Septic shock: Ongoing management after resuscitation in children
- 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
- Director, Division of Pediatric Emergency Medicine
- Associate Professor of Emergency Medicine and Pediatrics (Clinical)
- NYU School of Medicine
- 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 — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Sepsis is a clinical syndrome complicating severe infection that is characterized by systemic inflammation, immune dysregulation, microcirculatory derangements, and end-organ dysfunction. There is a continuity of severity ranging from sepsis to severe sepsis and septic shock. Severe sepsis and septic shock are characterized by dysfunction of ≥2 organ systems and cardiovascular dysfunction, respectively . With increased attention to rapid recognition, aggressive fluid administration, and early administration of vasoactive agents and antibiotics, pediatric mortality from severe sepsis and septic shock has decreased markedly [2-7].
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: Rapid recognition and initial resuscitation in children" 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: Rapid recognition and initial resuscitation in children".)
Repeated, frequent assessment of the patient in septic shock is essential. In children who have responded to therapy with resolution of hypotension, ongoing monitoring, antimicrobial therapy, and optimal respiratory support are essential.
In patients with fluid-refractory hypotension, ongoing aggressive resuscitation should continue after the initial resuscitation of pediatric septic shock according to the principles of goal-directed therapy (algorithm 1). (See "Septic shock: Rapid recognition and initial resuscitation in children", section on 'Physiologic indicators and target goals'.)
- Goldstein B, Giroir B, Randolph A, International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6:2.
- Odetola FO, Gebremariam A, Freed GL. Patient and hospital correlates of clinical outcomes and resource utilization in severe pediatric sepsis. Pediatrics 2007; 119:487.
- Watson RS, Carcillo JA, Linde-Zwirble WT, et al. The epidemiology of severe sepsis in children in the United States. Am J Respir Crit Care Med 2003; 167:695.
- Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics 2003; 112:793.
- Weiss SL, Parker B, Bullock ME, et al. Defining pediatric sepsis by different criteria: discrepancies in populations and implications for clinical practice. Pediatr Crit Care Med 2012; 13:e219.
- Jaramillo-Bustamante JC, Marín-Agudelo A, Fernández-Laverde M, Bareño-Silva J. Epidemiology of sepsis in pediatric intensive care units: first Colombian multicenter study. Pediatr Crit Care Med 2012; 13:501.
- Kutko MC, Glick RD, Butler LM, et al. Histone deacetylase inhibitors induce growth suppression and cell death in human rhabdomyosarcoma in vitro. Clin Cancer Res 2003; 9:5749.
- Rangel-Frausto MS, Pittet D, Costigan M, et al. The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study. JAMA 1995; 273:117.
- Brun-Buisson C, Doyon F, Carlet J, et al. Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. A multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis. JAMA 1995; 274:968.
- Wheeler AP, Bernard GR. Treating patients with severe sepsis. N Engl J Med 1999; 340:207.
- Randolph AG. Management of acute lung injury and acute respiratory distress syndrome in children. Crit Care Med 2009; 37:2448.
- Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580.
- Santschi M, Jouvet P, Leclerc F, et al. Acute lung injury in children: therapeutic practice and feasibility of international clinical trials. Pediatr Crit Care Med 2010; 11:681.
- Hanson JH, Flori H. Application of the acute respiratory distress syndrome network low-tidal volume strategy to pediatric acute lung injury. Respir Care Clin N Am 2006; 12:349.
- Holt TR, Withington DE, Mitchell E. Which pressure to believe? A comparison of direct arterial with indirect blood pressure measurement techniques in the pediatric intensive care unit. Pediatr Crit Care Med 2011; 12:e391.
- Fernandez EG, Green TP, Sweeney M. Low inferior vena caval catheters for hemodynamic and pulmonary function monitoring in pediatric critical care patients. Pediatr Crit Care Med 2004; 5:14.
- Yung M, Butt W. Inferior vena cava pressure as an estimate of central venous pressure. J Paediatr Child Health 1995; 31:399.
- Carcillo JA, Fields AI, American College of Critical Care Medicine Task Force Committee Members. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002; 30:1365.
- Foland JA, Fortenberry JD, Warshaw BL, et al. Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med 2004; 32:1771.
- Sutherland SM, Zappitelli M, Alexander SR, et al. Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis 2010; 55:316.
- Karam O, Tucci M, Ducruet T, et al. Red blood cell transfusion thresholds in pediatric patients with sepsis. Pediatr Crit Care Med 2011; 12:512.
- Nadel S, Goldstein B, Williams MD, et al. Drotrecogin alfa (activated) in children with severe sepsis: a multicentre phase III randomised controlled trial. Lancet 2007; 369:836.
- Martí-Carvajal AJ, Solà I, Gluud C, et al. Human recombinant protein C for severe sepsis and septic shock in adult and paediatric patients. Cochrane Database Syst Rev 2012; 12:CD004388.
- Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37:666.
- Branco RG, Garcia PC, Piva JP, et al. Glucose level and risk of mortality in pediatric septic shock. Pediatr Crit Care Med 2005; 6:470.
- van Waardenburg DA, Jansen TC, Vos GD, Buurman WA. Hyperglycemia in children with meningococcal sepsis and septic shock: the relation between plasma levels of insulin and inflammatory mediators. J Clin Endocrinol Metab 2006; 91:3916.
- Vlasselaers D, Milants I, Desmet L, et al. Intensive insulin therapy for patients in paediatric intensive care: a prospective, randomised controlled study. Lancet 2009; 373:547.
- Mesotten D, Gielen M, Sterken C, et al. Neurocognitive development of children 4 years after critical illness and treatment with tight glucose control: a randomized controlled trial. JAMA 2012; 308:1641.
- Agus MS, Steil GM, Wypij D, et al. Tight glycemic control versus standard care after pediatric cardiac surgery. N Engl J Med 2012; 367:1208.
- Sarthi M, Lodha R, Vivekanandhan S, Arora NK. Adrenal status in children with septic shock using low-dose stimulation test. Pediatr Crit Care Med 2007; 8:23.
- Zimmerman JJ. Moving beyond Babel. Pediatr Crit Care Med 2007; 8:73.
- Parker MM, Hazelzet JA, Carcillo JA. Pediatric considerations. Crit Care Med 2004; 32:S591.
- Melendez E, Bachur R. Advances in the emergency management of pediatric sepsis. Curr Opin Pediatr 2006; 18:245.
- Hauser, GJ. Early goal-directed therapy of pediatric septic shock in the emergency department. Isr J Emerg Med 2007; 7:5.
- Langer M, Modi BP, Agus M. Adrenal insufficiency in the critically ill neonate and child. Curr Opin Pediatr 2006; 18:448.
- Menon K, Ward RE, Lawson ML, et al. A prospective multicenter study of adrenal function in critically ill children. Am J Respir Crit Care Med 2010; 182:246.
- Markovitz BP, Goodman DM, Watson RS, et al. A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: what is the role of steroids? Pediatr Crit Care Med 2005; 6:270.
- Yildizdas D, Yapicioglu H, Celik U, et al. Terlipressin as a rescue therapy for catecholamine-resistant septic shock in children. Intensive Care Med 2008; 34:511.
- Meyer S, Gortner L, McGuire W, et al. Vasopressin in catecholamine-refractory shock in children. Anaesthesia 2008; 63:228.
- Masutani S, Senzaki H, Ishido H, et al. Vasopressin in the treatment of vasodilatory shock in children. Pediatr Int 2005; 47:132.
- Choong K, Bohn D, Fraser DD, et al. Vasopressin in pediatric vasodilatory shock: a multicenter randomized controlled trial. Am J Respir Crit Care Med 2009; 180:632.
- Barton P, Garcia J, Kouatli A, et al. Hemodynamic effects of i.v. milrinone lactate in pediatric patients with septic shock. A prospective, double-blinded, randomized, placebo-controlled, interventional study. Chest 1996; 109:1302.
- MacLaren G, Butt W, Best D, Donath S. Central extracorporeal membrane oxygenation for refractory pediatric septic shock. Pediatr Crit Care Med 2011; 12:133.
- El-Nawawy A, El-Kinany H, Hamdy El-Sayed M, Boshra N. Intravenous polyclonal immunoglobulin administration to sepsis syndrome patients: a prospective study in a pediatric intensive care unit. J Trop Pediatr 2005; 51:271.
- INIS Collaborative Group, Brocklehurst P, Farrell B, et al. Treatment of neonatal sepsis with intravenous immune globulin. N Engl J Med 2011; 365:1201.
- Nguyen TC, Han YY, Kiss JE, et al. Intensive plasma exchange increases a disintegrin and metalloprotease with thrombospondin motifs-13 activity and reverses organ dysfunction in children with thrombocytopenia-associated multiple organ failure. Crit Care Med 2008; 36:2878.
- Larsen GY, Mecham N, Greenberg R. An emergency department septic shock protocol and care guideline for children initiated at triage. Pediatrics 2011; 127:e1585.
- Kutko MC, Calarco MP, Flaherty MB, et al. Mortality rates in pediatric septic shock with and without multiple organ system failure. Pediatr Crit Care Med 2003; 4:333.
- Proulx F, Fayon M, Farrell CA, et al. Epidemiology of sepsis and multiple organ dysfunction syndrome in children. Chest 1996; 109:1033.
- Graciano AL, Balko JA, Rahn DS, et al. The Pediatric Multiple Organ Dysfunction Score (P-MODS): development and validation of an objective scale to measure the severity of multiple organ dysfunction in critically ill children. Crit Care Med 2005; 33:1484.
- 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
- Advanced therapies
- - Extracorporeal membrane oxygenation (ECMO)
- - Intravenous immune globulin
- EXPERIMENTAL THERAPIES
- Plasma exchange or plasmapheresis
- Other therapies
- GUIDELINE IMPLEMENTATION
- SUMMARY AND RECOMMENDATIONS