Pediatric Septic Shock: Recognition and Management in the Emergency Department

Table of Contents

 

About This Issue

Sepsis is a leading cause of morbidity and mortality in children. Early recognition and timely goal-directed therapy using sepsis bundles has been shown to reduce in-hospital mortality among pediatric patients with sepsis and septic shock. This issue reviews pediatric septic shock management, reinforcing the importance of early recognition and rapid resuscitation. In this issue, you will learn:

Common causes of pediatric septic shock

Historical findings that may indicate sepsis

Physical examination findings that can help distinguish warm and cold shock

Laboratory studies that can be used to evaluate patients with sepsis or those at risk for developing sepsis

Key aspects of therapy for sepsis, including prompt initiation of broad-spectrum antibiotics, fluid resuscitation, and vasoactive support

Recommendations for airway management in patients with septic shock

Special considerations for managing newborns with septic shock

Criteria for critical care admission

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Definitions
7. Etiology and Pathophysiology
8. Differential Diagnosis
9. Prehospital Care
10. Emergency Department Evaluation
    1. History
    2. Physical Examination
       1. Septic Shock with Concurrent Cardiogenic Shock
       2. Warm and Cold Shock
       3. Evolving Physical Examination Findings
11. Diagnostic Studies
    1. Laboratory Studies
    2. Imaging Studies
12. Treatment
    1. Medications
    2. Airway Management
13. Special Populations
    1. Patients With Febrile Neutropenia and Septic Shock
    2. Newborns With Septic Shock
14. Controversies and Cutting Edge
    1. Volume of Fluid Resuscitation
    2. Type of Resuscitation Fluid
    3. Time to Antibiotic Administration
    4. Corticosteroid Use
15. Disposition
16. 5 Things That Will Change Your Practice
17. Risk Management Pitfalls in Pediatric Patients With Septic Shock
18. Summary
19. Time- and Cost-Effective Strategies
20. Case Conclusions
21. Clinical Pathways
    1. American College of Critical Care Medicine Algorithm for Time-Sensitive, Goal-Directed Stepwise Management of Hemodynamic Support in Infants and Children
    2. American College of Critical Care Medicine Algorithm for Time-Sensitive, Goal-Directed Stepwise Management of Hemodynamic Support in Newborns
22. Tables
23. References

Abstract

Sepsis is a leading cause of mor­bidity and mortality in children. Early recognition and timely initiation of empiric broad-spectrum antibiotics and crystalloid fluid administration have been as­sociated with better outcomes. Although evidence for diagnosis and treatment of septic shock was first generated in adult studies, it is clear that pediatric studies are needed for management of septic shock in children. This issue provides guidance for managing septic shock in children, with a focus on early recognition and appropriate resuscitation.

Case Presentations

An 8-year-old boy is brought in by his parents for fever, redness to his left shin, vomiting, and diarrhea...

• The boy’s parents tell you he scraped his shin 5 days earlier while playing at a park. His shin became progressively red and hot. He has had fever with vomiting and diarrhea for 3 days. He started to seem unusually tired, prompting their visit to the ED.
• On examination, the boy is lethargic, with shallow respirations. His vital signs are: temperature, 38.9°C; heart rate, 176 beats/min; respiratory rate, 35 breaths/min; and blood pressure, 80/57 mm Hg. After an initial response to bag-valve mask ventilation, the patient's mental status again deteriorated.
• If the patent needs an advanced airway, what medications should you choose to secure his airway? What are the possible consequences of initiating rapid sequence induction?

A 2-year-old boy with a history of short-bowel syndrome presents with fever and fatigue for 1 day…

• The boy’s short-bowel syndrome is secondary to necrotizing enterocolitis, and he has total parenteral nutrition dependence. He was well 1 day prior and started to have loose stools on the day of presentation. His temperature at home was 38.7°C axillary, and he received a 15 mg/kg dose of acetaminophen en route to the ED.
• The boy’s presenting vital signs are: temperature, 37.8°C; heart rate, 176 beats/min; respiratory rate, 28 breaths/min; blood pressure, 97/42 mm Hg; and oxygen saturation, 95% on his home 0.5 L/min oxygen. He seems tired and is noted to have bounding radial pulses.
• You immediately suspect septic shock based on his fever, fatigue, central line, tachycardia, tachypnea, and bounding pulses. Which antibiotics would be best for this patient? If vasoactive support is needed, which agents should be used first?

A 16-year-old girl with a diagnosis of leukemia presents after a syncopal episode...

• The girl recently completed induction chemotherapy. She was at her routine hospital discharge follow-up visit and had a syncopal episode while walking to the restroom. She has normal mental status, denies fever or vomiting, and reports still feeling dizzy when walking, despite drinking several bottles of water prior to the ED visit.
• The laboratory values obtained from her portacath during her clinical visit do not reveal neutropenia, and her hemoglobin is 10.2 g/dL, with normal electrolytes and a negative pregnancy test. Her vital signs are as follows: temperature, 37.6° C; heart rate, 110 beats/min; respiratory rate, 22 breaths/min; blood pressure, 110/72 mm Hg; and oxygen saturation, 99% on room air.
• What is the cause of her syncope? Why does she remain dizzy?

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Clinical Pathways

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Tables

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

6. * Paul R, Melendez E, Stack A, et al. Improving adherence to PALS septic shock guidelines. Pediatrics. 2014;133(5):e1358-e1366. (Prospective cohort study; 242 patients) DOI: 10.1542/peds.2013-3871

7. * Weiss SL, Balamuth F, Hensley J, et al. The epidemiology of hospital death following pediatric severe sepsis: when, why, and how children with sepsis die. Pediatr Crit Care Med. 2017;18(9):823-830. (Retrospective observational study; 79 patients) DOI: 10.1097/pcc.0000000000001222

9. * Balamuth F, Weiss SL, Neuman MI, et al. Pediatric severe sepsis in U.S. children’s hospitals. Pediatr Crit Care Med. 2014;15(9):798-805. (Observational cohort study) DOI: 10.1097/pcc.0000000000000225

11. * Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign International Guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Pediatr Crit Care Med. 2020;21(2):e52-e106. (Consensus guideline) DOI: 10.1097/pcc.0000000000002198

13. * Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):762-774. (Consensus definition) DOI: 10.1001/jama.2016.0288

14. * Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017;376(23):2235-2244. (Retrospective study; 49,331 patients) DOI: 10.1056/NEJMoa1703058

15. * Evans IVR, Phillips GS, Alpern ER, et al. Association between the New York Sepsis Care Mandate and in-hospital mortality for pediatric sepsis. JAMA. 2018;320(4):358-367. (Cohort study; 1179 patients) DOI: 10.1001/jama.2018.9071

16. * Davis AL, Carcillo JA, Aneja RK, et al. American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Crit Care Med. 2017;45(6):1061-1093. (Consensus guideline) DOI: 10.1097/ccm.0000000000002425

17. * Lane RD, Funai T, Reeder R, et al. High reliability pediatric septic shock quality improvement initiative and decreasing mortality. Pediatrics. 2016;138(4):e20154153. (Retrospective cohort study; 1380 patients) DOI: 10.1542/peds.2015-4153

19. * Balamuth F, Weiss SL, Fitzgerald JC, et al. Protocolized treatment is associated with decreased organ dysfunction in pediatric severe sepsis. Pediatr Crit Care Med. 2016;17(9):817-822. (Retrospective cohort study; 189 patients) DOI: 10.1097/PCC.0000000000000858

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Keywords: shock, septic shock, sepsis, hypotension, sepsis bundle, antibiotics, crystalloid fluids, compensated shock, uncompensated shock, types of shock, warm shock, cold shock, laboratory studies for sepsis, hypotension, fluid resuscitation, shock in immunocompromised patients, airway management, newborn sepsis