Pediatric Septic Shock Algorithm
Algorithm at a Glance
- Assess for signs and symptoms of sepsis.
- Stabilize the child.
- Appropriately administer fluids.
- Appropriately administer medications as needed.
Goals for Management
The clinician will be able to:
- Identify sepsis early.
- Maintain normal vital signs and oxygen saturation.
- Improve the child’s mental status.
- Improve perfusion.
Pediatric Septic Shock Algorithm Explained
Boxes 1 and 2 are completed within the first 10 to 15 minutes and usually in the emergency department. Boxes 3 through 6 are typically completed in the first hour. Box 7 outlines medication treatment for septic shock.
Box 1: Assess for Signs of Septic Shock
Clinical signs of septic shock include fever and increased or decreased white blood cell count with a shift to the left and increased bands and immature WBCs, along with metabolic acidosis, respiratory alkalosis, and the presence of a petechial or purpuric rash.
The clinician watches for:
- Altered mental status
- Change in heart rate (usually tachycardia)
- Fever or hypothermia
- Increased capillary refill time
- Hypotension or normotension
- Change in peripheral perfusion
Box 2: Initial Stabilization
Goals at this stage are to normalize vital signs, increase perfusion, and improve mental status. The team follows local protocol, which should include:
- Monitoring heart rate, blood pressure, oxygen saturation, and waveform capnography to support ABCs
- Obtaining intravascular access (IV or IO)
- Administering fluid boluses at the rate of 10–20 mL/kg of an isotonic crystalloid solution, followed by an assessment for respiratory distress; fluid bolus administration is repeated as needed
Box 3: Treatment in the First Hour
Within the first hour, the team:
- Draws blood for cultures and other lab tests
- Administers broad-spectrum antibiotics (this step must not be delayed)
- Administers repeat fluid boluses for continued signs of shock while assessing after each bolus for respiratory distress or hepatomegaly
- Administers antipyretics for fever
- Continues to assess for signs of septic shock from Box 1
It’s important clinicians obtain bacteria cultures, as an infectious agent can cause septic shock.
Vancomycin is a broad-spectrum antibiotic commonly used to treat septic shock.
Box 4: Persistent Signs of Shock After 40–60 mL/kg Total Fluid?
If the signs of shock do not persist, the provider proceeds to Box 5.
If the signs of shock persist, the provider proceeds to Box 6.
Box 5: Signs of Shock Are Relieved
If the child’s signs and symptoms are relieved, the provider considers critical care consultation.
Box 6: Persistent Signs of Shock
If the signs of shock are NOT relieved, the team calls for a critical care consult and administers and titrates either epinephrine or norepinephrine.
Related Video – One Quick Question: What is the Epinephrine & Amiodarone Trick?
Box 7: Continued Treatment
When the initial stabilization is complete, the team:
- Establishes a central IV line and arterial pressure monitoring
- Titrates epinephrine or norepinephrine and fluid therapy to treat shock
- Maintains a patent airway and adequate ventilation and oxygenation
- Considers hydrocortisone if the hemodynamics are unresponsive to fluids and vasoactive drug treatment
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