What are the guidelines for managing shock in a pediatric patient?

Pediatric Shock Management Guidelines

Begin immediate resuscitation with 20 mL/kg isotonic crystalloid boluses (10 mL/kg in neonates) up to and exceeding 60 mL/kg within the first hour, while simultaneously establishing vascular access, correcting hypoglycemia and hypocalcemia, and administering broad-spectrum antibiotics within 60 minutes if septic shock is suspected. 1

Initial Recognition and Stabilization (0-5 Minutes)

Recognition Criteria

• Identify shock by: decreased mental status, capillary refill >2 seconds, weak pulses, cool extremities, tachycardia, and hypotension (though hypotension is a late finding in children) 1
• Establish high-flow oxygen and secure airway if needed 1
• Obtain vascular access via peripheral IV or intraosseous route immediately 1

Immediate Laboratory Assessment

• Blood glucose and ionized calcium (correct immediately if abnormal) 1
• Blood cultures before antibiotics, but do not delay antibiotic administration 2
• Arterial or venous blood gas for lactate and pH 1

Fluid Resuscitation Phase (0-15 Minutes)

Fluid Administration Protocol

• Children and infants: Push 20 mL/kg boluses of isotonic saline or lactated Ringer's solution 1
• Neonates: Push 10 mL/kg boluses 1
• Repeat boluses up to and exceeding 60 mL/kg until perfusion improves 1, 2
• Stop fluid resuscitation if rales or hepatomegaly develop, indicating fluid overload 1

Critical Pitfall

Do not use albumin or gelatin for initial resuscitation - the 2020 Surviving Sepsis Campaign strongly recommends against albumin and suggests against gelatin in pediatric septic shock 1. Use isotonic crystalloids only.

Fluid-Refractory Shock (15-60 Minutes)

Vasoactive Agent Selection

First-line vasoactive agents (start after 40-60 mL/kg fluid resuscitation if shock persists): 1

• Epinephrine is preferred over dopamine (weak recommendation, low quality evidence) 1
• Norepinephrine is preferred over dopamine (weak recommendation, very low quality evidence) 1
• Dopamine may be substituted if epinephrine or norepinephrine are not readily available 1

Peripheral vs. Central Administration

• Begin vasoactive infusions peripherally or via intraosseous access if central venous access is not immediately available 1
• Transition to central access as soon as feasible 1

Dosing Guidelines

• Dopamine: 5-10 mcg/kg/min initially 1
• Epinephrine: 0.05-0.3 mcg/kg/min 1
• Norepinephrine: titrate to restore normal blood pressure and perfusion 1

Shock Phenotype Considerations

The 2020 guidelines suggest against using bedside clinical signs in isolation to categorize shock as "warm" or "cold" 1. Instead, use advanced hemodynamic monitoring when available (cardiac output, systemic vascular resistance, ScvO2) to guide therapy 1.

Catecholamine-Resistant Shock (After 60 Minutes)

Hydrocortisone Therapy

Administer hydrocortisone for fluid-refractory, catecholamine-resistant shock with suspected or proven absolute adrenal insufficiency: 1, 3

• Dosing: 50 mg/m²/24 hours as continuous infusion, or 2 mg/kg IV bolus followed by weight-based continuous infusion 1, 3
• Risk factors for adrenal insufficiency: severe septic shock with purpura, previous chronic steroid therapy, pituitary/adrenal abnormalities 1
• Approximately 25% of children with septic shock have absolute adrenal insufficiency 1, 3

Important Nuance on Steroids

The 2020 Surviving Sepsis Campaign suggests against routine hydrocortisone if adequate fluid resuscitation and vasopressors restore hemodynamic stability 1. However, if stability cannot be achieved, either hydrocortisone or no hydrocortisone may be used (equipoise) 1. This represents evolution from the 2012 guidelines, which more strongly recommended hydrocortisone for catecholamine-resistant shock 1.

Second-Line Vasoactive Agents

• Add vasopressin OR further titrate catecholamines for high-dose catecholamine requirements (no consensus on optimal vasopressin threshold) 1
• Consider inodilators (milrinone, amrinone) for low cardiac output with high systemic vascular resistance 4

Hemodynamic Monitoring and Targets

Monitoring Parameters

• Capillary refill ≤2 seconds 1
• Normal blood pressure for age (though no consensus on targeting 5th vs 50th percentile MAP) 1
• ScvO2 >70% 1
• Cardiac index 3.3-6.0 L/min/m² 1
• Urine output >1 mL/kg/h 1
• Lactate trending downward 1

Advanced Monitoring

Use advanced hemodynamic variables (cardiac output, systemic vascular resistance, ScvO2) in addition to clinical assessment to guide resuscitation when available 1.

Respiratory Support

Intubation Considerations

• No clear recommendation exists on whether to intubate children with fluid-refractory, catecholamine-resistant shock 1
• Avoid etomidate for intubation in septic shock - it suppresses the HPA axis and increases mortality risk 1, 3
• Consider non-invasive ventilation for sepsis-induced PARDS without clear intubation indication if responding to initial resuscitation 1

Ventilation Strategy for PARDS

• Use high PEEP (though exact level not determined) 1
• Consider prone positioning for at least 12 hours daily in severe PARDS 1
• Avoid routine inhaled nitric oxide, but consider as rescue therapy for refractory hypoxemia 1

Transfusion Thresholds

Hemoglobin Targets

• During resuscitation with ScvO2 <70%: Target hemoglobin 10 g/dL 1, 4
• After stabilization: Target hemoglobin 7 g/dL may be reasonable 1

This represents a nuanced approach - the 2020 guidelines suggest similar targets as adults, but acknowledge that the severe sepsis subgroup in the TRIPICU trial had increased nosocomial infections with restrictive transfusion 1.

Refractory Shock

ECMO Consideration

Consider ECMO for refractory pediatric septic shock unresponsive to fluid resuscitation, high-dose catecholamines, and adjunctive therapies 4. Survival rates are 73% for newborns and 39% for older children 4.

Fluid Overload Management

• Use diuretics to reverse fluid overload once shock resolves 4
• Initiate continuous renal replacement therapy to prevent >10% total body weight fluid overload 1, 4

Neonatal-Specific Considerations

Neonatal Resuscitation Protocol

• Smaller fluid boluses: 10 mL/kg (vs 20 mL/kg in older children) 1
• Begin prostaglandin infusion until ductal-dependent lesion ruled out 1
• First-line inotropes: Dopamine 5-9 mcg/kg/min plus dobutamine up to 10 mcg/kg/min 1
• Escalate to epinephrine 0.05-0.3 mcg/kg/min if dopamine-resistant 1

Persistent Pulmonary Hypertension

• Hyperoxygenate with 100% oxygen initially 1
• Metabolic alkalinization to pH 7.50 with sodium bicarbonate 1
• Inhaled nitric oxide as first treatment when available 1
• Target: <5% difference in preductal and postductal oxygen saturation 1

Critical Pitfalls to Avoid

• Never delay antibiotics waiting for cultures in suspected septic shock - mortality increases with each hour of delay 2
• Do not use etomidate for intubation in septic shock 1, 3
• Stop aggressive fluid resuscitation once rales or hepatomegaly develop 1, 2
• Do not use dopamine as first-line vasopressor - epinephrine or norepinephrine are preferred 1
• Avoid albumin and gelatin for initial fluid resuscitation 1
• Do not fast children with adrenal insufficiency for more than 6 hours 3