What are the current guidelines for managing pediatric shock?

Current Pediatric Shock Management Guidelines

The most recent pediatric shock guidelines recommend initial fluid resuscitation with 10-20 mL/kg crystalloid boluses up to 40-60 mL/kg in the first hour, titrated to patient response and discontinued if signs of fluid overload develop, followed by vasoactive medications if shock persists. 1

Initial Assessment and Recognition

• Recognize shock by:
  • Altered mental status
  • Capillary refill >2 seconds
  • Decreased peripheral pulses
  • Tachycardia
  • Hypotension (late sign)
  • Decreased urine output

Fluid Resuscitation

For Systems with ICU Availability:

• Administer 10-20 mL/kg isotonic crystalloid boluses
• Titrate to patient response (improved perfusion, mental status, urine output)
• Continue up to 40-60 mL/kg in first hour
• Stop if signs of fluid overload develop (hepatomegaly, rales) 1

For Systems without ICU Availability:

• If hypotensive: 10-20 mL/kg boluses up to 40 mL/kg total
• If normotensive: Avoid bolus fluids, start maintenance fluids 1

Fluid Administration Methods:

• Use pressure bag (300 mmHg) or manual push-pull system for rapid delivery
• Gravity flow is inadequate for meeting guidelines 2
• 30 mL or 60 mL syringes provide most efficient fluid delivery 3

Vasoactive Support

• Begin vasoactive medications after 40-60 mL/kg fluid if perfusion remains abnormal 1

• First-line agents:

  • Epinephrine or norepinephrine preferred over dopamine 1
  • Can be administered peripherally if central access not immediately available

• For persistent shock:

  • Consider adding vasopressin for high-dose catecholamine requirements 1
  • Consider hydrocortisone for suspected adrenal insufficiency 1

Monitoring and Goals

• Target goals in first hour:

  • Normalized heart rate
  • Capillary refill ≤2 seconds
  • Normal blood pressure
  • Improved mental status
  • Adequate urine output

• Advanced monitoring goals:

  • ScvO₂ >70%
  • Normal perfusion pressure (MAP-CVP)
  • Cardiac index >3.3 L/min/m² 1

Respiratory Support

• For sepsis-induced PARDS (Pediatric Acute Respiratory Distress Syndrome):
  • Consider non-invasive ventilation if no clear indication for intubation
  • Use high PEEP if intubated
  • Consider prone positioning for severe PARDS
  • Avoid routine use of inhaled nitric oxide 1

Important Caveats

• Excessive fluid administration may be harmful in trauma patients - recent evidence shows increased mortality with >20 mL/kg in first hour 4
• Children >40 kg may require alternative fluid delivery methods to achieve guideline-recommended rates 2
• Reassessment after each intervention is critical to avoid fluid overload
• Different shock types (septic, cardiogenic, hypovolemic) may require tailored approaches 5
• Cardiogenic shock requires particular caution with fluid administration and early consideration of inotropic support 5

The 2020 Surviving Sepsis Campaign guidelines represent the most current comprehensive approach to pediatric septic shock, with recommendations tailored to resource availability and emphasizing frequent reassessment during resuscitation 1.