What are the diagnostic criteria and first‑hour management of septic shock in a child (neonate to 18 years) presenting with suspected infection and persistent hypotension or tissue‑perfusion abnormalities despite adequate fluid loading?

Pediatric Septic Shock: Diagnosis and First-Hour Management

In a child with suspected infection and persistent hypotension or tissue perfusion abnormalities despite adequate fluid loading, immediately administer broad-spectrum antibiotics within the first hour, continue aggressive fluid resuscitation up to 60 mL/kg in the first hour (or up to 200 mL/kg if needed), and initiate vasoactive support with dopamine or epinephrine if shock persists after 40-60 mL/kg of fluid. 1, 2

Diagnostic Criteria

Clinical Recognition of Septic Shock

Septic shock is diagnosed when a child with proven or suspected infection has persistent hypotension or signs of tissue hypoperfusion despite adequate fluid resuscitation. 1

Key diagnostic features include:

• Perfusion abnormalities: Capillary refill >2 seconds, cold extremities, weak peripheral pulses compared to central pulses, altered mental status, decreased urine output (<1 mL/kg/h) 1, 2
• Hypotension: Systolic blood pressure below age-appropriate norms (though hypotension is a late finding in children and should not delay diagnosis) 1
• Tachycardia: Heart rate persistently elevated for age despite fever control 1
• Temperature instability: <36°C or >38°C 1

Critical Pitfall in Diagnosis

Do not wait for hypotension to diagnose shock in children—hypotension is a late and ominous sign indicating decompensated shock. 1, 3 Children maintain blood pressure through compensatory mechanisms (tachycardia, increased SVR) until cardiovascular collapse is imminent. Diagnosis must be based on perfusion abnormalities even when blood pressure appears normal.

First-Hour Management Algorithm

0-5 Minutes: Immediate Actions

Establish vascular access immediately (peripheral IV or intraosseous if IV cannot be obtained within minutes) and begin high-flow oxygen. 1

• Place intraosseous access if reliable venous access cannot be attained within 1-2 attempts 1, 2
• Begin oxygen supplementation and assess airway patency 1
• Obtain blood cultures before antibiotics if this does not delay antibiotic administration 4

5-15 Minutes: Aggressive Fluid Resuscitation

Administer rapid 20 mL/kg boluses of isotonic crystalloid (0.9% saline or lactated Ringer's) by push or pressure bag, reassessing after each bolus. 1, 2

• Give each bolus over 5-10 minutes 1, 2
• Most children require 40-60 mL/kg in the first hour 1, 2
• Up to 200 mL/kg may be required in the first hour if signs of fluid overload are absent 1
• Stop fluid administration immediately if hepatomegaly, rales, gallop rhythm, or increased work of breathing develops 1, 2

Reassess after each bolus for:

• ≥10% increase in systolic/mean arterial pressure 1, 2, 3
• ≥10% reduction in heart rate 1, 2, 3
• Improved capillary refill (goal ≤2 seconds) 1, 2
• Improved mental status 1, 2
• Warm extremities with strong peripheral pulses 1, 2

5-15 Minutes: Antibiotic Administration

Administer broad-spectrum empiric antibiotics within the first hour of recognition—delays beyond one hour are associated with significantly increased mortality (29% vs 20%). 4

This is a critical time-sensitive intervention that must occur in parallel with fluid resuscitation, not after it. 4

15-60 Minutes: Vasoactive Support for Fluid-Refractory Shock

If shock persists after 40-60 mL/kg of fluid, begin peripheral inotrope (low-dose dopamine or epinephrine) through a second peripheral IV/IO while establishing central venous access. 1

For Cold Shock (Low Cardiac Output, High SVR):

• First-line: Central dopamine 5-10 mcg/kg/min 1
• If dopamine-resistant: Central epinephrine 0.05-0.3 mcg/kg/min 1
• Consider adding dobutamine up to 10 mcg/kg/min if dopamine alone is insufficient 1

For Warm Shock (High Cardiac Output, Low SVR):

• First-line: Central norepinephrine to restore vascular tone 1

Clinical distinction: Cold shock presents with cool extremities, prolonged capillary refill, and narrow pulse pressure (high diastolic BP). Warm shock presents with warm extremities, bounding pulses, and wide pulse pressure (low diastolic BP). 1 Most pediatric septic shock (58%) presents as low cardiac output/high SVR state, contrary to adults who typically have high cardiac output/low SVR. 1

Additional First-Hour Interventions

Correct metabolic derangements immediately:

• Hypoglycemia: Administer D10%-containing isotonic IV solution at maintenance rates 1
• Hypocalcemia: Correct ionized calcium concentration 1

Consider hydrocortisone stress-dose therapy if the child is at risk for absolute adrenal insufficiency (purpura fulminans, prior steroid exposure, congenital adrenal hyperplasia). 1

Hemodynamic Goals and Monitoring

Target Parameters

Therapeutic endpoints to achieve in the first hour and maintain thereafter: 1, 2

• Capillary refill ≤2 seconds 1, 2
• Normal heart rate for age 1, 2
• Normal blood pressure for age 1, 2
• Warm extremities with strong peripheral pulses equal to central pulses 1, 2
• Urine output >1 mL/kg/h 1, 2
• Normal mental status 1, 2

Advanced Hemodynamic Goals (PICU Setting)

Once in intensive care, target: 1

• Cardiac index 3.3-6.0 L/min/m² 1
• Central venous oxygen saturation (ScvO₂) >70% 1
• Normal perfusion pressure (MAP-CVP) for age 1

Attainment of cardiac index >3.3 L/min/m² is associated with improved survival in pediatric septic shock, as low cardiac output—not low SVR—is the primary determinant of mortality in children. 1 This is fundamentally different from adult septic shock, where vasomotor paralysis predominates. 1

Airway Management Considerations

Intubation and mechanical ventilation can reverse shock by reducing oxygen consumption from work of breathing (which can consume up to 40% of cardiac output). 1

Before intubation, ensure adequate volume loading and consider peripheral/central inotropic support, as positive pressure ventilation reduces preload and can precipitate cardiovascular collapse. 1

• Avoid etomidate (associated with adrenal suppression) 1
• Preferred induction: Ketamine with atropine pretreatment and benzodiazepine post-intubation to maintain cardiovascular integrity 1

Special Considerations for Neonates

Neonatal septic shock has unique physiologic considerations: 1

• Smaller initial fluid boluses: 10 mL/kg (rather than 20 mL/kg), up to 60 mL/kg total in first hour 1
• Rule out ductal-dependent congenital heart disease: Begin prostaglandin infusion if cyanosis, heart murmur, or differential upper/lower extremity pulses/pressures are present until echocardiography excludes complex congenital heart disease 1
• Persistent pulmonary hypertension (PPHN): Common in neonatal septic shock; may require inhaled nitric oxide, hyperoxia (100% O₂), and metabolic alkalinization (pH 7.50) 1
• Monitor preductal and postductal oxygen saturation: Goal <5% difference 1

Critical Pitfalls to Avoid

Do not delay antibiotics while completing fluid resuscitation—antibiotic administration beyond one hour doubles mortality risk. 4 These interventions must occur simultaneously.

Do not rely solely on blood pressure to guide therapy—assess comprehensive perfusion parameters including capillary refill, mental status, and urine output. 1, 3

Do not continue aggressive fluid resuscitation without reassessing for fluid overload after each bolus. 1, 2 Signs of overload (hepatomegaly, rales, gallop, increased work of breathing) mandate immediate cessation of fluids and initiation of inotropic support.

Do not use hypotonic fluids for shock resuscitation—only isotonic crystalloid (0.9% saline or lactated Ringer's) should be used. 2, 3

Do not delay vasopressor initiation in fluid-refractory shock—begin after 40-60 mL/kg in children. 1, 2 Persistent shock despite adequate fluid resuscitation requires vasoactive support, not more fluid.