Abstract
BackgroundShock may complicate several acute childhood illnesses in hospitals within low-income countries and has a high case fatality. Hypovolemic shock secondary to diarrhoea/dehydration and septic shock are thought to be common, but there are few reliable data on prevalence or treatment that differ for the two major forms of shock. Examining prevalence and treatment practices has become important since reports suggest high risks from liberal use of fluid boluses in African children. The present study aims to estimate the prevalence, fluid management practices and outcomes of shock among hospitalised children.MethodsWe analysed paediatric in-patient data collected using discharge case record review between October 2013 and February 2016 from 14 hospitals in Kenya which are part of a network (referred to as the Clinical Information Network) using similar tools for standardised clinical records with care directed by the local clinical team leaders. Data are from a period after dissemination of national guidance seeking to limit use of bolus fluids.ResultsA total of 74,402 children were admitted between October 2013 and February 2016. Children aged < 30 days or > 5 years, with severe acute malnutrition, surgical/burns, or cases with pre-defined minimum data sets were excluded from analysis. This resulted in 42,937 patients meeting the inclusion criteria. Prevalence of clinically diagnosed shock was 1.5 % (n = 622) and overall bolus use was 0.9 % (n = 366); 41 % (256/622) of children with clinically diagnosed shock did not receive a fluid bolus (but had a fluid plan for management of dehydration). Identified cases appeared mostly to be hypovolaemic shock secondary to dehydration/diarrhoea (94 %, 582/622), with a high case fatality (34 %, 211/622). Overall mortality for all admitted children was 5 % (2115/42,937) and was 7.9 % (798/10,096) in children with dehydration/diarrhoea. The diagnosis of hypovolaemic shock was nearly always accompanied by additional clinical diagnosis (99 %), most often pneumonia or malaria. Where bolus fluids were used, they were prescribed in accordance with guidelines (isotonic fluid at correct volume) in 92 % of cases. Inappropriate use of bolus fluids to treat milder forms of impaired circulation appeared very rarely.ConclusionA diagnosis of shock is uncommon at admission and use of fluid bolus is rare in admissions to Kenyan hospitals. A fluid bolus, when prescribed, is mostly used in children with hypovolemic shock secondary to dehydration and case fatality in these cases is high. We found little evidence of liberal use of fluid bolus that might cause harm in a period following dissemination of national guidelines suggesting very strict criteria for fluid bolus use.
Highlights
Shock may complicate several acute childhood illnesses in hospitals within low-income countries and has a high case fatality
A liberal approach to use of fluid bolus might be causing considerable harm in hospitalised children in low-income countries (LICs) where intensive care cannot be provided. This analysis aims to address these gaps in understanding by exploring the prevalence of shock, its clinically determined aetiology, fluid management practices and outcomes among hospitalised children aged under 5 years
Prevalence of shock, patient characteristics, and use of fluid bolus A total 74,402 children were admitted between October 2013 to February 2016 and 42,937 records were analysed after applying the exclusion criteria above
Summary
Shock may complicate several acute childhood illnesses in hospitals within low-income countries and has a high case fatality. The FEAST trial and the debate that followed its publication showed that there’s little understanding on how commonly clinicians diagnose shock in routine settings, what they associate the diagnosis with, and how often they initiate treatment for shock with fluid bolus The latter is of particular significance as bolus fluids were shown to be harmful in the FEAST trial when used in children without diarrhoea/dehydration [7, 13]. A liberal approach to use of fluid bolus might be causing considerable harm in hospitalised children in LICs where intensive care cannot be provided This analysis aims to address these gaps in understanding by exploring the prevalence of shock, its clinically determined aetiology, fluid management practices and outcomes among hospitalised children aged under 5 years. The study uses routine data collected from a network of 14 hospitals in Kenya referred to as the Clinical Information Network (CIN)
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