administration of Ringer's lactate 100 mL/kg over 8 hours for all ages may be used for children with severe dehydration but without severe anemia and/or malnutrition. This regimen may have similar efficacy as the WHO plan C guideline and is easier to implement [27,28]. For example, in a randomized trial of 120 children with suspected severe dehydration in resource-limited settings in Uganda and Kenya, compared with WHO plan C, children who received slower fluid administration (Ringer's lactate 100 mL/kg over 8 hours) had similar mortality (3.3 percent in both groups) and shorter but not significantly different time to acceptance of oral fluids (7 versus 12 hours). Median time to correction of dehydration, urination, and discharge were also similar.

●With severe acute malnutrition – In low and low-middle income countries, malnutrition is a common comorbid condition found in children with diarrhea and dehydration. The WHO signs of dehydration may be unreliable in patients with malnutrition. Thus, in children with severe acute malnutrition (table 7), the diagnosis of severe dehydration also requires a history of fluid loss or an acute change in general appearance, eye appearance, oral intake, and skin pinch. For children who meet these additional criteria, the WHO plan C guidance advises against IV fluids. The approach to oral rehydration for these patients is provided separately. (See "Management of complicated severe acute malnutrition in children in resource-limited settings", section on 'Dehydration'.)

●Circulatory impairment without severe dehydration – Children with circulatory impairment without severe dehydration have evidence of fluid loss, have one or two signs of circulatory impairment, but do not meet criteria for severe dehydration. The WHO management for these patients consists of:

•Using oral rehydration solution, give maintenance fluids as appropriate for age and weight with replacement of estimated fluid deficit and ongoing losses or, if not tolerated, use IV D5LR. Calculation of maintenance fluid and replacement of estimated losses are described separately. (See "Maintenance intravenous fluid therapy in children" and "Treatment of hypovolemia (dehydration) in children in resource-abundant settings", section on 'Secondary fluid repletion phase'.)

•Evaluate for the cause of fluid loss and institute specific therapy, as needed.

Hemorrhagic hypovolemic shock — Hemorrhagic shock after trauma is another important cause of hypovolemic shock in children in resource limited settings. Hemorrhagic hypovolemic shock requires direct compression of external bleeding, infusion of balanced crystalloid solutions and, as indicated and available, blood transfusion. In pediatric trauma patients, clinical findings of shock rather than hemoglobin levels should be used to guide blood transfusion therapy. (See "Trauma management: Approach to the unstable child", section on 'Blood products'.)

Dengue shock syndrome — The WHO has developed fluid resuscitation guidelines for children with dengue shock syndrome (algorithm 6 and algorithm 7). These patients also may require blood or colloid to offset intravascular volume depletion caused by capillary leak (algorithm 8). The treatment of shock in patients with dengue virus infection is discussed in detail separately. (See "Dengue virus infection: Prevention and treatment", section on 'Treatment approach'.)

Cardiogenic and obstructive shock — While the ability to reverse cardiogenic and obstructive shock may be limited, principles of treatment do not differ between resource-limited and resource-abundant settings for these two causes of shock. (See "Shock in children in resource-abundant settings: Initial management", section on 'Initial stabilization'.)

When used by a properly trained and experienced provider, point-of-care ultrasound (POCUS) can assist with rapid detection of myocardial dysfunction, cardiac tamponade [29], or pneumothorax. (See "Bedside pleural ultrasonography: Equipment, technique, and the identification of pleural effusion and pneumothorax", section on 'Evaluation for pneumothorax'.)

Myocardial dysfunction appears to significantly contribute to mortality in children with severe sepsis, and interventions to improve cardiac function may be helpful in these patients. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Patients with fluid-refractory shock'.)

Nonhemorrhagic shock and severe anemia (blood transfusion) — Children in resource-limited settings with nonhemorrhagic shock and severe anemia (eg, hemoglobin <6 g/dL [PCV/HCT <18 percent] or, in malaria-endemic regions, ≤5 g/dL [PCV/HCT <15 percent]) require blood transfusion as follows:

●Afebrile patient (hypovolemic shock) – Typical volume and rate is 30 mL/kg whole blood or 15 mL/kg settled or packed red blood cells over 4 hours. If blood is not available within 30 minutes, then we suggest 10 mL/kg of BCS over 60 minutes rather than higher fluid boluses or maintenance fluids alone until blood is available.

●Febrile patient (severe sepsis or septic shock) – Typical volume and rate is 20 mL/kg whole blood or 10 mL/kg settled or packed red blood cells over 4 hours. If blood is not available within 30 minutes, then, until it becomes available, fluid management is given as follows:

•Severe sepsis – For children with severe sepsis, we suggest maintenance fluids (eg, lactated Ringer's with 5 percent dextrose [D5LR]) and replacement of ongoing losses from diarrhea, vomiting, or poor oral intake.

•Septic shock – For patients with septic shock, we suggest LR 10 mL/kg over 60 minutes followed by D5LR at maintenance and replacement of ongoing losses.

There is lack of consensus for hemoglobin (Hb) levels at which blood transfusion is indicated. For some experts, severe anemia is defined as a Hb level of <4 g/dL (clinically stable) or <6 g/dL (unstable patients with clinical signs of respiratory distress, altered mental status, or hemoglobinuria). Per the WHO guidance for severe malaria, severe anemia is defined as a Hb ≤5 g/dL in high malaria transmission regions. Application of these overlapping but differing recommendations to specific patients must weigh the availability of blood and the specific patient's clinical condition. (See "Treatment of severe malaria", section on 'Transfusion'.)

The evidence supporting the above transfusion volumes in children with shock treated in resource-limited settings is derived from a trial of almost 3200 children (2 months to 12 years) who received blood transfusion for severe anemia (approximately one-third with shock). The volume received was randomly assigned as 30 mL/kg whole blood or 15 mL/kg packed or settled red blood cells versus 20 mL/kg whole blood or 10 mL/kg packed or settled red blood cells [30]. Primary analysis demonstrated similar mortality by 28 days for higher versus lower transfusion volume (3.4 versus 4.5 percent). However, in prespecified subgroup analyses, children who were afebrile and assigned to the higher volume transfusion had lower 28-day mortality compared with lower volume transfusion (2 versus 6 percent, respectively). Conversely, children who were febrile and assigned to lower volume transfusion had a lower 28-day mortality compared with those assigned to higher volume transfusion (2 versus 5 percent). In this and other studies, including a reanalysis of blood administration in the FEAST trial, mortality was not impacted by the presence of malaria, shock, or severe acute malnutrition [31]

Ongoing fluid administration — After initial fluid resuscitation, the child should be transitioned to oral feeding as soon as possible. During this transition, the clinical team should keep the IV cannula in place in case more IV fluids are needed. Our approach is to provide half of the child's fluid requirements by IV infusion with dextrose-containing fluid (eg, LR with D5W) and half by intermittent feedings while monitoring for deterioration (eg, vomiting or increased diarrhea). During this transition, gastrointestinal losses should be replaced, as described separately. If tolerated, we then advance to full oral feedings. (See "Maintenance intravenous fluid therapy in children".)

Imaging — In resource-limited settings, plain radiographs and point of care ultrasound (POCUS) are the imaging modalities that are most frequently available:

●Plain radiographs – An anterior-posterior and lateral chest radiograph is indicated for children with shock who present with tachypnea, rales, wheezing, hypoxemia, or who do not respond to initial treatment. Key findings include:

•Bronchopneumonia

•Pulmonary edema with increased heart size suggesting fluid overload, cardiomyopathy (myocarditis), or congenital heart disease

•Small heart size suggesting hypovolemia

●Point of care ultrasonography (POCUS) — When available and performed by trained and experienced clinicians, POCUS has emerged as a clinical tool in high-income countries (HICs) for the evaluation and management of children presenting in shock and shows promise for resource-limited settings [32-36]. For shock in particular, POCUS can assist with the rapid detection of cardiac tamponade [29] or pneumothorax while also giving a global overview of cardiac function and fluid status [37].

Known or suspected adrenal insufficiency — Patients at risk for absolute adrenal insufficiency due to purpura fulminans, recent or chronic treatment with corticosteroids, hypothalamic or pituitary abnormalities, or other causes of congenital or acquired adrenal insufficiency should be treated with stress-dose corticosteroids early during resuscitation. The recommended regimen is IV hydrocortisone 50 to 100 mg/m²/day or approximately 2 to 4 mg/kg/day, intermittent or continuous infusion, maximum dose 200 mg/day. Prednisolone or prednisone are second-line choices if hydrocortisone is not available. Do not use dexamethasone. (See "Treatment of adrenal insufficiency in children".)

Children with shock and receiving stress-dose corticosteroids warrant stress ulcer prophylaxis. (See "Stress ulcers in the intensive care unit: Diagnosis, management, and prevention".)

TRANSFER TO DEFINITIVE CARE — If available and if the risks of transfer do not exceed the benefit, children in resource-limited settings should undergo transfer to facilities with higher level of pediatric-specific critical care after resuscitation. Pediatric intensive care units (PICUs) are becoming more available in low income and low-middle income countries. Where PICU resources are available, the space is usually limited. Thus, it is important to weigh all the risks and benefits of every admission to ensure optimal use of intensive care capability. Whenever possible, it is important to establish admission guidelines. Where these are absent, unclear, or are not relevant to a specific patient a rapid multidisciplinary discussion among PICU personnel helps to optimize resource allocation.

Although mortality rates for children with shock remain higher than in high-middle and high income countries, these PICUs provide a much higher level of care than what is typically available elsewhere including personnel (physicians, nurses, and other personnel) trained in pediatric critical care, ability to perform mechanical ventilation, continuous vasoactive infusions, intensive monitoring, and point-of-care testing [38].

GUIDELINES — While WHO guidelines provide a framework for practice in resource-limited settings, they may not adequately address variability in regional or local epidemiology of shock, resources, and capability [39-41]. Furthermore, WHO guidelines frequently take a significant amount of time to incorporate the latest evidence. More specific national, regional, and local guidelines for the diagnosis and treatment of pediatric shock may be available. Clinicians must be familiar with these guidelines wherever they may be practicing.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sepsis in children and adults" and "Society guideline links: Shock in children".)

SUMMARY AND RECOMMENDATIONS

●Topic scope – This topic is intended for the recognition and initial management of children with shock in resource-limited settings (RLS), primarily located in low- and low-middle income countries where the availability of advanced pediatric intensive care is variable or not available, and the advanced therapies cannot be reliably performed. (See 'Resource-limited settings' above and 'Low- and low middle-income countries (LICs and LMICs)' above.)

●Approach – For children with shock in resource-limited settings, the priorities in care are the same as in resource-abundant settings. Interventions should target improvement in tissue perfusion with monitoring of central and peripheral pulses, capillary refill time, mental status, blood pressure, and urine output:

•Airway and breathing – Give supplemental oxygen to maintain an oxygen saturation of 94 to 98 percent (table 3). Provide basic airway management including suctioning, positioning of the airway (figure 1 and figure 2), and bag-mask ventilation (picture 1 and picture 2) as needed. (See 'Airway and breathing' above and "Basic airway management in children".)

•Circulation – Establish intravenous access and obtain the following studies (see 'Circulation' above):

-Rapid blood glucose; treat hypoglycemia (table 4)

-Malaria Rapid Diagnostic Testing and/or thick and thin blood smear

-Hemoglobin and/or hematocrit

-Lactate

-Blood culture

-Rapid HIV testing in high prevalence areas

-Urine dipstick/microscopy and culture

Recommendations for laboratory assessment by type of shock in resource-abundant settings are provided separately. (See "Initial evaluation of shock in children", section on 'Ancillary studies'.)

●Shock management – In resource-limited settings, the clinician must tailor fluid resuscitation to the type of shock identified by clinical findings and modify the type and volume of fluid, as needed, in children with severe anemia or malnutrition.

•Type of fluid – For children with nonhemorrhagic shock and without severe anemia, we suggest lactated Ringer's (LR) or other balanced crystalloid solutions (table 6) rather than normal saline (NS) or colloid (Grade 2C). NS is an option if LR is not available. (See 'Type of fluid' above.)

•Severe sepsis (severe febrile illness with compensated shock) or septic shock – We agree with the approach endorsed by the WHO for fluid therapy for severe sepsis or septic shock as described in the algorithm (algorithm 1) (see 'Severe sepsis and septic shock' above):

-Septic shock – For patients with severe hypotensive septic shock based on either clinical findings (table 1) or the WHO blood pressure thresholds (table 2) and without severe anemia, we suggest rapid fluid infusion (Grade 2C). The initial IV fluids typically consist of LR 10 to 20 mL/kg over 30 to 60 minutes; NS is an acceptable alternative if LR is not available. Children with severe acute malnutrition (table 7) typically receive LR 10 to 15 mL/kg over 60 minutes. For children who remain in shock, give an additional 10 mL/kg of LR over 30 minutes. The clinician should have a heightened awareness for signs of fluid overload and discontinue fluid administration if the patient develops these signs.

Children with septic shock and severe anemia (eg, hemoglobin <6 g/dL [PCV/HCT <18 percent] or, in malaria-endemic regions, ≤5 g/dL [PCV/HCT <15 percent]) require blood transfusion. In these patients, transfusion volume and rate consist of 20 mL/kg whole blood or 10 mL/kg settled or packed red blood cells (pRBCs) over 4 hours. (See 'Nonhemorrhagic shock and severe anemia (blood transfusion)' above.)

If blood will not be available within 30 minutes, then we suggest 10 mL/kg LR over 60 minutes followed by maintenance fluids (such as LR with 5 percent dextrose) and replacement of estimated fluid losses until blood is available rather than no rapid infusion of fluids (Grade 2C). (See "Maintenance intravenous fluid therapy in children", section on 'Prescribing maintenance intravenous fluid therapy'.)

-Severe sepsis – For children with severe sepsis (fever and one or two signs of circulatory impairment according to WHO criteria (table 1)), we recommend maintenance fluids such as LR with 5 percent dextrose (D5LR) or, in infants LR with 10 percent dextrose (D10LR) rather than rapid infusions of fluids (Grade 1B). In these patients, rapid infusions of fluid increases mortality. (See 'Risk of harm' above.)

-Empiric antibiotics – Children with severe febrile illness or septic shock require prompt administration of broad-spectrum antimicrobial agents within an hour of presentation. In malaria-endemic regions, empiric antimicrobial therapy should also include anti-malarial agents (table 8). (See 'Empiric antimicrobial therapy' above.)

Empiric antimicrobial therapy should also be informed by other endemic infections found in the region and in accordance with hospital and national guidelines. (See "Septic shock in children in resource-abundant settings: Rapid recognition and initial resuscitation (first hour)", section on 'Empiric regimens' and "Sepsis in children: Definitions, epidemiology, clinical manifestations, and diagnosis", section on 'Epidemiology'.)

-Vasoactive agents – Children with fluid refractory septic shock require peripheral continuous IV administration of vasoactive agents such as epinephrine. (See 'Fluid refractory shock' above.)

•Hypovolemic shock (nonhemorrhagic) – Children with nonhemorrhagic hypovolemic shock by WHO criteria and without severe anemia require rapid fluid therapy and further treatment based upon response, as described in the algorithm (algorithm 3). (See 'Nonhemorrhagic hypovolemic shock' above.)

Children with hypovolemic shock and severe anemia require blood. Transfusion volume and rate consist of 30 mL/kg whole blood or 15 mL/kg settled or pRBCs over 4 hours. If blood is not available within 30 minutes, then, until blood is available, we suggest 10 mL/kg of LR over 60 minutes followed by IV maintenance fluids (eg, D5LR or, in infants, D10LR) rather than higher fluid boluses or maintenance fluids alone (Grade 2C). (See 'Nonhemorrhagic shock and severe anemia (blood transfusion)' above.)

Vasoactive agents should not be used for patients with hypovolemic shock unless they have received fluid resuscitation and demonstrate signs of fluid overload. (See 'Fluid refractory shock' above.)

•Severe dehydration without shock – For children in resource-limited settings with severe dehydration (table 10) but who do not meet the WHO criteria for shock, we suggest initial fluid resuscitation according to the WHO plan C (algorithm 4) rather than other regimens (Grade 2C). In settings where an IV cannot be placed, the WHO provides guidance for oral rehydration and timing of transfer to a higher level of care (when available) (algorithm 5). (See 'Severe dehydration (The WHO plan C)' above.)

During initial IV fluid resuscitation, the clinician must monitor blood glucose and provide maintenance dextrose infusion (either 5 or 10 percent dextrose depending on patient age) to avoid hypoglycemia. Patients who develop lethargy or seizures during fluid repletion and for whom rapid glucose testing is unavailable should receive dextrose, as described in the rapid overview (table 4).

•Hypovolemic shock (hemorrhagic) – Children with hemorrhagic shock caused by trauma and bleeding should receive a combination of LR, blood, and, whenever available, blood products depending upon the degree of shock; clinical findings of shock rather than hemoglobin levels should be used to guide blood transfusion therapy, as described separately. (See "Trauma management: Approach to the unstable child", section on 'Fluid resuscitation'.)

•Dengue shock syndrome – The WHO has developed fluid resuscitation guidelines for children with dengue shock syndrome (algorithm 6 and algorithm 7). These patients also may require blood or colloid to offset intravascular volume depletion caused by capillary leak (algorithm 8). The treatment of shock in patients with dengue virus infection is discussed in detail separately. (See "Dengue virus infection: Prevention and treatment", section on 'Treatment approach'.)

•Cardiogenic and obstructive shock – While the ability to reverse cardiogenic and obstructive shock may be limited, principles of treatment do not differ between resource-limited and resource-abundant settings for these two types of shock. (see "Shock in children in resource-abundant settings: Initial management", section on 'Initial stabilization')

●Ongoing fluid administration – After initial fluid therapy, the child should be transitioned to oral feeding as soon as possible. During this transition, the clinical team should keep the IV cannula in place until the child fully recovers. Our approach is described above. (See 'Ongoing fluid administration' above.)