Short-acting barbiturates and propofol are associated with hypotension and should be avoided in children with septic shock. Establishing venous access - IV access (preferably two sites and of the largest caliber that can be inserted reliably) should be established within five minutes in patients with septic shock. Additional discussion of the interpretation of laboratory findings in children with septic shock is provided separately.
Blood transfusion - In hemodynamically unstable children with septic shock (eg, profound hypotension, persistence of lactate >2 mmol/L, progressive/persistent end-organ dysfunction, and/or ScvO <70 percent despite high levels of vasopressor support or profound hypoxia) suggest we blood transfusion to maintain a hemoglobin threshold of 9 g/dL [1,2]. See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Timing'.). See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Vasopressors'.).
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SUMMARY AND RECOMMENDATIONS
Pediatric systemic inflammatory response syndrome vital signs and laboratory values by age
Initial resuscitation of children with septic shock in setting with intensive care capability*
A clinical diagnosis of severe sepsis or septic shock is made in children who have signs of suspected or proven infection, inadequate tissue perfusion, and two or more age-based criteria for systemic inflammatory response syndrome (SIRS). SIRS is present when a child has a temperature abnormality (fever or hypothermia) or age-specific white blood cell count abnormality and one of the following: tachycardia, bradycardia, respiratory distress, or pulmonary condition requiring mechanical ventilation. Refer to the UpToDate content on the signs and symptoms of SIRS and recognizing sepsis and septic shock.
A trial of noninvasive ventilation, such as continuous positive airway pressure ventilation or bilevel positive airway pressure ventilation, may avoid the need for endotracheal intubation in selected patients. When performing rapid sequence intubation in children with septic shock, ketamine, if available and not contraindicated (ie, patients younger than three months or with psychosis), is suggested for sedation. If the patient develops signs of fluid overload (eg, rales, worsening respiratory distress, new or worsening oxygen requirement, gallop rhythm, hepatomegaly, or has cardiomegaly or pulmonary edema on chest radiograph), fluid bolus should be removed or reduced (eg, 5 to 10 mL/kg given over 15 minutes).
Consultation with a pediatric infectious disease expert is strongly encouraged for all children with septic shock. See UpToDate topics on recognition and initial resuscitation of septic shock in children for specific regimens. For recommended dosage and administration of dextrose or calcium infusion, refer to UpToDate topics on hypoglycemia or hypocalcemia.
For recommended dosing and administration of vasoactive infusions in children, refer to UpToDate topics on initial resuscitation of septic shock in children. Surviving Sepsis Campaign International guidelines for the management of septic shock and sepsis-associated organ dysfunction in children.
Septic shock trigger/identification tool
American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock.
Acral purpura in disseminated intravascular coagulation
Petechiae
Toxic shock syndrome
Conjunctival suffusion in staphylococcal toxic shock syndrome
Physical findings of volume depletion in infants and children
Skin abscess
Skin nodule associated with Staphyloccoccus aureus infection
Ecthyma gangrenosum
Ecthyma gangrenosum caused by Pseudomonas aeruginosa bacteremia
Rapid sequence intubation in children: Rapid overview of emergency management
Use in children with contraindications to succinylcholine or as a primary paralytic if sugammadex is readily available. Do not use with extensive crush with rhabdomyolysis, chronic skeletal muscle disease (eg, Becker muscular dystrophy), or denervating neuromuscular disease (eg, cerebral palsy with paralysis); 48 to 72 hours after a burn, multiple trauma or If cervical spine injury is not potentially present, place the patient in the "sniffing position" (ie, with the head forward so that the external ear canal is in front of the shoulder and the nose and mouth are toward the ceiling).
Use external laryngeal manipulation or, in infants, gentle annular pressure to optimize the view of the glottis during direct laryngoscopy if the initial view is suboptimal or inadequate despite correct positioning of the laryngoscope blade. Sugammadex at a dose of 16 mg/kg can immediately reverse paralysis when administered approximately 3 minutes after a single dose of rocuronium or vecuronium. Vecuronium can be used in children with contraindications to succinylcholine and when rocuronium is not available.
Defasciculating agents (eg, rocuronium or vecuronium at one-tenth the paralyzing dose) are not routinely recommended for children receiving succinylcholine. The onset of paralysis is slower by the IM route; the clinician should ensure full pre-oxygenation prior to administration whenever possible and be prepared to perform bag-mask ventilation if desaturation occurs before the patient is completely paralyzed for endotracheal intubation. For a description of how to perform the ELM, refer to the UpToDate topics on Emergency Endotracheal Intubation in Children and Rapid Sequence Intubation in Children.
Quick reference for emergency diagnosis and treatment of hypoglycemia in adolescents and children (except neonates).
Rapid overview for diagnosis and treatment of hypoglycemia in adolescents and children (other than neonates) in the Emergency
Monitor blood glucose every 10 to 15 minutes as the effects of glucagon may be transient. Establishing vascular access as soon as possible; if access cannot be achieved and hypoglycemia persists or recurs, ensure that the airway is protected and, if not, secure it by rapid sequence intubation. Then insert a nasogastric tube and administer 0.2 to 0.25 g/kg dextrose using the volume and concentration guidelines for IV administration above.
For patients with diabetes mellitus type 1: provide a normal diet; initiate IV dextrose-containing fluids if intake is inadequate. Measure a rapid plasma glucose level 15 to 30 minutes after the initial IV glucose bolus and then check every 30 to 60 minutes until stable (at least four hours) to ensure that the plasma glucose concentration remains within the normal range (>70 to 100 mg/hour). dL [>3.89 to 5.55 mmol/L]). Obtain a pediatric endocrinology consultation for patients with persistent hypoglycemia and for hypoglycemia of unknown cause.
Obtain a medical toxicology consultation for patients with ingestion of oral hypoglycemic agents by calling a regional poison control center. These findings may also occur in infants with sepsis, congenital heart disease, respiratory distress syndrome, intraventricular hemorrhage, other metabolic disorders, and in children and adolescents with a variety of underlying conditions. Specific laboratory studies that should be obtained in children include blood samples for glucose, insulin, C-peptide, beta-hydroxybutyrate, lactate (free-flowing blood should be obtained without a tourniquet), plasma acylcarnitine, free fatty acids, hormone of growth and cortisol.
Δ Higher doses of glucose (e.g., 0.5 to 1 g/kg [5 to 10 mL/kg 10% dextrose in water or 2 to 4 mL/kg 25% dextrose in water]) are recommended by Pediatric Advanced Life Support and may be necessary to correct hypoglycemia caused by excessive insulin administration or ingestion of sulfonylureas. Glucagon will reverse hypoglycemia caused by excess endogenous or exogenous insulin and will not be effective in patients with inadequate glycogen stores (prolonged fasting), ketotic hypoglycemia, or who are unable to mobilize glycogen (glycogen storage diseases).
Weight-for-age percentiles, females 0 to 24 months, WHO growth standards
Weight-for-age percentiles, males 0 to 24 months, WHO growth standards
Weight-for-age percentiles, males 2 to 20 years, CDC growth charts: United States
Weight-for-age percentiles, females 2 to 20 years, CDC growth charts: United States
Example of setting up an epinephrine infusion for unresponsive anaphylaxis symptoms for a 10 kg pediatric emergency/critical patient. Infuse an initial dose of 0.1 microgram/kg/minute using a programmable infusion pump and titrate as necessary while continuously monitoring the patient's heart rate and blood pressure. For details on titrating the infusion based on response, see the UpToDate topic on emergency treatment of anaphylaxis.
Pediatric dose for 10 kg child Administration rate for infusion pump to deliver pediatric dose shown micrograms. It should only be administered by clinicians trained and experienced in dose titration of intravenous epinephrine using continuous noninvasive electronic monitoring of heart rate and blood pressure. To reduce the risk of a medication error, we suggest that centers have available an institutionally approved protocol for epinephrine infusion that includes steps on how to prepare and administer the infusion and standard concentration(s).
Unused diluted solutions should be discarded within 24 hours or less after preparation, depending on local standards. Example of preparation of epinephrine infusion for refractory symptoms of anaphylaxis for pediatric patients weighing 20 kg for emergency/critical. For more information about titrating the infusion based on response, see the UpToDate topic on the emergency treatment of anaphylaxis.
Pediatric dose for a 20 kg child The rate of administration for the pediatric dose infusion pump is shown in micrograms. Unused diluted solutions should be discarded within 24 hours or less of preparation, depending on local standards.
World Health Organization 2016 guidelines: Fluid management in
In infants and children aged 6 to 59 months, severe acute malnutrition is defined as weight-for-height Z-score <–3 using WHO growth standards, MUAC <11.5 cm, or clinical signs of bilateral edema with nutritional origin.
Rapid overview: Emergency management of infants ( ≥ 1 month) and children with suspected bacterial meningitis
Consider dexamethasone therapy* (0.15 mg/kg IV) in patients with certain risk factors (eg, unimmunized patients) or if Haemophilus influenzae infection is known or suspected (eg, based on Gram stain results). If dexamethasone is given, it should be given before or immediately after the first dose of antibiotic therapy. STAT: the intervention is performed urgently; CBC: complete blood count; CRP: C-reactive protein; BUN: blood urea nitrogen; PT: prothrombin time; INR: International Normalized Ratio; PTT: partial thromboplastin time; LP: lumbar puncture; CT: computed tomography; CSF: cerebrospinal fluid; CNS: central nervous system; IV: Intravenous.
The optimal use of dexamethasone in children with suspected meningitis is uncertain, and expert opinion varies. UpToDate's author would administer dexamethasone only to children known or highly suspected to have H. In addition, it may be reasonable to use dexamethasone in older adolescent patients as dexamethasone is a recommended component of therapy for adult patients with suspected bacterial meningitis.
Evidence supporting the efficacy of dexamethasone in reducing the risk of hearing loss in children with meningitis is most clearly established for infections caused by Hib. For further details, refer to the UpToDate topics on bacterial meningitis in children and the use of dexamethasone and other measures to prevent neurologic complications of pediatric bacterial meningitis.
Cerebrospinal fluid patterns in different causes of viral meningitis in children
Differences in laboratory findings for cerebrospinal fluid samples obtained from patients with meningitis or encephalitis due to herpes simplex virus (HSV) documented by detection of HSV DNA. Clinical and analytical characteristics and short-term evolution of enteroviral meningitis in young infants with fever without a source. Characteristics of young infants in whom human parechovirus, enterovirus, or neither were detected in cerebrospinal fluid during sepsis evaluations.
Rapid overview: Adrenal crisis in children and adolescents
For patients without an existing diagnosis of adrenal insufficiency, obtain baseline blood samples before administration of glucocorticoids for later analysis. If blood samples cannot be taken quickly and the patient is seriously ill, continue treatment immediately. BSA-based dosing is preferred if the patient's BSA is known or if BSA can be readily calculated based on measured height and weight.
