How to manage Pediatric Septic Shock?

The three pathophysiologic contributors to septic shock are-

• Different combinations of hypovolemia (relative > absolute)

• Reduced vascular tone or vasoplegia 

• Myocardial dysfunction

The three pillars of hemodynamic support are- 

• Fluid boluses

• Vasopressors with inotrope infusions

• Vasopressors without inotrope infusions

The three end-points of hemodynamic resuscitation are-

• Adequate cardiac output (CO)

• Adequate mean arterial pressure (MAP) and diastolic blood pressure (DBP) for organ perfusion 

• Avoiding congestion (worse filling) parameters 

Post-fluid bolus CO improvements are seen only in 33-50% of septic patients, which is sustained in ≥ 10% due to sepsis-mediated glycocalyx injury. A pragmatic approach would be administering a small bolus (10 mL/kg over 20-30 min) and judging the response based on clinical perfusion markers, pressure elements, and congestive features. 

Vasoplegia characterized by low DBP leads to hypotension in septic shock. Hence, restricted fluid bolus with early low-dose norepinephrine (NE) (0.05- 0.1 µg/kg/min) can be useful. NE can also be used as an initial agent in septic myocardial dysfunction (SMD) to hold adequate coronary perfusion and DBP while minimizing tachycardia and providing inotropy. Additional inotropy (epinephrine/dobutamine) benefits severe SMD. Most vasoactive drugs (except vasopressin) may safely be administered via a peripheral route. The lowest MAP (5th centile for age) is an acceptable target, provided end-organ perfusion is satisfactory. 

A clinical individualized approach considering the history, serial physical assessment, laboratory investigations, available monitoring tools, and repeated assessment to individualize circulatory support will help better outcomes than one-size-fits-all algorithms.

Ranjit S, Natraj R. Hemodynamic Management Strategies in Pediatric Septic Shock: Ten Concepts for the Bedside Practitioner. Indian Pediatrics. 2024;61