What is the management approach for a pediatric patient presenting with shock?

Management of Pediatric Shock

Immediately begin aggressive fluid resuscitation with 20 mL/kg isotonic crystalloid boluses (10 mL/kg in neonates), repeating up to and exceeding 60 mL/kg within the first hour while simultaneously correcting hypoglycemia and hypocalcemia, then escalate to vasoactive medications if shock persists after 40-60 mL/kg of fluid. 1, 2

Initial Recognition and Stabilization

Recognize shock clinically before hypotension develops by identifying these signs: altered mental status, capillary refill >2 seconds, cool extremities, weak peripheral pulses, tachycardia (HR >150 bpm in children or >160 bpm in infants), or bradycardia (HR <70 bpm in children or <90 bpm in infants). 1, 2

• Establish high-flow oxygen and secure IV/IO access immediately—do not delay resuscitation attempting multiple peripheral IV attempts when IO access can be rapidly obtained. 1, 2
• Obtain blood cultures before antibiotics if septic shock is suspected, but never delay antibiotic administration beyond 1 hour waiting for cultures, as mortality increases with each hour of delay. 2
• Begin continuous monitoring: pulse oximetry, ECG, temperature, and blood pressure (invasive arterial line preferred once initial stabilization achieved). 1
• Check and correct immediately: glucose (maintain 80-150 mg/dL) and ionized calcium (normalize levels). 1, 3

Fluid Resuscitation Protocol

Children (>1 month to 18 years)

• Administer 20 mL/kg boluses of isotonic crystalloid (0.9% saline or lactated Ringer's) as rapidly as possible, repeating up to and exceeding 60 mL/kg until perfusion improves. 1, 2
• Children commonly require 40-60 mL/kg in the first hour, and up to 200 mL/kg can be administered if no signs of fluid overload develop. 3
• Stop fluid boluses immediately if rales or hepatomegaly develop, indicating pulmonary edema or fluid overload. 1, 2
• Use crystalloid if hemoglobin >10 g/dL; transfuse packed red blood cells if hemoglobin <10 g/dL, particularly in hemorrhagic or septic shock. 1, 3

Neonates (<1 month)

• Administer 10 mL/kg boluses of isotonic crystalloid, repeating up to 60 mL/kg total, using a more cautious approach than in older children. 1, 4
• Begin prostaglandin infusion (0.05-0.1 mcg/kg/min) until ductal-dependent congenital heart disease is excluded. 1, 4
• Monitor for patent ductus arteriosus in very low birth weight infants, as rapid fluid administration may worsen left-to-right shunting and cause pulmonary edema. 1

Fluid-Refractory Shock (After 40-60 mL/kg)

If shock persists after 40-60 mL/kg of fluid within 15 minutes, immediately initiate vasoactive medications while establishing central venous access. 1, 2

Initial Vasoactive Therapy

• Start dopamine 5-10 mcg/kg/min via peripheral or IO access as first-line agent for fluid-refractory shock. 1, 5
• If central access is available, titrate epinephrine 0.05-0.3 mcg/kg/min for cold shock (poor perfusion, cool extremities, weak pulses). 1
• For warm shock (bounding pulses, flash capillary refill, wide pulse pressure), titrate norepinephrine 0.05-1 mcg/kg/min to restore vascular tone. 1

Neonatal-Specific Vasoactive Therapy

• Start dopamine 5-9 mcg/kg/min, then add dobutamine up to 10 mcg/kg/min if shock persists. 1, 4
• Escalate to epinephrine 0.05-0.3 mcg/kg/min if dopamine-dobutamine combination fails. 1, 4

Catecholamine-Resistant Shock (After 60 minutes)

For shock persisting beyond 60 minutes despite adequate fluid and catecholamines, perform advanced hemodynamic assessment and adjust therapy based on cardiac output and vascular resistance patterns. 1

Hemodynamic Monitoring Goals

• Target ScvO2 >70%, cardiac index 3.3-6.0 L/min/m², MAP-CVP (perfusion pressure) normal for age, capillary refill ≤2 seconds, urine output >1 mL/kg/h. 1
• Use echocardiography, Doppler ultrasound, or invasive monitoring (pulmonary artery catheter, PICCO) to guide therapy when shock persists. 1

Low Cardiac Output with High SVR (Cold Shock)

• Add milrinone loading dose 50 mcg/kg over 10-60 minutes, then 0.25-0.75 mcg/kg/min infusion to reduce afterload and improve contractility. 1
• Alternative: nitroprusside 0.5-8 mcg/kg/min or nitroglycerin 0.5-5 mcg/kg/min for afterload reduction. 1
• Caution: Type III phosphodiesterase inhibitors have long half-lives and can cause irreversible hypotension or arrhythmias, particularly with renal/hepatic dysfunction. 1

High Cardiac Output with Low SVR (Warm Shock)

• Add norepinephrine to epinephrine to increase diastolic blood pressure and systemic vascular resistance. 1
• If norepinephrine fails, consider vasopressin 0.0003-0.002 units/kg/min (maximum 0.01 units/kg/min), but monitor cardiac output closely as vasopressin can reduce cardiac output. 1

Low Cardiac Output with Low SVR

• Combine norepinephrine (for vascular tone) with dobutamine or milrinone (for inotropy), targeting ScvO2 >70% and cardiac index >3.3 L/min/m². 1

Hormone Replacement Therapy

• Administer hydrocortisone 50 mg/m²/day (stress dosing) to 50 mg/kg/day (shock reversal dosing) if absolute adrenal insufficiency suspected: purpura fulminans, prior steroid exposure, or shock unresponsive to catecholamines. 1
• Obtain baseline cortisol level before hydrocortisone administration when possible, but do not delay treatment waiting for results. 1
• Consider thyroid hormone replacement (triiodothyronine) if hypothyroidism documented. 1

Special Considerations

Shock with Coma (Glasgow Coma Score ≤8)

• Use more cautious fluid resuscitation in children presenting with both shock and coma. 1
• Prefer human albumin solution over saline for volume expansion in this subgroup, as albumin may reduce mortality (5% vs 46% with saline in one trial). 1

Mechanical Ventilation in Shock

• Intubate electively if shock persists despite 40 mL/kg fluid and catecholamines, before respiratory failure develops. 1
• When initiating ventilation in children with severe metabolic acidosis, avoid rapid rise in PaCO2 even to normal levels before acidosis is corrected, as this can precipitate cardiovascular collapse. 1
• Use 8-10 breaths/minute with advanced airway to avoid excessive ventilation. 2

Refractory Shock

• Consider ECMO for refractory pediatric septic shock (39% survival) or sepsis-associated respiratory failure (41% survival) unresponsive to maximal medical therapy. 1, 2, 4
• Veno-arterial ECMO is preferred for refractory shock; veno-venous ECMO for respiratory failure with persistent shock requires continued vasopressor support. 1

Fluid Management After Resuscitation

• Once shock is reversed, use diuretics, peritoneal dialysis, or continuous renal replacement therapy to remove fluid in patients who are >10% fluid overloaded and unable to maintain fluid balance. 1
• Urine output <1 mL/kg/h (absent urinary retention or established renal failure) indicates inadequate renal perfusion and need for continued resuscitation. 1

Critical Pitfalls to Avoid

• Never use dopamine as first-line vasopressor in distributive/septic shock—norepinephrine is superior and dopamine is associated with increased arrhythmias. 2
• Do not add sodium bicarbonate to dopamine infusions, as dopamine is inactivated in alkaline solutions. 5
• Avoid dorsal hand or ankle veins for vasoactive infusions due to high risk of extravasation causing tissue necrosis—use large antecubital veins or central access. 5
• Do not continue aggressive fluid resuscitation once rales or hepatomegaly develop, as this indicates dangerous fluid overload. 1, 2
• Never delay source control in septic shock—drain abscesses, debride necrotizing infections, remove infected devices urgently. 2