What is the management of septic shock in pediatric patients?

Management of Septic Shock in Children

Administer empiric broad-spectrum antibiotics within 1 hour of recognizing septic shock, initiate aggressive fluid resuscitation with up to 40-60 mL/kg of crystalloids over the first hour (titrated to clinical markers and stopped if fluid overload develops), and begin peripheral inotropic support immediately if the child remains fluid-refractory. 1, 2

Immediate Recognition and Time-Critical Actions (First 5-15 Minutes)

• Begin initial resuscitation immediately upon recognizing septic shock, defined by abnormal vital signs, altered mental status, decreased capillary refill (>2 seconds), diminished peripheral pulses, and decreased urine output 2
• Obtain blood cultures before antibiotics when possible, but never delay antibiotic administration beyond obtaining specimens 1
• Correct hypoglycemia and hypocalcemia during initial assessment 2
• Assess for reversible causes including pneumothorax, pericardial tamponade, or endocrine emergencies in refractory cases 1

Antimicrobial Therapy (Within 1 Hour)

• Start broad-spectrum empiric antibiotics within 1 hour of recognizing septic shock—this is non-negotiable and directly impacts mortality 1, 2
• Choose empiric coverage based on local epidemiology and patient-specific risk factors (recent ICU stay, neutropenia, H1N1, MRSA, resistant organisms) 1
• Add clindamycin and anti-toxin therapies for suspected toxic shock syndromes with refractory hypotension 1
• Perform daily assessment starting at 48 hours to guide de-escalation based on culture results, clinical improvement, and inflammatory markers 1, 2

Fluid Resuscitation (First Hour)

In Healthcare Systems WITH Intensive Care Availability:

• Administer 40-60 mL/kg in boluses (10-20 mL/kg per bolus) over the first hour 1, 2
• Titrate to clinical markers of cardiac output: heart rate, blood pressure, capillary refill time, level of consciousness, and urine output 1, 2
• Stop fluid boluses immediately if signs of fluid overload develop (hepatomegaly, rales/pulmonary edema, new or worsening hepatomegaly) 1, 2
• Use balanced/buffered crystalloids (e.g., lactated Ringer's) rather than 0.9% saline as first-line 1
• Avoid albumin for initial resuscitation (crystalloids are equally effective and more cost-effective) 1
• Never use starches (strong recommendation against) 1

In Healthcare Systems WITHOUT Intensive Care Availability:

• Do NOT give bolus fluids if hypotension is absent—start maintenance fluids only 1
• If hypotension is present, give up to 40 mL/kg in boluses with careful titration and frequent reassessment 1

Critical Pitfall to Avoid:

Do not continue fluid administration if hepatomegaly or rales develop—this indicates the need to switch to inotropic support, not more fluids 1, 2. Continuing fluids despite overload worsens outcomes 2.

Hemodynamic Support (Within 15 Minutes if Fluid-Refractory)

• Begin peripheral inotropic support immediately if the child does not respond to initial fluid resuscitation—do not wait for central access 1, 2
• For cold shock (high systemic vascular resistance, low cardiac output): titrate central dopamine, or if resistant, titrate central epinephrine 2
• For warm shock (low systemic vascular resistance): titrate central norepinephrine 2
• Add vasodilator therapies (e.g., milrinone, nitroprusside) for patients with low cardiac output and elevated systemic vascular resistance who have normal blood pressure 1

Corticosteroid Therapy (Within 60 Minutes if Indicated)

• Administer hydrocortisone for fluid-refractory, catecholamine-resistant shock with suspected or proven absolute adrenal insufficiency 1, 2
• Consider hydrocortisone within 60 minutes for catecholamine-resistant shock in at-risk patients 2

Source Control

• Implement emergent source control as soon as possible after diagnosis (e.g., surgical drainage, abscess removal) 1, 2
• Remove intravascular access devices confirmed as the infection source after establishing alternative vascular access 1, 2
• Perform thorough examination for focal infection sites (umbilicus, skin, respiratory tract, joints) 2

Supportive Care and Monitoring

Blood Product Management:

• Target hemoglobin of 10 g/dL during resuscitation of low superior vena cava oxygen saturation shock (<70%); after stabilization, a lower target of <7 g/dL is acceptable 1, 2
• Use plasma therapies for sepsis-induced thrombotic purpura disorders (DIC, secondary thrombotic microangiopathy, TTP) 1, 2

Mechanical Ventilation:

• Use lung-protective strategies if mechanical ventilation is required 1, 2
• Secure airway within 15 minutes if needed for shock management 2

Metabolic Management:

• Control hyperglycemia with target <180 mg/dL 1, 2
• Always accompany insulin therapy with glucose infusion in newborns and children (some are insulin-deficient, others insulin-resistant) 1, 2

Drug Monitoring:

• Monitor drug toxicity labs closely because drug metabolism is reduced during severe sepsis, increasing risk of adverse events 1, 2

Sedation:

• Use sedation with a defined sedation goal in mechanically ventilated patients 1

Refractory Shock Management

• Consider ECMO for refractory pediatric septic shock and respiratory failure 1, 2
• Use diuretics to reverse fluid overload once shock has resolved 1, 2
• If diuretics fail, initiate continuous venovenous hemofiltration (CVVH) or intermittent dialysis to prevent fluid overload 1, 2

Duration of Antimicrobial Therapy

• Determine duration based on site of infection, microbial etiology, response to treatment, and ability to achieve source control 1, 2
• If cultures are negative at 48 hours and clinical probability of sepsis is low with clinical improvement, discontinue antibiotics 2
• Adjust based on pathogen identified and ongoing clinical response 1, 2

Common Pitfalls to Avoid

• Do not rely solely on blood pressure as an endpoint for resuscitation in children—assess multiple clinical markers of perfusion (capillary refill, mental status, urine output, peripheral pulses) 2
• Do not delay antibiotics waiting for all cultures—obtain blood cultures quickly but never delay antimicrobial therapy beyond specimen collection 1, 2
• Do not underestimate the need for early inotropic support—delaying inotropes in fluid-refractory shock increases mortality 2
• Do not continue fluid boluses if signs of fluid overload appear—switch to inotropic support immediately 1, 2
• Do not forget frequent reassessment—clinical status can change rapidly, requiring adjustment of fluids, inotropes, and antimicrobials 1, 2