How to manage a child with viral fever who presents with collapse and signs of shock?

Management of Pediatric Collapse with Shock in Viral Fever

This child has septic shock until proven otherwise and requires immediate aggressive fluid resuscitation, oxygen therapy, empiric antibiotics, and consideration for oseltamivir—delay in treatment significantly increases mortality risk. 1, 2

Immediate Resuscitation (First 60 Minutes)

Fluid Resuscitation

• Administer 20 mL/kg boluses of crystalloid (normal saline or balanced crystalloid) rapidly, repeated up to 40-60 mL/kg total in the first hour while continuously reassessing for signs of fluid overload 1
• Reassess after each bolus for: capillary refill time, heart rate, blood pressure, mental status, urine output, and hepatomegaly/pulmonary edema 1
• Stop fluid boluses immediately if hepatomegaly or pulmonary rales develop—these indicate fluid overload requiring diuretics and inotropic support 1
• Use crystalloids rather than albumin for initial resuscitation (lower cost, equivalent outcomes) 1

Oxygen Therapy

• Maintain SpO2 >92% using nasal cannulae, head box, or face mask as needed 1, 3
• Start supplemental oxygen immediately if SpO2 ≤92% on room air 3
• Monitor oxygen saturation continuously in all shocked children 3

Empiric Antimicrobial Therapy

Start within the first hour—every hour of delay increases mortality 1, 2

Antibiotics (for secondary bacterial sepsis)

• Co-amoxiclav is first-line: 1, 2
  • <1 year: 2.5 mL/kg of 125/31 suspension three times daily
  • 1-6 years: 5 mL of 125/31 suspension three times daily

  • 6 years: 5 mL of 250/62 suspension three times daily

  • IV dosing: 30 mg/kg three times daily for all ages 1
• Alternative if penicillin allergy: Clarithromycin 1
  • Weight-based dosing from 7.5 mg/kg twice daily (<8.5 kg) to 250 mg twice daily (>10 years)

Antiviral Therapy (Oseltamivir)

• Start immediately if fever >38.5°C with influenza-like illness, regardless of time from symptom onset in severely ill children 1, 2, 3
• Dosing for children >1 year: 1
  • <15 kg: 30 mg every 12 hours
  • 15-23 kg: 45 mg every 12 hours

  • 24 kg: 75 mg every 12 hours

Vasoactive Support

If shock persists after 40-60 mL/kg fluid resuscitation, start inotropes/vasopressors immediately—do not delay for central access 1

First-Line Vasoactive Agents

• Epinephrine or norepinephrine are preferred over dopamine (lower mortality, fewer arrhythmias) 1
• Can be administered peripherally or via intraosseous access initially if central venous access not immediately available 1
• Dopamine may be substituted only if epinephrine/norepinephrine unavailable 1

Hemodynamic Phenotypes Requiring Different Approaches

• Low cardiac output/high systemic vascular resistance ("cold shock"): Requires inotropes ± vasodilators 1
• High cardiac output/low systemic vascular resistance ("warm shock"): Requires vasopressors 1
• Do not rely on clinical assessment of "warm" vs "cold" shock alone—use advanced hemodynamic monitoring when available 1

Critical Monitoring and Investigations

Immediate Bedside Assessment

• Vital signs every 15 minutes during resuscitation: heart rate, respiratory rate, blood pressure, temperature, mental status 1, 3
• Capillary refill time, peripheral perfusion, urine output 1
• Signs of fluid overload: hepatomegaly, pulmonary rales 1

Laboratory Investigations

• Full blood count with differential, urea, creatinine, electrolytes, liver enzymes, blood culture 1, 2
• Serial lactate measurements to guide resuscitation—persistent elevation indicates inadequate resuscitation 1
• Blood glucose (correct hypoglycemia immediately) 1
• Coagulation studies if bleeding or purpura present 1

Advanced Monitoring (When Available)

• Central venous oxygen saturation (ScvO2) target >70% 1
• Cardiac output/cardiac index, systemic vascular resistance 1
• Arterial blood gas for pH, PaCO2, base deficit 1

Criteria for HDU/PICU Transfer

Transfer immediately if any of the following present: 1, 2

• Failure to maintain SpO2 >92% despite FiO2 >60%
• Persistent shock despite fluid resuscitation and vasoactive support
• Severe respiratory distress with PaCO2 >6.5 kPa
• Rising respiratory and pulse rates with severe distress
• Recurrent apnea or irregular breathing
• Altered conscious level/encephalopathy
• Requirement for mechanical ventilation

Special Considerations

Fluid-Refractory Shock Management

• After 60 mL/kg fluid resuscitation without improvement, prioritize vasoactive support over additional fluids 1
• Consider hydrocortisone (50 mg/m²/24h) if absolute adrenal insufficiency suspected (purpura, prior steroid use, pituitary/adrenal abnormalities) 1
• ECMO may be considered for refractory septic shock unresponsive to conventional therapy 1

Common Pitfalls to Avoid

• Do not delay antibiotics waiting for cultures—obtain blood culture then start antibiotics immediately 1, 2
• Do not use aspirin for fever in children (Reye's syndrome risk) 1
• Do not restrict fluids to 80% maintenance initially—this applies only after stabilization in children on oxygen therapy to prevent SIADH 3
• Do not rely on blood pressure alone—children maintain blood pressure until cardiovascular collapse is imminent 1
• Do not delay inotropes waiting for central access—peripheral/IO administration is acceptable initially 1

Transfusion Thresholds

• Target hemoglobin 10 g/dL during active resuscitation if ScvO2 <70% 1
• After stabilization, hemoglobin target can be lowered to 7 g/dL 1