How should I manage fluid and electrolyte balance in a patient with SSSS presenting with extensive skin involvement?

For a patient with Staphylococcal Scalded Skin Syndrome (SSSS) presenting with extensive skin involvement, managing fluid and electrolyte balance requires careful assessment, appropriate intravenous fluid therapy if indicated, and continuous monitoring.

1. Assessment for Dehydration and Shock

• Initially, assess for clinical dehydration and hypovolaemic shock using clinical features such as altered responsiveness, sunken eyes, dry mucous membranes, tachycardia, tachypnoea, prolonged capillary refill time, reduced skin turgor, hypotension, pale or mottled skin, and cold extremities ¹,².
• It is important to recognise that children younger than 1 year, particularly those younger than 6 months, are at an increased risk of dehydration ².

2. Laboratory Investigations

• Measure plasma electrolyte concentrations (sodium, potassium, urea, creatinine) and blood glucose when starting intravenous (IV) fluids ¹,².
• These measurements should be repeated at least every 24 hours, or more frequently if there are electrolyte disturbances or a risk of hypoglycaemia ¹.
• If shock is suspected or confirmed, measure venous blood acid-base status and chloride concentration ².
• Consider point-of-care testing for measuring plasma electrolyte concentrations and blood glucose in time-critical situations when IV fluids are needed ¹.

3. Intravenous Fluid Therapy (if indicated)

• For fluid resuscitation in newborn babies under 28 days, use glucose-free crystalloids containing sodium in the range of 130 to 154 mmol/litre, with a bolus of 10 to 20 ml/kg over less than 10 minutes ³.
• For patients up to 16 years, use glucose-free crystalloids containing sodium in the range of 130 to 154 mmol/litre, with a bolus of 10 ml/kg over less than 10 minutes ³. When administering fluids, take into account pre-existing conditions (for example, cardiac disease or kidney disease), as smaller fluid volumes may be needed ³.
• For patients aged 18 years and over, use crystalloids containing sodium in the range of 130 to 154 mmol/litre, with a bolus of 500 ml over less than 15 minutes ³.
• Do not use starch-based solutions or hydroxyethyl starches for fluid resuscitation ³.
• Human albumin solution 4 to 5% should only be considered for fluid resuscitation in patients with sepsis and shock ³.
• For children under 12 years, use a pump, or a syringe if no pump is available, to deliver intravenous fluids for resuscitation in bolus form ³.

4. Ongoing Monitoring and Reassessment

• Record the types and volumes of fluid input and output (urine, gastric, and other) hourly, maintaining running totals ¹.
• Maintain 12-hourly fluid balance subtotals and 24-hourly fluid balance totals ¹.
• Reassess the fluid prescription, current hydration status, and whether oral fluids can be started every 12 hours ¹.