Training course on the inpatient management of severe acute malnutrition: module 3: initial management. Web annex A: critical care pathway

Training course on the inpatient management of severe acute malnutrition: Module 3. Initial management Web Annex A. Critical care pathway In iti al m an ag em en t Co m m en ts o n pr e- re fe rr al a nd /o r e m er ge nc y tr ea tm en t a lre ad y gi ve n: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ SI G N S O F SE VE RE A CU TE M A LN U TR IT IO N S IG N S O F SH O CK : N on e S em i-c on sc io us /u nc on sc io us * C ol d ha nd s Sl ow c ap ill ar y re fil l ( > 3 se co nd s) W ea k or fa st p ul se B ila te ra l p itt in g oe de m a? 0 + + + + ++ **II ff ss eemm ii--cc oonn sscc iioo uuss oo rr uu nncc oonn sscc iioo uuss ,, cc ooll dd hhaa nndd ss,, pp lluu ss eeii tthh eerr ss lloo ww cc aapp iillll aarr yy rree ffiill ll oo rr ww eeaa kk oorr ffaa sstt pp uull ssee , g iv e ox yg en . G iv e IV g lu co se a s de sc rib ed un de r “ bl oo d gl uc os e” (l ef t). Th en g iv e IV fl ui ds : a m ou nt s IV fl ui ds p er h ou r: 15 m l x _ __ __ __ __ __ kg (c hi ld ’s w t.) = _ __ __ __ __ __ __ m l W ei gh t ( kg ): __ __ __ __ __ _ H ei gh t / le ng th (c m ): __ __ __ __ __ __ __ W FH /L Z -s co re : _ __ __ __ __ __ __ __ M U A C (m m ): __ __ __ __ __ __ D er m at os is ? 0 + ++ ++ + (r aw s ki n, fi ss ur es ) St ar t (1 st h r) M on ito r e ve ry 5 –1 0 m in ut es 2n d h r* * M on ito r e ve ry 5 –1 0 m in ut es TE M PE RA TU RE __ __ __ __ _° C r ec ta l ax ill ar y If re ct al < 3 5. 5° C, o r a xi lla ry < 3 5° C, a ct iv el y w ar m c hi ld . Ch ec k te m pe ra tu re e ve ry 3 0 m in ut es . T im e R es pi ra to ry ra te B LO O D G LU CO SE (m m ol /L ): P ul se ra te If < 3 m m ol /L a nd a le rt, g iv e 50 m l b ol us o f 1 0% g lu co se o r s uc ro se o ra lly o r b y N G tu be . I f < 3 m m ol /L a nd s em i-c on sc io us , u nc on sc io us , o r c on vu ls in g, g iv e st er ile 1 0% g lu co se 5m l/k g IV To ta l a m ou nt = 5 m l x _ __ k g (c hi ld ’s w t) = __ __ m l T he n gi ve 5 0 m l b ol us b y N G tu be . Ti m e gl uc os e gi ve n: O ra l N G T IV W ei gh t * *II ff ii mm pprr oovv eemm eenn ttss aa ffttee rr 11 hh oouu rr (( rree sspp iirraa ttoo rryy aa nndd pp uull ssee rraa ttee ss aarr ee ssll ooww eerr )),, re pe at s am e am ou nt IV fl ui ds fo r s ec on d ho ur ; t he n al te rn at e Re So M al a nd F - 75 fo r u p to 1 0 ho ur s. I Iff nn oo iimm pprr oovv eemm eenn tt aa ffttee rr 11 hh oouu rr,, tre at fo r s ep tic s ho ck (t ra ns fu se w ho le fr es h bl oo d, s ee “ ha em og lo bi n” ), gi ve m ai nt en an ce IV flu id s (4 m l/k g/ ho ur ) w hi le w ai tin g fo r b lo od . H A EM O G LO B IN (H b) (g /L ): _ __ __ __ __ __ P ac ke d ce ll vo l ( PC V) : _ __ __ __ __ _ B lo od ty pe : D EH YD RA TI O N : If Hb < 4 0 g/ L or P CV < 1 2% , t ra ns fu se 1 0 m l/k g w ho le fr es h bl oo d (o r 5 –7 m l/k g pa ck ed c el ls ) sl ow ly o ve r 3 h ou rs . Am ou nt : _ __ __ __ __ __ Ti m e st ar te d: _ __ __ __ __ __ E nd ed : _ __ __ __ __ __ W at er y di ar rh oe a? Ye s N o B lo od in s to ol ? Ye s N o Vo m iti ng ? Ye s N o R es tle ss /ir rit ab le L et ha rg ic T hi rs ty R ec en t s un ke n ey es D ry m ou th /to ng ue N o te ar s M EA SL ES Ye s N o EY E SI G N S: N on e Le ft Ri gh t Pu s/ in fla m m at io n B ito t's s po ts Co rn ea l c lo ud in g Co rn ea l u lc er at io n If ey e si gn s, g iv e vi ta m in A im m ed ia te ly . A dd at ro pi ne if c or ne al u lc er at io n. R ec or d be lo w a nd o n da ily c ar e pa ge . FE ED IN G B eg in fe ed in g w ith F - 75 a s so on a s po ss ib le (i f c hi ld is re hy dr at ed , r ew ei gh b ef or e de te rm in in g am ou nt to fe ed ) NN eeww ww eeii gghh tt: _ __ __ (k g) A m ou nt fo r 2 -h ou rl y fe ed in gs : _ __ __ m l F -7 5* Ti m e fir st fe d: _ __ __ _ *R eecc oorr dd aall ll ff eeee ddss oo nn 2244 --hh oouu rr ff oooo dd iinn ttaa kkee cc hhaa rrtt O ra l d os es < 6 m on th s 50 0 00 IU V ita m in A : 6– 12 m on th s 10 0 00 0 IU > 12 m on th s 20 0 00 0 IU IIff ddee hhyy ddrr aatt iioo nn,, gg iivv ee RRee SSoo MM aall oo rraa llllyy ((oo rr bb yy NN GG ttuu bbee iiff ttoo oo iillll )) ee vvee rryy 33 00 mm iinn uutt eess ffoo rr ff iirrss tt 22 hh oouu rrss aa nndd mm oonn iittoo rr.. Am ou nt : 5 m l x _ __ _ kg (cc hhii lldd ’’ss w ei gh t) = __ __ m l R eS oM al FFoo rr uu pp ttoo 11 00 hhoo uurr ss,, gg iivv ee RRee SSoo MM aall aa nndd FF --77 55 oorr aall llyy ((oo rr bb yy NN GG ttuu bbee )) ii nn aall ttee rrnn aatt ee hhoo uurr ss aann dd mm oonn iittoo rr ee vvee rryy hh oouu rr.. Am ou nt : 5 –1 0 m l x _ __ _ kg (cc hhii lldd ’’ss w ei gh t) = __ __ _ to _ __ __ m l R eS oM al e ve ry 2 h ou rs T im e St ar t: R es pi ra to ry ra te * (b re at hs /m in ut e) P ul se ra te * (b ea ts /m in ut e) W ei gh t* * P as se d ur in e (Y es /N o) N um be r o f s to ol s N um be r o f v om its H yd ra tio n si gn s (Y es /N o) ** A m ou nt ta ke n (m l) F- 75 F- 75 F- 75 F- 75 F- 75 ** SStt oopp RR eeSS ooMM aall iiff aa nnyy ss iigg nn ooff oo vvee rrhh yydd rraa ttiioo nn:: F as t b re at hi ng , i nc re as in g pu ls e an d re sp . r at es , e ng or gi ng ju gu la r v ei ns , p uf fin g of e ye lid s. ** SS ttoo pp RRee SSoo MM aall iiff ttww oo oorr mm oorr ee ssii ggnn ss ooff hh yydd rraa ttiioo nn: T he c hi ld h as re ac he d ta rg et w ei gh t, pa ss in g ur in e, m oi st to ng ue , m ak in g sa liv a, n ot th irs ty . Ca re fu l j ud ge m en t f or e ac h ca se is n ee de d. A N TI B IO TI CS (F or a ll ch ild re n) D ru g/ ro ut e D os e/ fr eq ue nc y/ du ra tio n Ti m e of 1 st d os e IIff ddii aarr rrhh ooee aa,, cc iirrcc llee ss iigg nnss pprr eess eenn tt:: 1 Da ily ca re W ee k 1 W ee k 2 W ee k 3 D ay s in h os pi ta l 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 D at e D ai ly w ei gh t ( kg ) W ei gh t g ai n (g /k g) Ca lc ul at e da ily d ur in g tra ns iti on B ila te ra l p itt in g oe de m a 0 + + + + ++ D ia rr ho ea (i nd ic at e nu m be r o f l oo se s to ol s) Vo m iti ng (i nd ic at e th e fr eq ue nc y) Fe ed p la n: T yp e of fe ed # da ily fe ed s A m ou nt to g iv e pe r f ee d (m l) To ta l a m ou nt ta ke n (m l) N G tu be Y es /N o B re as tfe ed in g Ye s/ N o A nt ib io tic s an d ot he r d ru gs Li st p re sc rib ed a nt ib io tic s an d ot he r d ru gs in le ft co lu m n. A llo w o ne ro w fo r e ac h da ily d os e. D ra w a b ox a ro un d da ys /ti m es th at e ac h dr ug s ho ul d be g iv en . S ig n yo ur in iti al s w he n gi ve n. Fo lic a ci d (if th er e is c lin ic al a na em ia ) 5m g 1m g da ily (i f n ot in fe ed ) Vi ta m in A Gi ve a t t he e nd o f r eh ab ili ta tio n ro ut in el y un le ss e vi de nc e of d os e in p as t m on th a nd n o ey e si gn . G iv e Da y 1, D ay 2 a nd e nd o f r eh ab ili ta tio n if ch ild a dm itt ed w ith e ye si gn o r r ec en t m ea sl es . M ul tiv ita m in (i f n ot in fe ed s) D ru g fo r w or m s (T yp e of w or m ) Ir on 2 x da ily Gi ve ir on o nl y in re ha bi lit at io n ph as e if ch ild is o n F- 10 0 Do n ot g iv e iro n if ch ild is o n RU TF Ey e pr ob le m s Te tr ac yc lin e oi nt m en t 3 x da ily o r ch lo ra m ph en ic ol 1 d ro p 4x d ai ly Le ft Ri gh t Af te r 7 –1 0 da ys , w he n ey e dr op s ar e no lo ng er n ee de d, s ha de b ox es fo r e ye d ro ps A tr op in e 1 dr op 3 x da ily D er m at os is 0 + + + ++ + Z in c ox id e oi nt m en t d ai ly O th er 2 M on ito rin g r ec or d M on ito r r es pi ra to ry ra te , p ul se ra te , a nd te m pe ra tu re ee vvee rryy 44 hh oouu rrss u nt il af te r t ra ns iti on to R UT F or F -1 00 . T he n m on ito rin g ca n be le ss fr eq ue nt (e .g . t w ic e da ily ). Re sp ir at or y ra te B re at hs /m in ut e Pu ls e ra te B ea ts /m in ut e Te m pe ra tu re 39 .5 39 .0 38 .5 38 .0 37 .5 37 .0 36 .5 36 .0 35 .5 35 .0 34 .5 T im e D ay DDaa nngg eerr ss iigg nnss :: W at ch fo r i nc re as in g pu ls e an d re sp ira tio n, fa st o r d iff ic ul t b re at hi ng , s ud de n in cr ea se o r d ec re as e in te m pe ra tu re , r ec ta l t em pe ra tu re b el ow 3 5. 5° C, a nd o th er c ha ng es in co nd iti on (s ee M on ito rin g Da ng er S ig ns d ur in g In pa tie nt M an ag em en t o f Se ve re Ac ut e M al nu tri ti on J ob Ai d) . N or m al p ul se : 0 to 1 y ea rs 10 0 to 1 60 b ea ts/ m in 1 to 3 y ea rs 90 to 1 50 b ea ts/ m in 3 to 6 y ea rs 80 to 1 40 b ea ts/ m in No rm al re sp ira tio n ra te < 2 m on th s < 60 b re at hs /m in 2 to 1 1 m on th s < 50 b re at hs /m in 1 to 5 y ea rs < 40 b re at hs /m in 3 W ei gh t c ha rt W ei gh t o n ad m iss io n: __ __ _k g He ig ht /le ng th on a dm iss io n: __ __ __ _c m M UA C on a dm iss io n: __ __ __ _ m m Bi la te ra l p itt in g oe de m a on a dm iss io n: 0 + + + + ++ W ei gh t b ef or e tr an sf er to ou tp at ie nt ca re : _ __ __ _k g Weight (use appropriate scale) DA Y 1 2 3 4 5 6 7 8 9 1 0 1 1 12 1 3 14 1 5 16 1 7 18 1 9 20 2 1 2 2 23 2 4 2 5 2 6 2 7 2 8 En te r l ik el y ra ng e of w ei gh ts o n th e ve rt ica l a xi s in a n ap pr op ria te sc al e. Al lo w ro w s b el ow th e st ar tin g w ei gh t i n ca se w ei gh t d ec re as es ; w ei gh t m ay d ec re as e by a s m uc h as 3 0% if th e ch ild h as se ve re o ed em a. 4 24 -h ou r f oo d in ta ke ch ar t Co m pl et e on e ch ar t f or e ve ry 2 4- ho ur p er io d du rin g st ab ili za tio n an d tr an sit io n. St ar tin g w ei gh t ( kg ): T od ay ’s w ei gh t ( kg ): Oe de m a: 0 + + + ++ + D at e: Ty pe o f f ee d (c irc le ): F -7 5 F -1 00 I nf an t f or m ul a or F -1 00 -d ilu te d R UT F Fe ed s Gi ve _ __ _ m ilk fe ed s o f _ __ __ _ m l, or _ __ __ __ m l p er d ay (X ) GI VE _ __ _R UT F fe ed s o f a bo ut _ __ __ __ __ pa ck et , o r __ __ _ pa ck et s p er d ay (Y ) Ti m e a. Am ou nt o f m ilk of fe re d (m l) b. Am ou nt o f m ilk le ft in cu p (m l) c. Am ou nt o f m ilk ta ke n or al ly (m l) (a – b ) d. Am ou nt o f m ilk ta ke n by N G tu be if ne ed ed (m l) e. Es tim at ed a m ou nt of m ilk v om ite d (m l) f. Es tim at ed a m ou nt o f RU TF ta ke n (p ro po rt io n of p ac ke t) g. Am ou nt o f m ilk o ffe re d to co m pl et e th e RU TF fe ed (m l) (2 0 g RU TF o r 2 te as po on s = 13 5 m l F -7 5 or 1 00 m l F -1 00 ) i. Pa ss ed lo os e st oo ls (Y es /N o) j. Co m m en ts (e .g . i f vo m ite d fe ed s w er e re pl ac ed ) To ta ls C. D. E. F. G. 24 -h ou r in ta ke To ta l d ai ly a m ou nt o f m ilk ta ke n (H ) = (C ) + (D ) – (E ) = _ __ __ m l Es tim at ed p ro po rt io n of d ai ly a m ou nt o f m ilk ta ke n (H /X ): __ __ _ % Es tim at ed p ro po rt io n of d ai ly a m ou nt o f R UT F t ak en (F /Y ): __ __ _ % 5 Co m m en ts /o ut co m e CCOO MM MM EENN TTSS FFOO LLLL OO WW --UU PP IINN SSTT RRUU CCTT IIOO NN SS CCOO UU NN SSEE LLLL IINN GG aa nndd TT RRAA IINN IINN GG GG IIVV EENN TT OO PP AARR EENN TTSS //CC AARR EEGG IIVV EERR SS PPAA TTII EENN TT OO UU TTCC OO MM EE ((rr eeww rriitt ee tthh iiss ttoo rree ffllee cctt ttrr aann ssff eerr ttoo oo uutt ppaa ttiiee nntt cc aarr ee)) IIMM MM UU NN IIZZ AATT IIOO NN SS NN aamm ee ooff ttrr aann ssff eerr rriinn gg ooff ffiicc eerr NN aamm ee ooff oo uutt ppaa ttiiee nntt cc aarr ee ffaa ccii lliitt yy:: OO UU TTCC OO MM EE ((cc iirrcc llee )) DDaa ttee VVaa cccc iinn aatt iioo nn AAtt bb iirrtt hh FFii rrss tt SSee ccoo nndd TThh iirrdd TTrr aann ssff eerr rree dd (t ra ns fe r t o ou tp at ie nt c ar e to c on tin ue tr ea tm en t) W ei gh t: __ __ __ __ k g H ei gh t: __ __ __ __ _ cm M U AC : _ __ __ __ _ m m BC G At b irt h — — — CCuu rree dd (d isc ha rg e at fu ll re co ve ry ) O PV At b irt h At 6 w ee ks At 1 0 w ee ks At 1 4 w ee ks EEaa rrllyy dd eepp aarr ttee dd oorr dd eeff aauu llttee dd (a bs en ce a ga in st m ed ic al a dv ic e) Pe nt a — At 6 w ee ks At 1 0 w ee ks At 1 4 w ee ks RRee ffee rrrr aall PC V At 6 w ee ks At 1 0 w ee ks At 1 4 w ee ks Ro ta vi ru s — At 6 w ee ks At 1 0 w ee ks — NN oonn --cc uurr eedd IP V At 1 4 w ee ks DDee aatt hh N um be r o f d ay s a ft er a dm iss io n (c irc le ): < 24 hr s 1 –3 d ay s 4 –7 d ay s > 7 d ay s Ti m e of d ea th : _ __ __ __ __ D ay N ig ht Di d ch ild re ce iv e IV fl ui ds ? Ye s N o Ap pa re nt c au se (s ) o f d ea th : M ea sle s — At 9 m on th s At 1 5 m on th s — BCG: Bacillus Calmette–Guérin; IPV: inactivated poliomyelitis vaccine; IV: intravenous; MUAC: mid-upper arm circumference; NG: nasogastric; OPV: oral poliomyelitis vaccine; PCV: pneumococcal vaccine; ReSoMal: rehydration solution for malnutrition; RUTF: ready-to-use therapeutic food. WHO/HEP/NFS/21.6 © World Health Organization 2021. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. 6