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 — 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
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'.)
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- 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
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS