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

Abstract

Paediatric shock is still a common emergency of public health importance with an estimated 400,000–500,000 reported cases annually. Mortality due to paediatric shock has varied over the years. Data in 1980s show that mortality rates due to septic shock in children were over 50%; but by the end of the year 2000 data indicated that though a marked decline in mortality rates had been achieved, it had stagnated at about 20%. Descriptions of paediatric shock reveal the lack of a common definition and there are important gaps in evidence-based management in different settings. In well-resourced healthcare systems with well-functioning intensive care facilities, the widespread implementation of shock management guidelines based on the Paediatric Advanced Life Support and European Paediatric Advanced Life Support courses have reduced mortality. In resource limited settings with diverse infectious causative agents, the Emergency Triage Assessment and Treatment (ETAT) approach is more pragmatic, but its impact remains circumscribed to centres where ETAT has been implemented and sustained. Advocacy for common management pathways irrespective of underlying cause have been suggested. However, in sub Saharan Africa, the diversity of underlying causative organisms and patient phenotypes may limit a single approach to shock management.Data from a large fluid trial (the FEAST trial) in East Africa have provided vital insight to shock management. In this trial febrile children with clinical features of impaired perfusion were studied. Rapid infusion of fluid boluses, irrespective of whether the fluid was colloid or crystalloid, when compared to maintenance fluids alone had an increased risk of mortality at 48 h. All study participants were promptly managed for underlying conditions and comorbidity such as malaria, bacteraemia, severe anaemia, meningitis, pneumonia, convulsions, hypoglycaemia and others. The overall low mortality in the trial suggests the potential contribution of ETAT, the improved standard of care and supportive treatment across the subgroups in the trial. Strengthening systems that enable rapid identification of shock, prompt treatment of children with correct antimicrobials and supportive care such as oxygen administration and blood transfusion may contribute to better survival outcomes in resources limited settings.

Management of Shock in the Pediatric Emergency Unit of the National Teaching Hospital HKM (CNHU-HKM) in Cotonou

“…The identification of severely ill children is rapid in the pediatric emergency unit of the CNHU, as the doctors at the reception desk are trained in the ABCD method of assessment. The absence of systematic Blood Pressure (BP) measurement could be explained by the fact that it is not part of the WHO diagnostic criteria and that, in general, its drop in states of shock in children is delayed [2,9]. For some authors, BP measurement is necessary because it allows classification into compensated shock when it is normal, and into decompensated shock when hypotension is present [10].…”

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“…Mental confusion and disorientation may also develop quickly. Because patients regularly suffer from persisting hypotension despite volume resuscitation, the treatment with a vasopressors agent is required to keep a mean arterial blood pressure ≥ 65 mmHg along with other emergency treatment which may include supplemental oxygen, intravenous fluids, antibiotics and other medications etc 66,67 .…”