Septic shock in pediatric patients?

From the Guidelines

Management of Septic Shock in Pediatric Patients

In pediatric patients with septic shock, initial management involves administration of broad-spectrum antibiotics and fluid resuscitation with crystalloids, aiming to achieve a minimum of 40-60 mL/kg in the first hour 1.

• Broad-spectrum antibiotics, such as ceftriaxone (50-75 mg/kg/dose) or meropenem (20 mg/kg/dose), should be administered promptly.
• Fluid resuscitation with crystalloids, such as normal saline or lactated Ringer's solution, should be initiated to achieve a minimum of 40-60 mL/kg in the first hour 1.
• Vasoactive medications, including epinephrine (0.05-0.5 mcg/kg/min) or norepinephrine (0.05-0.5 mcg/kg/min), may be initiated to support blood pressure and perfusion after initial fluid resuscitation 1.
• Hydrocortisone (50 mg/m2/24 h) may be considered for patients with refractory shock or suspected adrenal insufficiency, administered as a stress dose 1.

The goal of fluid resuscitation is to reverse hypotension, increase urine output, and attain normal capillary refill, peripheral pulses, and level of consciousness without inducing hepatomegaly or rales 1.

• Monitoring of the patient's hemodynamic status, including blood pressure, heart rate, and urine output, is crucial to guide further management.
• Adjustments to fluid resuscitation and vasoactive medications should be made based on the patient's response to initial therapy.

In pediatric patients with septic shock, low cardiac output is associated with mortality, and attainment of a therapeutic goal of cardiac index (CI) 3.3-6.0 L/min/m2 may result in improved survival 1.

• Goal-directed therapies, including the use of inotropes and vasodilators, may be necessary to maintain normal CI and systemic vascular resistance (SVR) in patients with persistent shock.

Overall, the management of septic shock in pediatric patients requires a multidisciplinary approach, including prompt administration of broad-spectrum antibiotics, aggressive fluid resuscitation, and supportive care with vasoactive medications and hydrocortisone as needed.

From the Research

Definition and Epidemiology of Septic Shock in Pediatric Patients

• Septic shock is a leading cause of morbidity, mortality, and health care costs for children worldwide, with over 3 million deaths annually 2.
• The incidence of septic shock is increasing, with mortality rates ranging from 30% to 70% 3.

Clinical Manifestations and Pathophysiology

• Septic shock occurs due to complex interactions between the infecting microorganism(s) and the responses of the human host 3.
• It is characterized by alterations in the coagulant/anticoagulant balance, resulting in a pro-coagulant phenotype 3.

Management and Treatment

• The initial resuscitation and management of pediatric sepsis focus on rapid recognition of abnormal tissue perfusion, restoration of adequate cardiovascular function, eradication of the inciting invasive infection, and supportive care of organ system dysfunction 4.
• Early diagnosis, coordinated and aggressive approach to initial resuscitation, and timely and appropriate antibiotic therapy are crucial to improving outcomes 5.
• The basic tenets of initial and ongoing resuscitation include rapid isotonic intravenous fluid boluses, empiric broad-spectrum antibiotics, source control, vasoactive infusions, and supportive critical care 5.
• Prompt initiation of broad-spectrum empiric antimicrobial therapy, fluid resuscitation, and vasoactive medications are key components of initial management 2.

Resuscitation Strategies

• Goal-directed therapy has been shown to improve outcomes in pediatric severe sepsis and septic shock, although recent trials have failed to replicate these findings 6.
• The use of vasoactive drugs and large volume resuscitation may be associated with worse clinical outcomes, and lower blood pressure targets and restricted volume resuscitation may be feasible and well-tolerated 6.
• Lung protective ventilation and Rivers early goal-directed therapy are recommended for the treatment of patients with septic shock 3.

Antibiotic Therapy and Source Control

• Intravenous broad-spectrum antibiotics should be administered as rapidly as possible, and certainly within one hour, to patients with septic shock 3.
• Empiric antibiotic choice should be directed to cover suspected sources of infection, and definitive management of infections caused by specific organisms should be guided by susceptibility patterns and clinical response 5.