Recognizing Pediatric Septic Shock: Treatment Guidelines | EB Medicine
TOC Will Appear Here

Septic Shock: Recognizing And Managing This Life-Threatening Condition In Pediatric Patients

Below is a free preview. Log in or subscribe for full access. Or, get a free sample article ED Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion:
Please provide a valid email address.
Table of Contents
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Epidemiology, Etiology, And Pathophysiology
    1. Epidemiology
    2. Etiology
    3. Pathophysiology
      1. Destruction Of Cellular Integrity
      2. Organ Dysfunction
      3. Onset Of Septic Shock
      4. From Systemic Inflammatory Response Syndrome To Septic Shock
  6. Differential Diagnosis
    1. Hypovolemic Shock
    2. Distributive Shock Distributive
    3. Cardiogenic Shock
    4. Obstructive Shock
    5. Adrenal Insufficiency (Endocrinologic Shock)
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. Initial Evaluation And Resuscitation
      1. Obtain A Focused History
      2. Provide Ventilation And Oxygen
      3. Obtain Vascular Access And Begin Fluid Resuscitation
      4. Administer Antibiotics Early
      5. Cautions In Patients With Decreased Cardiac Function
      6. Focus Care And Obtain Additional History
    2. Respiratory Support
      1. Medications For Rapid Sequence Intubation
        • Ketamine And Etomidate
        • Modified Rapid Sequence Intubation Technique
        • Atropine
      2. Endotracheal Tubes
      3. Airway Pressures
      4. Measuring Ventilatory Status
    3. Vascular Access
    4. Fluid Resuscitation
      1. Alternative Fluids For Resuscitation
      2. Determining Volume Status
    5. Inotropic And Vasoactive Agents
      1. Dopamine
      2. Epinephrine
      3. Milrinone
      4. Norepinephrine And Vasopressin
    6. Antibiotics
    7. Corticosteroids
  9. Monitoring Response To Therapy
  10. Diagnostic Studies
  11. Special Circumstances
  12. Controversies And Cutting Edge
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls For Pediatric Septic Shock
  16. Time- And Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway For Emergency Department Management Of Septic Shock In Pediatric Patients
  19. Tables and Figures
    1. Table 1.Risk Factors For Septic Shock
    2. Table 2. Sepsis, Septic Shock, And Shock Syndromes Definitions
    3. Table 3. Etiologies Of Cardiogenic Shock
    4. Table 4. Approximate Size And Depth For Placement Of Endotracheal Tubes And Central Venous Lines
    5. Table 5. Inotropes Mechanism, Doses, And Clinical Indications In Patients With Shock
    6. Table 6. Antibiotics Commonly Used In The Treatment Of Septic Shock
    7. Table 7. Normal Vital Signs For Pediatric Patients
    8. Table 8. Diagnostic Studies And Utility Of Each Test In The Management Of Septic Shock
  20. References


Septic shock is a relatively rare but life-threatening condition in pediatric patients that can often be difficult to recognize in the emergency department. Once recognized, the emphasis of therapy is to reverse deficits in cellular respiration by increasing oxygen and other substrate delivery to tissue beds. Providing oxygen, improving tissue perfusion through augmentation of cardiac output, and administering antibiotics in a timely manner have all been shown to significantly improve outcomes in children with septic shock. Goal-directed therapy is relatively straightforward, emphasizes the need for effective surveillance and timely recognition of this disease process, and has the potential to significantly reduce morbidity and mortality. This review discusses how to identify specific populations at the greatest risk for septic shock, lays out the essential components of goal-directed therapy, examines potential pitfalls in management, and distinguishes additional ways that emergency clinicians can avoid the devastating consequences of septic shock in pediatric patients.

Case Presentations

During a busy shift in the ED, an adolescent girl is wheeled back from triage. Her right arm is resting on the arm of the wheel chair, and she is holding her head. Her eyes are downcast, and she appears weak. She saw her doctor the day before with complaints of fever, nausea without vomiting, and generalized muscle aches. Her pediatrician diagnosed her with a flu-like illness and recommended plenty of fluids and ibuprofen as an antipyretic and analgesic. Earlier that morning when her parents went in to check on her, she was weak and could barely get out of bed. Her vital signs in the ED are temperature 39.4°C, heart rate of 141 beats/min, and blood pressure of 80/30 mm Hg. You begin examining the patient as a nurse inspects her upper extremities for a site to place a peripheral IV. She has a generalized erythematous non­palpable rash, a slightly red posterior oropharynx, supple neck, clear lung fields, tachycardia with an otherwise normal cardiac examination, lower abdominal tenderness without peritoneal signs, and extremities noticeable for 1+ peripheral pulses, 2+ central pulses, and a capillary refill time of 4 to 5 seconds. You ask the respiratory therapist to provide her oxygen by facemask, and now that the nurse has established an IV line, you ask for a rapid bolus of fluid and start to consider antibiotics. The nurse asks, “What type of fluid and how fast?” You think to yourself, “Which antibiotic should I use, and what will I do if her condition continues to decline?” Then you recall that you didn’t ask when her last menstrual period occurred.

Just then, a nurse rushes back from triage with a 7-month-old boy who is minimally responsive, limp, mottled, and pale. The child’s breathing is not labored, and his airway seems patent. The nurse quickly hooks up the monitors and then starts working to obtain IV access. The child has a pulse, and the monitor shows a heart rate of 190 beats/min, which matches what you feel on examination. The blood pressure cuff inflates, deflates, and re-cycles without giving a reading. The pulse oximeter shows a poor waveform and also seems unable to yield a reading. After several minutes of failed attempts, the nurse looks up and says, “I don’t think I’m going to be able to get this IV in.” You reach for an intraosseous needle driver and needle, and you drill into the infant’s anterior tibia. You ask the nurse to check glucose on the aspirate from the intraosseous needle and start pushing normal saline into it. Realizing just how sick this infant is now, you ask the clerk to call the tertiary children’s hospital to arrange transfer. You obtain a basic history from the mother, and she tells you that her baby is usually healthy, but he has had a fever and a couple of episodes of vomiting overnight. While standing over this child, a number of thoughts come to mind at once: “This kid is obviously in shock. Vomiting can be seen with hypovolemic shock, but his history doesn’t suggest substantial volume loss. Why is this kid in shock? If not hypovolemic shock, what kind of shock is this? Should I go ahead and intubate this baby? Should I start antibiotics even if I don’t know what is causing the infection? When is that transport team from the children’s hospital going to call me back?”

A 3-year-old boy undergoing induction therapy for acute lymphoblastic leukemia presents to the ED, and initially, he looked pretty good. His mother brought him in because he had a fever of 39.1°C at home, and she had been instructed to bring him to the hospital for any fevers. He had been in reasonably good spirits when the nurse accessed his central line to obtain blood for laboratory work and cultures. Only a few minutes have passed when the nurse comes to you saying that she is worried about him because he is still febrile but is now tachycardic and sallow in appearance. You go back to his room and agree with the nurse’s assessment. You ask for 20 mL/kg of normal saline to be rapidly pushed as you confirm that antibiotics have been given. After 2 more 20-mL/kg boluses of normal saline, there is little improvement in his tachycardia or pulses, and his blood pressure is starting to decline. He has developed “flash” cap refill, and he is less interactive. You ask the nurses to prepare a dopamine infusion and start it at 10 mcg/kg/min. You ask yourself, “What else will help with his tachycardia and hypotension? I’ve given him fluids and antibiotics, and I’m starting inotropes. Are there other things that have been shown to help in this situation?


For an emergency clinician, there may be nothing more anxiety-provoking than caring for an infant or young child who presents in septic shock. Signs and symptoms concerning for septic shock include fever, tachycardia, evidence of decreased perfusion (such as poor pulses, mottled skin, or delayed capillary refill), decreased urine output, and altered mental status. Conditions that place a child at increased risk for shock include younger age, immunocompromised state, chronic medical conditions, or surgically placed hardware or devices.

Once a child’s condition has progressed to this point, it can be very difficult to determine the exact cause. Shock is a common pathway for a multitude of life-threatening illnesses and injuries, and septic shock is one of the most common forms of shock in developed countries. Fortunately, the fundamental principles of early goal-directed therapy for children in septic shock have been shown to reduce the mortality of this condition. These include: (1) providing oxygen, (2) aggressive fluid resuscitation, (3) early antibiotic administration, (4) inotropic support for fluid-resistant shock, and (5) stress-dose steroids for inotropic-resistant shock.

Now more than ever, septic shock is best approached as a “team sport” in which the emergency medicine physician coordinates the initial care with a team of practitioners in the emergency department (ED). Additionally, children whose shock state does not improve with initial interventions, there must be effective coordination with transport teams and colleagues in pediatric tertiary care centers’ intensive care unit (ICU) to ensure that, when indicated, further therapies are initiated and appropriate monitoring is performed while this transition of care proceeds.

Critical Appraisal Of The Literature

Studies of septic shock in pediatric patients in the ED are somewhat limited. Most research on children with septic shock are usually studies of “pediatric shock,” which is a heterogeneous clinical entity of which septic shock is only one cause. Individual cases of pediatric shock are not common, and a single institution would have to study data spanning many years to have a reasonably sized study.

The cause of shock is often not immediately apparent on presentation to the ED or the ICU. Therefore, studies tend to be retrospective and rely on information that is only available as the case unfolds over time, which leads to studies that have limited applicability to ED care.

Children in shock are often critically ill, and some clinicians consider interventional or experimental studies to be unethical.1-3 Performing a study that substantially increases a child's risk for death is unappealing (to say the least) to many researchers, patients, and families.3 This leads to a paucity of relevant studies. Given the severity of illness, exceptions from informed consent may be needed to allow the performance of a study. Obtaining an exception from informed consent is an arduous process that few researchers have the resources or willingness to endure.3-5

It is impossible to compare treatments, for example, since many of the study populations assessing the treatment of shock in children include not just septic shock but also hemorrhagic shock from trauma, hypovolemic shock from a diarrheal illness, cardiogenic shock in children with congenital heart disease, and distributive shock from anaphylaxis. Any discussion of the literature on the treatment of septic shock in children must include the Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012.6 These guidelines were initially published in 2004, revised in 2008, and then revised again most recently in 2012. They contain the most updated evidencebased recommendations on the approach to managing septic shock and include specific considerations for treating children based on information available through early 2012, but it must be noted that these are consensus expert recommendations based on somewhat limited studies, which has lead to continued use of ineffective or even harmful therapies, simply because evidence is not available to refute their use.7,8 Some reasons cited for using these ineffective therapies include: a “love of the pathophysiological model (that is wrong),” “a need to do something,” and “clinical experience.”8

Another problem arises when the results of studies involving adults only are applied to the care of children. An example that illustrates this point nicely are the studies demonstrating that activated protein C is an effective therapy for adults in septic shock.9-11 However, a multicenter study of activated protein C for the treatment of children in septic shock was suspended due to excessive complications and a lack of demonstrated benefit over placebo.12 In this case, there was an increase in intracranial bleeding, particularly in children aged < 2 months. Reliance on adult data to guide the care of children in this instance would have been harmful.

Finally, some of the most fundamental concepts in the management of shock are supported by very small studies. For example, critically ill children are often found to be hypoglycemic on presentation. Studies that directly address this, however, are rare. One of the best known studies is by Losek, who reported on 49 children undergoing resuscitation, 9 of whom were discovered to be hypoglycemic.13 Another example involves fluid resuscitation. Although nearly universally recommended, few studies have directly explored whether or not fluid resuscitation is beneficial in management of shock. An early and widely cited study by Carcillo et al addresses fluid resuscitation, but it only included 34 children.14 Systematic reviews regarding fluid resuscitation seldom evaluate the unproven “facts” and instead compare 2 similar therapies.15,16

Risk Management Pitfalls For Pediatric Septic Shock

1. “He wasn’t hypotensive, so I didn't think he was in shock.”
In children, sometimes the only signs of compensated shock may be tachycardia and irritability, which are common findings. Although formal definitions of shock stress the presence of hypotension, it is important to note that it is not required to be present in children for the diagnosis of septic shock to be made.

2. “The pulse oximetry reading was normal, so I didn't give oxygen.”
The primary deficiency in shock is insufficient substrate for cellular respiration. The most essential substrate is oxygen. In all cases of presumed shock, supplemental oxygen should be provided at the onset of therapy.

3. “I waited to give a second bolus because I didn’t want to fluid overload this child.”
Children with symptoms of shock can have fluid deficits that are far greater than may initially be estimated. An initial fluid bolus of 20 mL/kg of isotonic crystalloid over 5 to 10 minutes is only the start of resuscitation. Continuous reassessment is essential. Except for children in cardiogenic shock, those with underlying congenital cardiac disorders, and possibly those with diabetic ketoacidosis, most children in shock benefit from the administration of relatively large fluid volumes.

4. “I gave the girl 60 mL/kg of normal saline, but it didn't seem to help. How could that not be enough?”
Especially in cases of ongoing fluid losses due to vomiting and diarrhea, both the fluid deficit and the ongoing losses need to be replaced.

5. “I don’t understand how she decompensated in the CT scanner. She looked fine 2 hours ago.”
Resuscitation of a child in shock requires that a therapy is not only implemented, but also that the results of that therapy are evaluated. Ongoing reevaluation of the child allows for additional appropriate therapy, as children who have been in shock can quickly decompensate.

6. “I didn’t give antibiotics for this child who was in shock because I couldn’t find a source of infection.”
Although it can be difficult to make a definitive diagnosis of shock caused by a bacterial infection, if other causes cannot be excluded with some confidence, timely administration of antibiotics may be lifesaving.

7. “The chest x-ray was normal, and there weren’t any infiltrates or effusions indicating a problem with the boy's heart. But I guess now that I take another look, the heart does seem big.”
Although dilated cardiomyopathy is not a common cause of shock, an enlarged heart can be seen on chest radiographs. Therefore, it should be considered in the differential, as the treatment for dilated cardiomyopathy is different from treatment for other causes of shock.

8. “I’ve never given dopamine to a child, so I just kept giving fluids.”
If, after the administration of 60 to 100 mL/kg of fluid, there is insufficient improvement in tissue perfusion, inotropic support should be initiated. Ideally, this is provided through a central venous line, but in some situations, it must be provided through whatever venous access is available, including a peripheral venous line or an intraosseous line.

9. “I thought fluids would be enough to treat the shock. Why should I have given hydrocortisone to this child?
Children who are on chronic steroids or who are steroid-dependent have increased steroid needs during even minor acute illnesses. Appropriate doses of steroids can successfully reverse shock.

10. “The little girl didn't have a fever, so I was not concerned about septic shock.”
Although fever often accompanies infection, it is not required in order to make the diagnosis of SIRS, sepsis, or septic shock. The use of nonsteroidal anti-inflammatory drugs, the use of immunosuppressive agents, or innate patient features can alter the expected febrile response to infection.

Tables and Figures

Table 1.Risk Factors For Septic Shock


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

  1. Dawson A, Spencer SA. Informing children and parents about research. Arch Dis Child. 2005;90(3):233-235. (Editorial/ review)
  2. Caldwell PHY, Butow PN, Craig JC. Pediatricians’ attitudes toward randomized controlled trials involving children. J Pediatr. 2002;141(6):798-803. (Qualitative study of focus group discussions; 16 pediatricians and 5 pediatric trainees)
  3. Morris MC, Nadkarni VM, Ward FR, et al. Exception from informed consent for pediatric resuscitation research: Community consultation for a trial of brain cooling after in-hospital cardiac arrest. Pediatrics. 2004;114(3):776-781. (Qualitative study of focus groups, parents, and hospital staff; 8 focus groups, 23 parents, and 33 hospital staff)
  4. Sloan EP, Nagy K, Barrett J. A proposed consent process in studies that use an exception to informed consent. Acad Emerg Med. 1999;6(12):1283-1291. (Review)
  5. Vanpee D, Gillet JB, Dupuis M. Clinical trials in an emergency setting: Implications from the fifth version of the Declaration of Helsinki. J Emerg Med. 2004;26(1):127-131. (Review)
  6. * Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39(2): 165-228. (Consensus guidelines)
  7. Alderson P, Groves T. What doesn’t work and how to show it. BMJ. 2004;328(7438):473. (Editorial)
  8. Doust J, Del Mar C. Why do doctors use treatments that do not work? BMJ. 2004;328(7438):474-475. (Review)
  9. Monnet X, Lamia B, Anquel N, et al. Rapid and beneficial hemodynamic effects of activated protein C in septic shock patients. Intensive Care Med. 2005;31(11):1573-1576. (Retrospective medical record review; 22 subjects)
  10. Thomas GL, Wigmore T, Clark P. Activated protein C for the treatment of fulminant meningococcal septicaemia. Anaesth Intensive Care. 2004;32(2):284-287. (Case series; 2 subjects)
  11. Medve L, Csitari IK, Molnar Z, et al. Recombinant human activated protein C treatment of septic shock syndrome in a patient at 18th week of gestation: a case report. Am J Obstet Gynecol. 2005;193(3 Pt 1):864-865. (Case report)
  12. Xigris [drotrecogin alfa (activated)]: Market Withdrawal - Failure to Show Survival Benefit. United States Food and Drug Administration. Accessed September 1, 2015. (Government report)
  13. Losek, JD. Hypoglycemia and the ABC’S (sugar) of pediatric resuscitation. Ann Emerg Med. 2000;35(1):43-46. (Retrospective medical record review; 49 children, of whom 9 were hypoglycemic)
  14. Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA 1991;266(9):242- 245. (Retrospective record review; 34 children)
  15. Schierhout G, Roberts I. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials. BMJ. 1998;316(7136):961-964. (Systematic review)
  16. Choi P, Yip G, Quinonez LG, et al. Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med. 1999;27(1):200-210. (Systematic review)
  17. Fisher JD, Nelson DG, Beyersdorf H, et al. Clinical spectrum of shock in the pediatric emergency department. Pediatric Emerg Care. 2010;26(9):622-625. (Observational study;147 patients)
  18. Hartman ME, Linde-Zwirble WT, Angus DC, et al. Trends in the epidemiology of pediatric severe sepsis. Pediatric Crit Care Med. 2013;14(7):686-693. (Retrospective observational cohort dataset from 7 U.S. states from 1995, 2000, and 2005; 17,542 children in 2005)
  19. 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(5):695-701. (Secondary analysis of prospectively collected database; 9675 children)
  20. Watson RS, Carcillo JA. Scope and epidemiology of pediatric sepsis. Pediatr Crit Care Med. 2005;6(3 Suppl):S3-S5. (Review)
  21. Wilkinson JD, Pollack MM, Ruttimann UE, et al. Outcome of pediatric patients with multiple organ system failure. Crit Care Med. 1986;14(4):271-274. (Case series; 831 patients)
  22. Proulx F, Fayon M, Farrell CA, et al. Epidemiology of sepsis and multiple organ dysfunction syndrome in children. Chest. 1996;109(4):1033-1037. (Prospective cohort study; 1058 consecutive hospital admissions)
  23. Guyton AC, Hall JE. Textbook of Medical Physiology. 10th ed. Philadelphia, PA: WB Saunders Company; 2000. (Textbook)
  24. Jacobs RF, Sowell MK, Moss MM, et al. Septic shock in children: bacterial etiologies and temporal relationships. Pediatr Infect Dis J. 1990;9(3):196-200. (Retrospective analysis; 2110 PICU admissions)
  25. Saez-Llorens X, McCracken GH, Jr. Sepsis syndrome and septic shock in pediatrics: current concepts of terminology, pathophysiology, and management. J Pediatr. 1993;123(4):497-508. (Review)
  26. Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6(1): 2-8. (Consensus statement)
  27. Benedict CR. Neurohumoral aspects of heart failure. Cardiol Clin. 1994;12(1):9-23. (Review)
  28. Hatherill M, Tibby SM, Hilliard T, et al. Adrenal insufficiency in septic shock. Arch Dis Child. 1999;80(1):51-55. (Prospective surveillance study; 33 children)
  29. Pizarro CF, Troster EJ, Damiani D, et al. Absolute and relative adrenal insufficiency in children with septic shock. Crit Care Med. 2005;33(4):855-859. (Prospective surveillance study; 57 children)
  30. * Rivers, Emanuel, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377. (Prospective randomized study; 263 adults)
  31. * Yealy, Donald M., et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370 (18):1683- 1693. (Prospective randomized multicenter study; 1341 adults)
  32. Jabre P, Cornbes X, Lapostolle F, et al. KETASED Collaborative Study Group. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009;374(9686):293-300. (Prospective multicenter randomized controlled trial; 655 patients)
  33. Dewhirst E, Frazier WJ, Leder M, et al. Cardiac arrest following ketamine administration for rapid sequence intubation. J Intensive Care Med. 2013;28(6):375-379. (Case reports; 2 patients)
  34. den Brinker, M, Hokken-Koelega AC, Hazelzet JA, et al. One single dose of etomidate negatively influences adrenocortical performance for at least 24h in children with meningococcal sepsis. Intensive Care Med. 2008;34(1):163-168. (Retrospective review; 60 children)
  35. Cuthbertson BH, Sprung CL, Annane D, et al. The effects of etomidate on adrenal responsiveness and mortality in patients with septic shock. Intensive Care Med. 2009;35(11):1868- 1876. (A-priori sub-study of a multi-center randomized trial; 499 adults)
  36. Albert SG, Ariyan S, Arora R. The effect of etomidate on adrenal function in critical illness: a systematic review. Intensive Care Med. 2011;37(6): 901-910. (Systematic review)
  37. Chan CM, Mitchell AL, Shorr AF. Etomidate is associated with mortality and adrenal insufficiency in sepsis: a meta-analysis. Critical Care Med. 2012;40(11): 2945-2953. (Meta-analysis)
  38. Doniger, Stephanie J., et al. Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients. Pediatr Emerg Care. 2009;25(3):154-159. (Prospective randomized controlled trial; 50 patients)
  39. Orlowski JP, Porembka DT, Gallagher JM, et al. Comparison study of intraosseous, central intravenous, and peripheral intravenous infusions of emergency drugs. Am J Dis Child. 1990;144(1):112-117. (Animal study)
  40. Orlowski JP. Emergency alternatives to intravenous access. Intraosseous, intratracheal, sublingual, and other-site drug administration. Pediatr Clin North Am. 1994;41(6):1183-1199. (Review)
  41. Carrera RM, Pacheco AMJ, Caruso J, et al. Intraosseous hypertonic saline solution for resuscitation of uncontrolled, exsanguinating liver injury in young Swine. Eur Surg Res. 2004;36(5):282-292. (Animal study)
  42. Goldstein B, Doody D, Briggs S. Emergency intraosseous infusion in severely burned children. Pediatr Emerg Care. 1990;6 (3):195-197. (Case series; 2 children)
  43. Neal CJ, McKinley DF. Intraosseous infusion in pediatric patients. J Am Osteopath Assoc. 1994;94(1):63-66. (Review)
  44. Bruzoni M, Slater BJ, Wall J, et al. A prospective randomized trial of ultrasound-vs landmark-guided central venous access in the pediatric population. J Am Coll Surg. 2013;216(5): 939-943. (Randomized prospective study; 150 patients)
  45. Gallagher RA, Levy J, Vieira RL, et al. Ultrasound assistance for central venous catheter placement in a pediatric emergency department improves placement success rates. Acad Emerg Med. 2014;21(9):981-986. (Retrospective cohort study; 168 patients)
  46. Nahum E, Dagan O, Sulkes J, et al. A comparison between continuous central venous pressure measurement from right atrium and abdominal vena cava or common iliac vein. Intensive Care Med. 1996;22(6):571-574. (Prospective comparative controlled trial; 9 patients)
  47. 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(1):14-18. (Prospective comparative controlled trial; 30 patients)
  48. De Bruin WJ, Greenwald BM, Notterman DA. Fluid resuscitation in pediatrics. Crit Care Clin. 1992;8(2):423-438. (Review)
  49. Carcillo JA, Fields AI. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med. 2002;30(6):1365-1378. (Clinical guidelines)
  50. Ngo NT, Cao XT, Kneen R, et al. Acute management of dengue shock syndrome: a randomized double-blind comparison of 4 intravenous fluid regimens in the first hour. Clin Infect Dis. 2001;32(2):204-213. (Prospective interventional controlled trial; 230 children)
  51. Schierhout G, Roberts I. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials. BMJ. 1998;316(7136):961-964. (Meta-analysis; 26 trials comparing colloids with crystalloids, 1622 subjects)
  52. Choi P, Yip G, Quinonez LG, et al. Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med. 1999;27(1):200-210. (Meta-analysis; 17 primary studies of 814 patients)
  53. * Oliveira CF, Noquiera de Sa FR, Oliveira DS, et al. Time-and fluid-sensitive resuscitation for hemodynamic support of children in septic shock: barriers to the implementation of the American College of Critical Care Medicine/ Pediatric Advanced Life Support Guidelines in a pediatric intensive care unit in a developing world. Pediatric Emerg Care. 2008;24(12): 810-815. (Retrospective chart review and prospective analysis; 90 children)
  54. Kirby A, Goldstein B. Improved outcomes associated with early resuscitation in septic shock: do we need to resuscitate the patient or the physician? Pediatrics. 2003;112(4):976-977. (Editorial)
  55. Parker MM, Hazelzet JA, Carcillo JA. Pediatric considerations. Crit Care Med. 2004;32(11 Suppl):S591-S594. (Review)
  56. Vincent JL, Gerlach, H. Fluid resuscitation in severe sepsis and septic shock: an evidence-based review. Crit Care Med 2004:32(11 Suppl);S451-S454. (Review)
  57. Upadhyay M, Singhi S, Murlidharan J, et al. Randomized evaluation of fluid resuscitation with crystalloid (saline) and colloid (polymer from degraded gelatin in saline) in pediatric septic shock. Indian Pediatr. 2005;42(3):223-231. (Prospective interventional comparative trial; 60 children)
  58. Santhanam, I, Sangareddi S, Venkataraman S, et al. A prospective randomized controlled study of two fluid regimens in the initial management of septic shock in the emergency department. Pediatric Emerg Care. 2008;24(10):647-655. (Prospective randomized controlled study; 147 patients)
  59. Alderson P, Bunn F, Lefebvre C, et al. Human albumin solution for resuscitation and volume expansion in critically ill patients. Cochrane Database Syst Rev. 2002;(1);CD001208. (Meta-analysis)
  60. Finfer S, Bellomo R, Boyce N, et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med. 2004;350(22):2247-2256. (Multicenter prospective interventional comparative trial; 6997 patients)
  61. Arnal LE, Stein F. Pediatric septic shock: why has mortality decreased? The utility of goal-directed therapy. Semin Pediatr Infect Dis. 2003;14(2):165-172. (Review)
  62. Beale RJ, Hollenberg SM, Vincent JL, et al. Vasopressor and inotropic support in septic shock: an evidence-based review. Crit Care Med. 2004;32(11 Suppl):S455-S465. (Evidence-based review)
  63. * Rhodes A, Bennett ED. Early goal-directed therapy: an evidence-based review. Crit Care Med. 2004;32(11 Suppl): S448- 450. (Evidence-based review)
  64. Shapiro NI, Howell M, Talmor D. A blueprint for a sepsis protocol. Acad Emerg Med. 2005;12(4):352-359. (Review)
  65. * 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(4):793- 799. (Retrospective record review; 91 children)
  66. Bhatt-Mehta V, Nahata MC. Dopamine and dobutamine in pediatric therapy. Pharmacotherapy. 1989;9(5):303-314. (Review)
  67. Ceneviva G, Paschall JA, Maffei F, et al. Hemodynamic support in fluid-refractory pediatric septic shock. Pediatrics. 1998;102(2):e19. (Multicenter prospective observational trial; 50 children)
  68. Zaritsky A, Chernow B. Use of catecholamines in pediatrics. J Pediatr. 1984;105(3):341-350. (Review)
  69. Zaritsky A. Pediatric resuscitation pharmacology. Members of the Medications in Pediatric Resuscitation Panel. Ann Emerg Med. 1993;22(2 Pt 2):445-455. (Review)
  70. Liet JM, Jacqueline C, Orsonneau JL, et al. The effects of milrinone on hemodynamics in an experimental septic shock model. Pediatr Crit Care Med. 2005 Mar;6(2):195-199. (Experimental animal model)
  71. Rich N, West N, McMaster P, et al. Milrinone in meningococcal sepsis. Pediatr Crit Care Med. 2003;4(3):394-395. (Letter)
  72. Heinz G, Geppert A, Delle Karth G, et al. IV milrinone for cardiac output increase and maintenance: comparison in nonhyperdynamic SIRS/sepsis and congestive heart failure. Intensive Care Med. 1999;25(6):620-624. (Clinical trial; 16 patients)
  73. Overgaard CB, Dzavik V. Inotropes and vasopressors: review of physiology and clinical use in cardiovascular disease. Circulation. 2008;118(10):1047-1056. (Review)
  74. 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(7):632-639. (Multicenter randomized controlled trial; 65 patients)
  75. 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(5):1302-1312. (Prospective interventional trial; 12 children)
  76. Shah SS, Aronson PL, Mohamad Z, et al. Delayed acyclovir therapy and death among neonates with herpes simplex virus infection. Pediatrics. 2011;128(6):1153-1160. (Multicenter retrospective cohort study; 262 neonates)
  77. Keh D, Sprung CL. Use of corticosteroid therapy in patients with sepsis and septic shock: an evidence-based review. Crit Care Med. 2004;32(11 Suppl):S527-S533. (Evidence-based review)
  78. Yildiz O, Doganay M, Aygen B, et al. Physiological-dose steroid therapy in sepsis. Crit Care. 2002;6(3):251-259. (Prospective interventional controlled trial; 40 patients)
  79. Keh D, Boehnke T, Weber-Cartens S, et al. Immunologic and hemodynamic effects of low-dose hydrocortisone in septic shock: a double-blind, randomized, placebo-controlled, crossover study. Am J Respir Crit Care Med. 2003;167(4):512- 520. (Double- blind randomized placebo-controlled crossover study; 40 patients)
  80. Meggison H, Jones G. Best evidence in critical care medicine: treatment: adrenal replacement therapy improves survival in patients with septic shock. Can J Anaesth. 2004;51(3):264-265. (Evidence-based review)
  81. Katsenos CS, Antonopoulou AN, Apostolidou EN, et al. Early administration of hydrocortisone replacement after the advent of septic shock: impact on survival and immune response. Crit Care Med. 2014;42(7):1651-1657. (Case series; 34 adults)
  82. Rousseaux J, Grandbastien B, Dorkenoo A, et al. Prognostic value of shock index in children with septic shock. Pediatric Emerg Care. 2013;29(10):1055-1059. (Retrospective review; 146 children)
  83. Sankar, Jhuma, et al. Early goal-directed therapy in pediatric septic shock: comparison of outcomes “with” and “without” intermittent superior venacaval oxygen saturation monitoring: a prospective cohort study. Pediatr Crit Care Med. 2014;15(4): e157-e167. (Prospective cohort study; 120 children)
  84. Vincent JL, Dufaye P, Berre J, et al. Serial lactate determinations during circulatory shock. Crit Care Med. 1983;11 (6):449- 451. (Prospective observational trial; 17 patients)
  85. Nguyen HB, Rivers EP, Knoblich BP, et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med. 2004;32(8):1637- 1642. (Prospective observational trial; 111 patients)
  86. Bakker J, Gris P, Coffernils M, et al. Serial blood lactate levels can predict the development of multiple organ failure following septic shock. Am J Surg. 1996;171(2):221- 226. (Prospective observational trial; 87 patients)
  87. Kobayashi S, Gando S, Morimoto Y, et al. Serial measurement of arterial lactate concentrations as a prognostic indicator in relation to the incidence of disseminated intravascular coagulation in patients with systemic inflammatory response syndrome. Surg Today. 2001;31(10):853- 859. (Prospective observational trial; 22 patients)
  88. Das JB, Joshi ID, Philippart AI. End-tidal CO2 and tissue pH in the monitoring of acid-base changes: a composite technique for continuous, minimally invasive monitoring. J Pediatr Surg. 1984;19(6):758-763. (Animal study)
  89. Sanders AB. Capnometry in emergency medicine. Ann Emerg Med. 1989;18(12):1287-1290. (Review)
  90. Guzman JA, Lacoma FJ, Najar A, et al. End-tidal partial pressure of carbon dioxide as a noninvasive indicator of systemic oxygen supply dependency during hemorrhagic shock and resuscitation. Shock. 1997;8(6):427-431. (Animal study)
  91. Jin X, Weil MH, Tang W, et al. End-tidal carbon dioxide as a noninvasive indicator of cardiac index during circulatory shock. Crit Care Med. 2000;28(7):2415-2419. (Animal study)
  92. Ranjit S, Aram G, Kissoon N, et al. Multimodal monitoring for hemodynamic categorization and management of pediatric septic shock: a pilot observational study. Pediatr Crit Care Med. 2014;15(1): e17-e26. (Prospective observational study; 48 children)
  93. Ng L, Khine H, Taragin BH, et al. Does bedside sonographic measurement of the inferior vena cava diameter correlate with central venous pressure in the assessment of intravascular volume in children? Pediatr Emerg Care. 2013;29(3):337- 341. (Prospective observational study; 51 children)
  94. Drayna PC, Abramo TJ, Estrada C. Near-infrared spectroscopy in the critical setting. Pediatr Emerg Care. 2011;27(5):432- 439. (Review)
  95. Beca J, Butt W. Extracorporeal membrane oxygenation for refractory septic shock in children. Pediatrics. 1994;93(5):726- 729. (Retrospective record review; 9 children)
  96. Meyer DM, Jessen ME. Results of extracorporeal membrane oxygenation in children with sepsis. The Extracorporeal Life Support Organization. Ann Thorac Surg. 1997;63(3):756-761. (Secondary analysis of prospectively collected database; 655 children)
  97. Goldman AP, Kerr SJ, Butt W, et al. Extracorporeal support for intractable cardiorespiratory failure due to meningococcal disease. Lancet. 1997;349(9050):466-469. (Retrospective record review; 12 patients)
  98. Luyt DK, Pridgeon J, Brown J, et al. Extracorporeal life support for children with meningococcal septicaemia. Acta Paediatr. 2004;93(12):1608-1611. (Retrospective record review; 11 patients)
  99. Maclaren G, Butt W, Best D, et al. Extracorporeal membrane oxygenation for refractory septic shock in children: one institution’s experience. Pediatr Crit Care Med. 2007;8(5):447-451. (Retrospective case series; 441 children)
  100. Maclaren G, Butt W. Central extracorporeal membrane oxygenation for refractory pediatric septic shock. Pediatr Crit Care Med. 2011;12(5):606-607. (Letter)
  101. Chang YC, Ng CJ, Chen LC, et al. Pediatric overtriage as a consequence of the tachycardia responses of children upon emergency department admission. Am J Emerg Med. 2015;33(1):1-6. (Retrospective follow-up study; 42,000 pediatric patients)
  102. Cruz AT, Williams EA, Grad JM, et al. Test characteristics of an automated age-and temperature-adjusted tachycardia alert in pediatric septic shock. Pediatr Emerg Care. 2012;28(9):889-894. (Automated triage tool analysis; 4552 emergency department visits)
  103. Larsen GY, Mecham N, Greenberg R. An emergency department septic shock protocol and care guideline for children initiated at triage. Pediatrics. 2011;127(6):e1585-e1592. (Prospective triage analysis; 345 patients)
Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.