Plan C Severe Dehydration

Dr Nor Azmi bin Abdullah Pakar Pediatrik Hospital Pekan, Pahang

Diagnosis of Severe Dehydration

If any two of the following signs are present, severe dehydration should be diagnosed: drowsy or unconscious sunken eyes not able to drink or drinking poorly. skin pinch goes back very slowly (2 seconds or more)

Skin pinch goes back very slowly

Sunken eyes?

Sunken eyes?

Sunken eyes?

Severe Drowsy or unconscious Dehydration: Sunken eyes 2 or more: Not able to drink or drinking poorly Skin pinch goes back very slowly
Some Restless, irritable Dehydration Sunken eyes 2 or more: Drinks eagerly, thirsty Skin pinch goes back slowly No Not enough signs to classify as some Dehydration dehydration

IMCI Indonesian version for comparison

IMCI Indonesian version for comparison

MANAJEMEN TERPADU BALITA SAKIT

Management of severe dehydration: Refer urgently to hospital

Management of severe dehydration: Refer urgently to hospital

Most children will be referred to hospital for IV management and most likely IV line already inserted at KK Initial fluid resuscitation according to IMCI guidelines
Later will be adjusted in hospital according to clinical condition and investigation results

However in certain situations you may need to manage severe dehydration at primary care

Senario
Kanak-kanak severe dehydration Boleh minum ORS perlahan-lahan Tak boleh refer sebab banjir Tak boleh set IV line Apa nak buat

Plan C Can you give IV drip?

If YES Start IV fluid immediately while arranging transport to hospital If the child can drink, give ORS by mouth while setting drip Give 100ml/kg IV fluid (NS or Hartmann)
First give 20ml/kg bolus Feel radial pulse after completion. If not detectable, repeat 20ml/kg

AGE Infants < 12 months

First give Then 80 20 ml/kg in ml/kg in 1 hour 5 hours

Children 30min 12mo to 5yrs

2 hours

Refer urgently to hospital once transport available

Continue IV fluids along the way

Plan C IV fluid
16-month-old (10 kg) child who is classified as having SEVERE DEHYDRATION. PPP was able to set IV line He followed Plan C. He gave the child 200 ml (20 ml x 10 kg) in the first 30 minutes. He gave 800 ml (80 ml x 10 kg) over the next 2.5 hours (320 ml per hour).

Still unable to refer

Continue plan C until complete. Review the child every 1 hour. Also give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 34 hours (infants) or 12 hours (children). Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriate plan (A,B, or C) to continue treatment. Observe for at least 6 hours after rehydration.

Which IV Fluid?

What IV fluid is suitable?

Recommended: Ringers lactate or Hartmann solution
Contains sodium (Na), potassium (K) and lactate

Normal saline (0.9% NaCl)

Only has Na (in hospital, potassium and bicarbonate can be added to NS but requires some calculation)

Another example

Plan C severe dehydration unable to refer to hospital

Ellen, A 10 month old, 9kg girl, diarrhoea with severe dehydration Not able to drink KK able to give IV treatment and has normal saline (0.9% NaCl) How to proceed?

Ellen, 10 month, 9kg

Give Ellen 180ml (20ml x 9kg) of Normal saline IV over 1 hour Then check radial pulse - detectable Over the following 5 hours, give her 720ml of IV fluid (80ml x 9) = 720. (720/5 =144 ml/hr) Assess hydration status every hour At 3 hours hydration status was improving

Ellen, 10 month, 9kg

After 4 hours of IV treatment, Ellen was able to drink. Give ORS 45ml (5ml/kg) per hour. After on IV fluid for 6 hours, Ellen was reassessed. She had improved and was classified as some dehydration. The health worker continued treatment with plan B. IV drip was stopped. Note: Still try to refer to hospital as soon as possible

Plan C can you give IV drip? NO Can you put in NG tube? YES

Senario
Kanak-kanak severe dehydration Tak nak minum Tak boleh rujuk ke hospital Tak dapat line Anda terlatih dan yakin boleh insert ryles tube

Plan C Can you give IV drip? No

Are you trained to use NG tube (Ryles tube) for rehydration? YES Start rehydration by tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120 ml/kg). Reassess the child every 1 hour: If there is repeated vomiting or increased abdominal distension, give the fluid more slowly. After 6 hours reassess the child. Observe at least 6 hours after rehydration to make sure mother can maintain hydration giving child ORS by mouth.

Plan C Can you give IV drip? NO Can you put in NG? NO Can the child drink? YES

Plan C Child able to drink ORS

Start rehydration by mouth with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120 ml/kg). Reassess the child every 1 hour: If there is repeated vomiting or increased abdominal distension, give the fluid more slowly. After 6 hours reassess the child. Observe at least 6 hours after rehydration to make sure mother can maintain hydration giving child ORS by mouth. STILL TRY TO SEND TO HOSPITAL AS SOON AS POSSIBLE

Senario
An 18 month old boy (8kg) is brought to KD c/o diarrhoea He has sunken eyes. Skin pinch goes back very slowly. He was able to take small sips of drink when offered.

18 month old boy, 8kg Severe dehydration

You are not able to provide IV treatment at your KD. However, IV treatment is available at KK nearby (within 30 minutes) What should you do?

18 month old boy, 8kg Severe dehydration

Go with patient urgently to KK Give frequent sips of ORS during the journey Aim to finish 20ml x 8 = 160ml ORS in 1 hour (At KK, set line, IV fluids, refer to hospital)

Example
KD Mat Daling does not give IV or NG therapy. The nearest hospital is more than 2 hours away A 15 month old girl, Eleli (weight 7kg), was brought by her mother. Eleli appeared to be sleeping but was able to take small sips of drink when aroused. The health worker found that she had sunken eyes. A skin pinch goes back very slowly.

Eleli 15 months old, 7kg

What would you do?

Eleli 15 months old, 7kg

What would you do? Try to refer to hospital as soon as possible Start to rehydrate by mouth according to plan C

Eleli 15 months old, 7kg

Since Eleli weighed 7kg, the JM calculated that she needed 7x20= 140ml ORS per hour. She showed Elelis mother how much ORS to give in 1 hour. Each hour during the next 6 hours, the JM checked Eleli to make sure she was not vomiting and her abdomen was not distended. The JM also checked her hydration status.

Reassess dehydration and choose the appropriate Treatment Plan

After 6 hours of taking ORS solution by mouth, reassess the child for dehydration. Classify dehydration. Select the appropriate treatment plan (Plan A, B or C), and continue treatment. After the child is rehydrated, keep the child at the clinic for 6 more hours if possible. During this time, encourage mother to give fluid according to plan A. Check the child periodically to make sure that signs of dehydration do not return.

Reminder Plan C - ORS

Reassess the childs hydration status every 1 to 2 hours If childs hydration status is not improving after 3 hours, try very hard to urgently refer the child for IV treatment

Pemantauan jika beri ORS plan C (Bahasa Indonesia)

Periksa kembali anak setiap 1-2 jam: - Jika anak muntah terus menerus atau perut makin kembung, beri cairan lebih lambat. - Jika setelah 3 jam keadaan hidrasi tidak membaik, rujuk anak untuk pengobatan intravena Sesudah 6 jam, periksa kembali anak. Klasifikasikan dehidrasi. Kemudian tentukan rencana terapi yang sesuai (A, B, atau C) untuk melanjutkan penanganan.

Severe dehydration cannot give IV or put in RT

If a child with SEVERE DEHYDRATION comes to your clinic and you cannot give IV or NG treatment, find out if the child is able to drink. If he is able to drink, you can try to rehydrate the child orally. If the child is not able to drink, you must refer him urgently to the nearest clinic or hospital where IV or NG treatment is available. If this child does not receive fluids, he will die.

Is there a situation when it may be harmful to give (too much) IV fluids?

Acute diarrhoea and

This 2 year old male child was brought to the KK c/o diarrhoea for 6 days. He had angular stomatitis, peri-anal ulceration, weighed 7.0 kg and has visible severe wasting

His hands were cold, pulse weak and fast and skin pinch went back very slowly. However, he appeared to be fully conscious and was not lethargic.

MALNUTRITION

Some or Severe Dehydration plus another severe classification

severe pneumonia, very severe febrile disease, severe malnutrition

This child has severe malnutrition Even though the child has some dehydration, it may be harmful to give too much IV fluids Management: Refer urgently to hospital Give frequent sips of ORS on the way and continue breastfeeding if still breastfeeding

Take home message

PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

Plan C: Refer to hospital Start IV fluid according to IMCI (100ml/kg)

20ml/kg over or 1 hour 80ml/kg over 2 or 5 hours Give ORS 5ml/kg/hr during journey if child able to take orally

If cannot set IV line and hospital is near

Refer to hospital ORS during journey (aim for 20ml/kg in 1 hr)

Take home message

PLAN C: TREAT SEVERE DEHYDRATION QUICKLY

What to do if cannot set IV line and hospital is far

Still refer ORS according to plan C (orally or NG tube) Stop at KK that can set IV

Know how to treat and assess severe dehydration esp if referral is delayed or cannot refer