A 2 years old child brought to an emergency department with complains of frequently episodes of lose stool, lethargy, weakness. The physical assessment findings reveals poor skin turgor, dry and dull mucous membrane and rapid heartbeat. The child is having severe dehydration. Which is the best management of fluid resuscitation for the child?

1. A

   30 ml/kg/body weight initial 60 minutes then 70 ml/kg/body weight in 5 hr

2. B

   50 ml/kg/body weight initial 30 minute then 70 ml/kg/body weight in 2.30 hr

3. C

   30 ml/kg/body weight initial 30 minute then 70 ml/kg/body weight in 2.30 hr

4. D

   20 ml/kg/body weight bolus and then 70 ml/kg/body weight in 5 hours

Appeared in: NORCET -4 , 2023

Explanation

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• The child is 2 years old and presents with signs of severe dehydration, requiring management as per WHO Plan C.
• For children aged 12 months to 5 years, WHO Plan C recommends a total of 100 ml/kg of IV fluid (Ringer's Lactate or Normal Saline).
• This is administered in two phases: an initial rapid infusion of 30 ml/kg over 30 minutes.
• This is followed by the remaining 70 ml/kg infused over the next 2.5 hours (2 hours and 30 minutes).

Why Other Options Were Wrong

• Option A: This protocol, with an initial infusion over 60 minutes and the remainder over 5 hours, is the correct management for infants under 12 months of age, not for a 2-year-old child.
• Option B: The initial bolus volume is incorrect. The WHO protocol specifies an initial volume of 30 ml/kg, not 50 ml/kg. Administering an excessive initial volume can increase the risk of complications like fluid overload and pulmonary edema.
• Option D: This option does not align with the specific two-phase, 100 ml/kg total volume protocol outlined in WHO Plan C. While a 20 ml/kg bolus is common in other resuscitation scenarios (like septic shock), the standard for severe dehydration from diarrhea is the 30/70 ml/kg split.

Related Visual

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing WHO guidelines (Plan C) for intravenous fluid resuscitation in pediatric severe dehydration in acute care settings.
• Accurate calculation and administration of IV fluids based on age and weight is a critical nursing responsibility to prevent life-threatening complications of dehydration, such as hypovolemic shock, and iatrogenic complications like fluid overload.
• Nurses must continuously monitor the child's response to treatment, including vital signs (heart rate, BP), urine output, and level of consciousness, every 15-30 minutes during the initial phase to assess for improvement and detect adverse effects.
• What if the child was 10 months old? The correct protocol would change to 30 ml/kg over 1 hour, followed by 70 ml/kg over the next 5 hours, highlighting the critical importance of age in determining the infusion rate.

How to Approach the Question

• First, identify the key clinical details from the scenario: the patient is a 2-year-old child with signs of severe dehydration.
• The question asks for the 'best management,' which in this context refers to the standard evidence-based protocol for fluid resuscitation.
• Recall the WHO guidelines for managing severe dehydration (Plan C).
• Differentiate the protocol based on the child's age. Remember there are different rates for infants (less than 12 months) and children (12 months to 5 years).
• Apply the correct protocol for a 2-year-old: 30 ml/kg in 30 minutes, then 70 ml/kg in 2.5 hours.
• Compare this with the given options to find the exact match.

Concept Tested & Keywords

• Concept Tested: WHO guidelines (Plan C) for intravenous fluid resuscitation in pediatric severe dehydration.
• Stem keywords: 2 years old child, severe dehydration, fluid resuscitation, lose stool, lethargy, poor skin turgor
• Lead-in keywords: best management
• Clinical cues: The patient's age of 2 years is the critical factor for determining the correct fluid administration rate.

Question ID

QrjiyRFqQaVHELYZH8OyKC

Copy ID

Reference Book

E6 Ghai Essential Pediatrics(pp 26-904 of 913) pp. 312-314, 313-315