What is the initial management of pediatric sepsis and septic shock?

Initial Management of Pediatric Sepsis and Septic Shock

The initial management of pediatric sepsis and septic shock requires immediate fluid resuscitation with isotonic crystalloids (20 mL/kg boluses up to and over 60 mL/kg) and early administration of empiric antibiotics within 1 hour of sepsis recognition, followed by hemodynamic support with inotropes/vasopressors for fluid-refractory shock. 1, 2

Recognition and Initial Assessment

Clinical Signs of Sepsis in Children

• Hypothermia or hyperthermia
• Altered mental status
• Abnormal peripheral perfusion
• Tachycardia or bradycardia
• Respiratory distress (most common presenting symptom)

Critical Vital Sign Thresholds

• Heart rate <90 or >160 beats per minute
• Hypotension (late sign in pediatric sepsis)

Initial Resuscitation (First 5 Minutes)

1. Fluid Resuscitation:

   • Administer boluses of 20 mL/kg isotonic saline or colloid
   • Continue up to and over 60 mL/kg until perfusion improves
   • Stop if rales or hepatomegaly develop 2

2. Establish Vascular Access:

   • IV or intraosseous (IO) access immediately
   • Obtain blood cultures before antibiotics if this doesn't delay administration 1

3. Antibiotic Administration:

   • Begin broad-spectrum antibiotics within 1 hour of sepsis recognition
   • Common regimens include gentamicin and cefotaxime, adjusted for local resistance patterns 1

4. Correct Metabolic Abnormalities:

   • Address hypoglycemia and hypocalcemia 2

Management of Fluid-Refractory Shock (15 Minutes)

If shock persists after initial fluid resuscitation:

1. Begin Inotropic Support:

   • Start peripheral inotropes until central access can be established
   • Use atropine/ketamine IV/IO for sedation if needed for central access 2

2. Hemodynamic Management Based on Shock Type:

   • Cold shock: Titrate central dopamine or epinephrine if resistant
   • Warm shock: Titrate central norepinephrine 2

3. Airway Management:

   • Secure airway if needed
   • Implement lung-protective ventilation strategies 2

Management of Catecholamine-Resistant Shock (60 Minutes)

If shock persists despite inotropes/vasopressors:

1. Consider Hydrocortisone:

   • For patients at risk of adrenal insufficiency
   • Initial treatment with hydrocortisone infusion at 50 mg/m²/24 hours
   • May require up to 50 mg/kg/day to reverse shock in short term 2

2. Hemodynamic Monitoring:

   • Monitor central venous pressure (CVP) in PICU
   • Target normal mean arterial pressure (MAP)-CVP and ScvO₂ >70% 2

3. Tailored Management Based on Shock Type and Blood Pressure:

   Cold Shock with Normal BP	Cold Shock with Low BP	Warm Shock with Low BP
   Titrate fluid & epinephrine	Titrate fluid & epinephrine	Titrate fluid & norepinephrine
   Target ScvO₂ >70%, Hgb >10 g/dL	Target ScvO₂ >70%, Hgb >10 g/dL	Target ScvO₂ >70%
   If ScvO₂ still <70%: Add vasodilator with volume loading	If still hypotensive and ScvO₂ <70%: Consider norepinephrine	If still hypotensive: Consider vasopressin, terlipressin or angiotensin
   Consider levosimendan	Consider low-dose epinephrine

Management of Persistent Catecholamine-Resistant Shock

1. Rule Out and Correct:

   • Pericardial effusion
   • Pneumothorax
   • Intra-abdominal pressure >12 mm Hg 2

2. Advanced Hemodynamic Monitoring:

   • Consider pulmonary artery catheter, PICCO, FATD catheter, or Doppler ultrasound
   • Guide fluid, inotrope, vasopressor, vasodilator, and hormonal therapies
   • Target cardiac index 3.3-6.0 L/min/m² 2

3. Consider ECMO:

   • For refractory septic shock or respiratory failure
   • Survival rates of 73% for newborns and 39% for older children with septic shock 2

Supportive Care

1. Blood Product Management:

   • Target hemoglobin of 10 g/dL during resuscitation of low ScvO₂ shock
   • After stabilization, lower target to <7.0 g/dL 2
   • Consider plasma therapy for sepsis-induced thrombotic disorders 2

2. Glycemic Control:

   • Target blood glucose <180 mg/dL
   • Accompany insulin therapy with glucose infusion in children 2

3. Fluid Overload Management:

   • Use diuretics when shock has resolved
   • Consider CVVH or intermittent dialysis to prevent >10% total body weight fluid overload 2

4. Nutrition Support:

   • Provide enteral nutrition when possible
   • Use parenteral nutrition when enteral feeding not possible 2

Common Pitfalls to Avoid

1. Delayed Recognition and Treatment:

   • Hypotension is a late sign in pediatric sepsis
   • Do not wait for hypotension to begin aggressive management 1

2. Inadequate Fluid Resuscitation:

   • Children may require large volumes (>60 mL/kg) in the first hour
   • Monitor for signs of fluid overload (hepatomegaly, rales) 2

3. Delayed Antibiotic Administration:

   • Each hour delay increases mortality
   • Start antibiotics within 1 hour of sepsis recognition 1, 3

4. Inappropriate Vasoactive Agent Selection:

   • Failure to match the agent to the hemodynamic profile
   • Recognize that children may transition between hemodynamic states 2

5. Overlooking Adrenal Insufficiency:

   • Approximately 25% of children with septic shock have adrenal insufficiency
   • Death from adrenal insufficiency and septic shock can occur within 8 hours of presentation 2

By following this time-sensitive, goal-directed approach to pediatric sepsis management, clinicians can significantly improve outcomes and reduce mortality in these critically ill children.