Prevalence, aetiology, treatment and outcomes of shock in children admitted to Kenyan hospitals

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.

Implications for paediatric shock management in resource-limited settings: a perspective from the FEAST trial

“…We identified six observational studies reporting features of paediatric shock [ 14 – 17 ]. Through personal communication, we obtained a sub-analysis of two published data sets from cohorts totaling over 20,000 children admitted to two coastal hospitals in Kenya (Table 2 ).…”

Rapid intravenous rehydration of children with acute gastroenteritis and dehydration: a systematic review and meta-analysis

“…Relevant to this review is that children with AGE were not enrolled in FEAST, thus the results cannot be extrapolated and therefore further research is required to clarify whether these findings are also relevant to those with diarrhoea-related dehydration. A large prospective multicentre observational study in Kenya examining physcians use of resusciation and rehydration fluids with respect to outcome iincluded a large subgroup with severe dehydrating diarrhoea [ 21 ]. Most fluid boluses given for resuscitation of hypovolaemic shock secondary to dehydration/diarrhoea (94%, 582/622), and case fatality was high in this group (34%, 211/622).…”

“…Most fluid boluses given for resuscitation of hypovolaemic shock secondary to dehydration/diarrhoea (94%, 582/622), and case fatality was high in this group (34%, 211/622). Overall mortality was 7.9% (798/10,096) in children with dehydration/diarrhoea [ 21 ].…”

Perspectives on aetiology, pathophysiology and management of shock in African children

“…Paediatric shock is a common emergency that is responsible for high morbidity and mortality [1] , [2] . Globally, an estimated 400,000–500,000 reported cases of paediatric septic shock occur annually [3] .…”