Guideline for the management of septic shock in children after the first hour
Paediatric Intensive Care Unit

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1. Aims
2. Target group
3. Introduction
4. Definitions
5. Resuscitation and initial management
6. Approach to ongoing management
7. Flowchart

1. Aims

To provide clear and structured guidance for the management of children with septic shock after the first hour of resuscitation who are admitted to the Paediatric Intensive Care Unit at Leeds Children’s Hospital.

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2. Target group

Medical, nursing and allied health professional staff working on the Paediatric Intensive Care Unit at Leeds Children’s Hospital.

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3. Introduction

Children with septic shock require early and aggressive management in order to optimise their survival. Mortality in children requiring PICU for septic shock is up to 25%. Children with the highest risk of poor outcome include:

• Those between the ages of 1-12 months (around 11% mortality)
• Those with other co-morbidities, especially children with cancer or HIV infection (12-16% mortality)
• Those with infections in the CNS, with endocarditis, and primary bacteraemia (15-20% mortality)
• Those with pneumococcal or fungal sepsis (15% and 13% respectively)
• Those with multi-organ failure (mortality estimated at 0-7% for one affected organ system versus 20-50% with two or more failing systems)
• Those on >1 vasoactive infusion

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4. Definitions

Sepsis is a clinical syndrome complicating severe infection that is characterized by systemic inflammation, immune dysregulation, microcirculatory derangements, and end organ dysfunction.

Septic shock refers to sepsis with cardiovascular dysfunction that persists despite administration of >40ml/kg fluid bolus in one hour.

Catecholamine-resistant shock is generally defined as cardiovascular dysfunction despite at least 40-60ml/kg fluid resuscitation and escalating doses of adrenaline, noradrenaline or dopamine.

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5. Resuscitation and initial management

The main components of initial management are identification of severe sepsis or septic shock, rapid clinical assessment, and rapid initiation of resuscitation. The key interventions in the initial resuscitation of children in septic shock should be according to Advanced Paediatric Life Support guidelines.
Goals in the first hour of resuscitation are to restore or maintain airway, breathing and circulation. To achieve this, the follow actions should be taken:

• Maintain airway, oxygenation and ventilation
• Vascular access within 5 minutes
• Start fluid resuscitation within 30 minutes
• Give broad spectrum antibiotics within 60 minutes
• For children with fluid-refractory shock, start peripheral or central inotropes within 60 minutes

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6. Approach to ongoing management

Frequent reassessment is key to guiding clinical management and optimizing outcomes. In children who have responded to initial resuscitation, ongoing monitoring and antimicrobial therapy, with further treatment as needed, should continue.

In children with fluid-refractory hypotension, aggressive therapy should be targeted to therapeutic endpoints, under the guidance of a consultant in paediatric intensive care.

Priorities for the continued management of children with septic shock include:

• Identify and treat the source of infection
• Provide optimal respiratory support
• Monitor tissue perfusion (capillary refill, heart rate, pulse volume, lactate, urine output, mental status)
• Correct electrolyte and metabolic derangements

In children with fluid-refractory septic shock requiring vasopressor support, additional priorities include:

• Invasive monitoring (central venous line, arterial line, urinary catheter)
• Continued fluid resuscitation and vasopressor delivery
• Administration of blood products as required
• Treatment of adrenal insufficiency and evaluation of other potential reversible causes
• Provision of advanced therapies when not responding to conventional therapy

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