Initial management of nonhemorrhagic hypovolemic shock in children without severe anemia managed in resource-limited settings

This algorithm summarizes the World Health Organization's recommended approach to initial treatment of children with nonhemorrhagic hypovolemic shock without severe anemia (either hemoglobin <6 g/dL or, per the WHO guidelines in regions with endemic malaria, <5 g/dL) and who are managed in facilities where access to advanced pediatric critical care and trained critical care personnel is variable or not available. These regions are most common in low and low-middle income countries. In resource-limited settings, 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. Refer to UpToDate content on evaluation and management of shock in children in resource-limited settings.

BP: blood pressure; D10LR: lactated Ringer's with 10% dextrose; D5LR: lactated Ringer's with 5% dextrose; IV: intravenous; LR: lactated Ringer's; ORT: oral rehydration solution; RBC: red blood cells; ReSoMal: rehydration solution for malnutrition.

* Closely monitor for signs of fluid overload (eg, every 5 to 15 minutes) during fluid therapy including:

Tachypnea and/or increased work of breathing with crackles on lung examination
Hypoxemia (if pulse oximetry is available)
In infants, periorbital puffiness or edema
Cardiac gallop
Hepatomegaly
Jugular venous distension in supine patient with head at 45 degrees relative to legs
Lethargy or coma
Enlarged heart on imaging (if available)

¶ Signs of clinical improvement include improved mental status, perfusion (decreased capillary refill time), and vital signs (ie, reduction in tachycardia or, for patients with hypotension, increased BP).

Δ If LR or other balanced crystalloid solution is unavailable for rapid fluid infusion, use normal saline. If D5LR or D10LR are unavailable for maintenance fluids, use D5NS or D10NS.

◊ Fluid volume and rate varies based on presence or absence of severe acute malnutrition. Refer to UpToDate content on shock in children managed in resource-limited settings and fluid management in children in resource-limited settings with severe dehydration (the WHO plan C).

§ The IV should be placed in the largest peripheral vein possible. Epinephrine (adrenaline) for continuous infusion should be diluted to a standard concentration, eg, 10 to 40 mcg/mL (not exceeding 64 mcg/mL) and administered using an IV pump. The starting dose of epinephrine is 0.02 to 0.05 mcg/kg per minute. Titrate up to 1 mcg/kg per minute as needed. If epinephrine is unavailable, norepinephrine is an acceptable alternative.

¥ For calculation of maintenance and replacement fluids, refer to UpToDate content on maintenance fluids in children and approach to the child with diarrhea in resource-limited settings.

‡ For details of oral rehydration, refer to separate UpToDate topics on oral rehydration therapy and management of diarrhea in resource-limited settings.

Reference:

World Health Organization. Paediatric Emergency Triage, Assessment and Treatment: Care of Critically Ill Children (updated guideline). World Health Organization 2016. Available at: https://www.who.int/publications/i/item/9789241510219 (Accessed on October 10, 2023).

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Initial management of nonhemorrhagic hypovolemic shock in children without severe anemia managed in resource-limited settings