Bibliographic information
Guideline—
Year of Publication—
Issuing Institution—
Recommendation
New
WHO suggests patients with suspected or confirmed filovirus disease with ongoing gastrointestinal fluid losses and severe dehydrationa be treated with a protocolized intravenous fluid regimenb compared with no protocolized intravenous fluid regimen
Recommended in favor
Conditional
Certainty of evidence
Low
Notes and Remarks
- This recommendation applies to both adults and children.
- Systematic and frequent monitoring of haemodynamic status, fluid input and output, and signs of fluid overload is required to titrate and individualize fluid therapy.
- Modifications of WHO Plan C are required to enhance monitoring to enable more restrictive fluid regimen in cases where it is difficult to discriminate between severe dehydration and sepsis-induced hypoperfusion (see Practical info section).
- Once dehydration is corrected, administer maintenance fluids based on calculated requirements based on weight and insensible and ongoing losses.
- Patients that develop shock, need careful re-evaluation for etiology of shock to guide appropriate resuscitation. a In children: Severe dehydration is defined as two or more of the following signs: lethargy or unconsciousness; sunken eyes; unable to drink or drinks poorly; skin pinch goes back very slowly (≥ 2 seconds). In adults: Severe dehydration, which requires urgent resuscitation with intravenous fluid, is suggested by any of: systolic blood pressure is less than 100 mmHg; heart rate is more than 90 beats per minute; capillary refill time is more than 2 seconds; peripheries are cold to touch; respiratory rate is more than 20 breaths per minute. b The panel emphasized that the majority of patients with severe dehydration and ongoing gastrointestinal losses would place high value on low certainty evidence of mortality impact with an intravenous rehydration regimen (such as Plan C) and expressed strong concern about the potential serious harms when clinical distinctions between sepsis and severe dehydration are evident in these recommendations. The panel noted that the use of Plan C was widely known by health and care providers treating patients with severe dehydration from other diarrhoeal causes and thus change of practice would require a stronger evidence base. However, adding modifications to the intravenous hydration regimen (modified Plan C, see Practical info) to mitigate harm and optimize effectiveness in populations where risk of harm may be greater such as patients with filovirus disease and sepsis and those with other chronic disease predisposed to volume overload (renal failure, liver failure, cardiac insufficiency, etc.). This applies to adults, children and pregnant women. However, the panel noted that for children with coexisting severe acute malnutrition, other fluid protocols should be considered (47). For patients with filovirus disease and sepsis, see subsequent recommendations. Practical info Plan C is for severe dehydration: if there is clinical suspicion of sepsis or septic shock, use the Fluids in patients with shock section. Modified Plan C for patients with filovirus disease
- Start intravenous fluid immediately.
- Use large cannulas.
- Reassess at least every 30 minutes, and monitor carefully for pulmonary oedema caused by fluid overload:
- features of pulmonary oedema include: dyspnoea/discomfort lying down (orthopnoea); worsening tachypnoea; increasing oxygen requirement; worsening hypertension or hypotension;
- for patients at higher risk of pulmonary oedema (those with pre-existing renal failure, pre-existing liver failure, or pre-existing cardiac insufficiency, or children with severe acute malnutrition), the rates and/or volume of fluid administration should be reduced;
- if pulmonary oedema is suspected, stop the infusion and perform a full clinical reassessment.
- When signs of severe dehydration have resolved, review the fluid regime and adjust it according to the patient’s latest clinical status and the ongoing losses. Initial fluid plan – review frequently, and adjust according to the patient’s response
- Write the start time on the intravenous bag to help track how quickly fluids are being given.
- Give ORS to replace ongoing losses as soon as the patient can drink safely. For infants younger than 12 months, give the first 30 mL/kg over 1 hour, followed by 70 mL/kg over 5 hours. For children aged 12 months or older and adults, give the first 30 mL/kg over 30 minutes, followed by 70 mL/kg over 2½ hours.