Septic shock in children: Ongoing management after resuscitation
- Scott L Weiss, MD
Scott L Weiss, MD
- Assistant Professor of Anesthesiology, Critical Care, and Pediatrics
- The Children’s Hospital of Philadelphia, University of Pennsylvania
- Wendy J Pomerantz, MD, MS
Wendy J Pomerantz, MD, MS
- Co-Director, Injury Free Coalition of Greater Cincinnati
- Professor of Clinical Pediatrics
- Cincinnati Children's Hospital Medical Center
- Section Editors
- Susan B Torrey, MD
Susan B Torrey, MD
- Section Editor — Pediatric Resuscitation; Pediatric Trauma
- Associate Professor of Pediatrics
- Baylor College of Medicine
- Pediatric Emergency Medicine
- Texas Children’s Hospital
- Adrienne G Randolph, MD, MSc
Adrienne G Randolph, MD, MSc
- Section Editor — Pediatric Critical Care Medicine
- Professor of Anaesthesia and Pediatrics
- Harvard Medical School
- Sheldon L Kaplan, MD
Sheldon L Kaplan, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Infectious Diseases
- Professor and Vice Chairman for Clinical Affairs
- Baylor College of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The management of severe sepsis and septic shock in children after the first hour of resuscitation is reviewed here. The rapid recognition and initial resuscitation of pediatric septic shock and the definitions, epidemiology, and clinical manifestations of sepsis in children are discussed separately. (See "Septic shock in children: Rapid recognition and initial resuscitation (first hour)" and "Systemic inflammatory response syndrome (SIRS) and sepsis in children: Definitions, epidemiology, clinical manifestations, and diagnosis".)
The key interventions in the initial resuscitation of children from septic shock are discussed in detail separately. (See "Septic shock in children: Rapid recognition and initial resuscitation (first hour)".)
INSTITUTIONAL "BUNDLE" FOR STABILIZATION BEYOND THE FIRST HOUR
Each pediatric institution should develop a multidisciplinary approach to the ongoing management of children with septic shock. Key aspects of the bundle include multimodal monitoring to optimize therapies designed to achieve hemodynamic goals (table 1) and to confirm appropriate treatment of infection (ie, appropriate antimicrobial therapy and source control .
APPROACH TO ONGOING MANAGEMENT
Whenever possible, children requiring resuscitation for septic shock should receive ongoing management by a pediatric critical care specialist or pediatrician with similar expertise in a pediatric intensive care unit (PICU).
Repeated, frequent assessment of the patient in septic shock is essential to good outcomes. In children who have responded to initial resuscitation in the first hour with resolution of hypotension, ongoing monitoring, antimicrobial therapy, and optimal respiratory support must continue.
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- INSTITUTIONAL "BUNDLE" FOR STABILIZATION BEYOND THE FIRST HOUR
- APPROACH TO ONGOING MANAGEMENT
- Eradicate infection
- Continue respiratory support
- Ongoing and invasive monitoring
- Continue fluid administration
- - Fluid overload
- Blood transfusion
- Treat disseminated intravascular coagulation
- Manage glucose abnormalities
- Avoid hypocalcemia
- Treat known hormonal deficiencies
- REFRACTORY SEPTIC SHOCK
- Treat reversible etiologies
- Obtain cardiac evaluation
- Address adrenal insufficiency
- Combination vasoactive drug therapy
- Extracorporeal membrane oxygenation
- Additional advanced therapies
- - Therapeutic plasma exchange or plasmapheresis
- - Intravenous immune globulin
- - Other therapies
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS