Severe sepsis and septic shock are major causes of death in children. Early recognition in the "golden hour" is critical, as aggressive fluid resuscitation in this period improves survival. The clinical diagnosis of early septic shock is based on signs of infection with hypothermia/hyperthermia, decreased mental status, prolonged capillary refill time, diminished or bounding pulses, and decreased urine output. Initial treatment involves rapid fluid boluses and broad-spectrum antibiotics within 1 hour. For fluid-refractory shock, vasoactive drugs like dopamine should be started, and for shock refractory to fluids and dopamine, other inotropes and vasopressors may be considered. The goal of resusc

1. MANAGEMENTOFSEPTICSHOCK

2. Severe sepsis and septic shock are the two
major causes of death in children with sepsis.
The incidence of septic shock is 2 – 4% of
admissions in western PICUs & 40% - 67% for
Indian PICUs.

3. Sepsis is the systemic response to infection with bacteria, viruses,
fungi, protozoa, or rickettsiae.
Severe sepsis is defined as sepsis plus one of the following –
• Cardiovascular organ dysfunction or;
• Acute respiratory distress syndrome or;
• Two or more other organ dysfunctions.
Septic shock in a child with sepsis is defined by the presence of –
• Hypotension (systolic BP < 70 mm Hg in infant); (< 70 + 2 × age after one
year) or;
• Need for any vasoactive drug to maintain BP above 5th centile range or;
• Signs of hypo-perfusion (any three of the following) or;
1. decreased pulse volume
2. capillary refilling time > 3 sec
3. tachycardia ( > 190/min in newborn; >160 in infants; >110 in a 10 yr
child)
4. difference in core to peripheral temp. > 3°C
5. urine output < 1 ml/kg/hr
6. Tache Cerebrale - stroke skin with a blunt instrument -> 30-60 sec ->
raised red rash
• Sepsis and cardiovascular organ dysfunction.

4. Early Recognition of Septic shock
The first hours following the diagnosis of severe sepsis and septic
shock are known as the “golden hour” as it is during this
period that aggressive hemodynamic resuscitation has been
shown to be associated with higher survival rates & reduced
organ dysfunctions.
The major cause of loss of “golden hours” in our country may be
due to –
• Delay in recognition
• Delay in transport
• Delay in initiating treatment

5. The clinical diagnosis of early septic shock is possible with presence of the
following in a case of suspected infection –
• Hypothermia or hyperthermia
• Decreased mental status
• Prolonged CRT
• Diminished or bounding pulses
• Mottled cool extremities
• Decreased urine output <1 ml/kg/hr
BP drops only in late shock & its presence in a child with suspected infection
is confirmatory.
The shock is further classified as –
Cold shock – characterized by signs of decreased perfusion with diminished
peripheral pulses.
Warm shock – characterized by signs of decreased perfusion with bounding
peripheral pulses.

6. PRINCIPLES OF MANAGEMENT
Initial treatment of child with septic shock –
This includes aggressive fluid resuscitation of up to
60 ml/kg as boluses of 20 ml/kg of isotonic crystalloid such as
Ringer lactate or Normal saline by I/V push in 10 to 15 mins to
achieve desired heart rate and blood pressure.
Colloids (starch, gelatins) produce greater & more sustained
increase in plasma volume, but they may not be readily
available.
Fluid overload should be assessed by –
• Jugular venous distension
• Increasing liver span
• Puffy eyelids
• Signs of pulmonary edema & congestion on chest radiograph

7. If a patient does not respond to aggressive fluid therapy,
vasoactive drugs should be started.
• Dopamine is recommended as the first line agent in a
fluid refractory shock, started at a infusion rate of 10
µg/kg/min.
• Dobutamine is to be used as the first choice in children
with normal BP & low cardiac output.
• Mixing of more than one vasoactive drug in the same
infusion set is not recommended.
• Infusion should be prepared in D5% or D5% with NS

8. Management in Intensive care setting –
In case of fluid refractory shock, central venous line should be
inserted & vasoactive drugs like dopamine and dobutamine be
started.
In case of shock refractory to these above drugs, epinephrine & nor-
epinephrine can be used depending on whether the child has
cold shock or warm shock, respectively.
If there is no response to the above catecholamines, then ScvO2
can be monitored & vasodilators/ PDE inhibitors can be added in
children with normal BP & cold shock with ScvO2 <70%.
In children with low BP, either epi. or nor-epi. can be titrated
depending on whether it is cold shock or warm shock.

9. Early initiation of Appropriate Antimicrobial
Therapy
Administration of broad spectrum antibiotic to cover the likely
pathogens (including gram +ve and gram -ve) within 1 h of dx
of septic shock as well as reassessment after microbiologic
data is available, to narrow the coverage, is recommended.
Blood culture should be obtained before starting antibiotic.
Source control- All pts. should be evaluated for presence of focus
of infection amenable to source control measures like abscess
drainage, debridement of necrotic tissue, or removal of
infective device.

10. Use of adjuvant therapy like steroid
Steroid are to be used only in children with suspected or
proven adrenal insufficiency which shows high prevalence
in septic shock, especially catecholamine refractory shock.
Mechanical Ventilation
• Due to low functional residual capacity young infants and
neonates with severe sepsis may require early intubation.
• The early use of mechanical ventilation aided by sedation
reduces the work of breathing and allows for redistribution
of limited cardiac output to vital organs, improves
oxygenation and decreases PVR & left ventricular afterload.

11. Blood products
Hb conc. Should be maintained at a minimal level of 10 g/dL.
Platelet transfusion should be done when
PC < 5000/mm³ regardless of apparent bleeding.
PC 5000-30,000/mm³ with significant risk of bleeding.
Higher PC > 50,000/mm³ are typically required for surgery or
invasive procedure.
FFP is indicated in-
Active bleeding
Before surgery
Before invasive procedure
Reverse warfarin effect

12. Other supportive care
Avoid hypoglycemia
Prophylaxis for DVT in post-pubertal children
Correction of symptomatic hypocalcemia
Renal replacement therapy
Done for ARF which includes peritoneal dialysis, intermittent
hemodialysis, cont. renal replacement therapies
IV immunoglobulin
IVIg has shown to reduce mortality and length of PICU stay and
less progression to complications, esp. DIC.

13. Therapeutic end points of
resuscitation of septic shock
• Normalization of HR
• CRT ≤ 2 sec.
• Palpable peripheral pulses with no difference b/w
peripheral and central pulses
• Warm extremities
• Normal BP and PP
• UO > 1 ml/kg/hr
• Return to baseline mental status, tone and posture
• Normal RR

14. Algorithm

15. •Recognize depressed mental status and poor perfusion in a febrile
child with or without foci of infection
•O2 by non-rebreathing mask if effortless tachypnea and septic
shock
•BMV if arirway unstable, bradypnea, apnea; plan early intubation
•Establish IV/IO access
•Start saline/RL 20 ml/kg over 15-20 min(BP N/High); more rapidly
by pull-push if BP is low.
•First dose of antibiotics, correct documented hypoglycemia and
hypocalcemia
•Monitor for clinical therapeutic goals after each bolus till all goals
are achieved; viz RR, work of breathing, HR, CRT, BP, peripheral
temp., UO, sensorium, liver span
0 min
5 min

16. 20 min
40 min
Therapeutic goals
attained
No PE/hepatomegaly
Goals not attained
No PE/hepatomegaly
Goals not attained
PE/hepatomegaly
2nd bolus
3rd bolus, if needed
Goals not attained
PE/hepatomegaly
Goals not attained
after 60 ml/kg
No PE/hepatomegaly
Fluid refractory shock
Start dopamine, interrupt
fluids briefly, intubate,
catheterize
Start PPV

17. 20 min
40 min
Goals not attained
PE/ hepatomegaly
Goals not attained
after 60 ml/kg
No PE/ hepatomegaly
Fluid refractory shock
Start dopamine, interrupt
fluids briefly, intubate,
catheterize
Start PPV
Dopamine @ 10-20 microgram/kg/min
Consider intubation
Catheterize for UO monitoring
Cont. fluids in smaller amount, till goals
attained or
PE/hepatomegaly occur
PE and hepatomegaly
resolve
Goals not attained
Titrate 10-20 ml/kg @
10-20 min until goals
achieved
PE/hepatomegaly recur
Or PE/hepatomegaly
not resolved, No further
fluids
Fluid refractory dopamine
resistant shock
Continue monitoring
Goals achieved
Shift to ICU
60 min

18. Fluid refractory, Dopamine/Dobutamine resistant shock
Reassess clinical status, and
Wherever possible, monitor BP, CVP, perform echocardiography, check ScVO2
And Hb and PCCV
Cold shock Warm shock
BP >5th centileHypotensive
Low pulse pressure
≤ 20 mm Hg
Start epinephrine
< 0.3 µg/kg/min
Epinephrine resistant low CO
If BP normal add nitroso
vasidilator or add milrinone
after volume loading
If PP is low-
milrinone
If PP is N-titrate
NE+dobutamine
Hydrocortisone
50 mg/m²/dose
Hypotensive
Wide pulse pressure,
Target-PP < 40 mm Hg
Titrate NE up @
0.1-1 µg/kg/min
and fluids
Catecholamine
Resistant Shock
Consider
vasopressin

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