What is the management approach for pediatric patients presenting with shock?

Management of Pediatric Shock

Immediately recognize shock clinically before hypotension develops by identifying altered mental status, capillary refill >2 seconds, cool extremities, weak peripheral pulses, tachycardia, or bradycardia, then rapidly administer 20 mL/kg isotonic crystalloid boluses up to 60 mL/kg in the first hour, and if shock persists after 40-60 mL/kg, immediately initiate dopamine 5-10 mcg/kg/min or epinephrine for cold shock while establishing central venous access. 1

Initial Recognition and Stabilization

Early recognition is critical because children compensate well initially but can deteriorate rapidly once decompensation occurs. 2

• Recognize shock by clinical signs before blood pressure drops: altered mental status, capillary refill >2 seconds, cool extremities, weak peripheral pulses, tachycardia (or bradycardia in infants), decreased urine output, or mottled skin. 1
• Establish high-flow oxygen immediately and secure vascular access (IV or intraosseous) without delay—do not waste time attempting multiple peripheral IV attempts when IO access can be rapidly obtained. 1
• Begin continuous monitoring: pulse oximetry, ECG, temperature, and blood pressure (invasive arterial line preferred once initial stabilization achieved). 1
• Check and immediately correct glucose and ionized calcium levels—both are critical therapeutic endpoints in pediatric shock. 1, 3
• Obtain blood cultures before antibiotics if septic shock suspected, but never delay antibiotic administration beyond 1 hour as mortality increases with each hour of delay. 1

Fluid Resuscitation Protocol

Aggressive fluid resuscitation is the cornerstone of initial shock management in pediatric patients. 4

• Administer 20 mL/kg boluses of isotonic crystalloid (normal saline or lactated Ringer's solution) rapidly, repeating up to and exceeding 60 mL/kg in the first hour. 1, 3
• Children commonly require 40-60 mL/kg in the first hour, and up to 200 mL/kg total can be administered if no signs of fluid overload develop. 1, 3
• Stop fluid boluses immediately if rales or hepatomegaly develop, indicating pulmonary edema or fluid overload. 1
• For hemorrhagic shock specifically, crystalloid resuscitation with lactated Ringer's solution is standard, with maximum 60 mL/kg in the first hour. 3, 5

Special Fluid Considerations

• Use more cautious fluid resuscitation in children presenting with both shock and coma—prefer human albumin solution over saline for volume expansion in this subgroup as albumin may reduce mortality. 1
• Transfuse red blood cells to children with hemoglobin <10 g/dL, particularly in hemorrhagic shock or active bleeding. 6, 3
• Administer fresh frozen plasma as an infusion (not bolus) for patients with prolonged INR. 6

Fluid-Refractory Shock Management

If shock persists after 40-60 mL/kg of fluid, this defines fluid-refractory shock and requires immediate vasoactive medication. 1

First-Line Vasoactive Agents

• Start dopamine 5-10 mcg/kg/min as first-line agent for fluid-refractory shock while establishing central venous access. 1, 3, 7
• Dopamine is indicated for correction of hemodynamic imbalances in shock due to myocardial infarction, trauma, endotoxic septicemia, open heart surgery, renal failure, and chronic cardiac decompensation. 7

Shock Phenotype-Directed Therapy

• For cold shock (low cardiac output, high systemic vascular resistance): titrate epinephrine 0.05-0.3 mcg/kg/min. 1
• For warm shock (high cardiac output, low systemic vascular resistance): titrate norepinephrine 0.05-1 mcg/kg/min. 1
• For persistent low cardiac output with normal blood pressure and high SVR: use nitroprusside or nitroglycerin as first-line vasodilators; if toxicity develops or low cardiac output persists, substitute milrinone or inamrinone. 6

Advanced Hemodynamic Monitoring

When poor perfusion persists despite initial therapies, advanced monitoring guides further management. 6

• Target ScvO2 >70%, cardiac index 3.3-6.0 L/min/m², and normal perfusion pressure (MAP-CVP) for age. 6, 1
• Use pulmonary artery catheter, pulse index contour cardiac output, femoral artery thermodilution catheter, or Doppler ultrasound when poor perfusion (reduced urine output, acidosis, or hypotension) persists. 6
• Monitor continuously: pulse oximetry, ECG, intraarterial blood pressure, temperature, urine output, central venous pressure/O2 saturation, cardiac output, glucose, calcium, INR, lactate, and anion gap. 6, 3

Management of Metabolic Derangements

Elevated lactate and anion gap require specific interventions beyond fluid resuscitation. 6

• Ensure adequate oxygen delivery (ScvO2 >70%) by achieving hemoglobin ≥10 g/dL and cardiac output >3.3 L/min/m² using volume loading and inotrope/vasodilator support. 6
• Provide appropriate glucose delivery with D10% containing isotonic IV solution at maintenance rate. 6
• For hyperglycemic patients, titrate insulin infusion to maintain glucose 80-150 mg/dL while carefully monitoring to avoid hypoglycemia. 6

Hormone Replacement Therapy

• Administer hydrocortisone 50 mg/m²/day for suspected absolute adrenal insufficiency. 1
• Obtain baseline cortisol level before hydrocortisone when possible, but do not delay treatment waiting for results. 1

Post-Resuscitation Fluid Management

Once shock is reversed, prevent fluid overload complications. 6, 1

• 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 with native urine output. 6, 1
• Urine output <1 mL/kg/h indicates inadequate renal perfusion and need for continued resuscitation. 1

Hemorrhagic Shock-Specific Considerations

Definitive control of bleeding source is obligatory before continuing with more fluids. 3

• Control the source of bleeding surgically as quickly as possible. 3
• Maintain therapeutic endpoints: capillary refill ≤2 seconds, normal pulses, warm extremities, urine output >1 mL/kg/h, normal mental status, normal blood pressure for age, and normal glucose and ionized calcium concentrations. 3

Critical Pitfalls to Avoid

• Never delay antibiotics waiting for cultures in suspected septic shock—mortality increases with each hour of delay. 1
• Do not continue aggressive fluid resuscitation once rales or hepatomegaly develop—this indicates fluid overload. 1
• Do not waste time attempting multiple peripheral IV attempts when IO access can be rapidly obtained. 1
• Recognize that hemodynamic states may completely change with time—children with persistent shock commonly have worsening cardiac failure, requiring reassessment and adjustment of therapy. 6
• Pay attention to dopamine dosing—at higher than optimal doses, urinary flow may decrease, requiring dose reduction. 7