Initial resuscitation of children with septic shock in setting with intensive care capability*

ICU: intensive care unit; IV: intravenous; BP: blood pressure; ECHO: echocardiography.
* 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 the systemic inflammatory response syndrome (SIRS). The SIRS is present when a child has an abnormality of temperature (fever or hypothermia) or age-specific abnormality of the white blood cell count and one of the following: tachycardia, bradycardia, respiratory distress, or pulmonary condition requiring mechanical ventilation. Systematic screening is recommended to assist with early recognition. Refer to UpToDate content on signs and symptoms of SIRS and recognition of sepsis and septic shock.
¶ A trial of noninvasive ventilation, such as continuous positive airway pressure ventilation or bi-level positive airway pressure ventilation, may avoid the need for endotracheal intubation in selected patients. Patients with hemodynamic instability should receive appropriate interventions to achieve hemodynamic stability prior to or during intubation. When performing rapid sequence intubation in children with septic shock, ketamine, if available and not contraindicated (ie, patients younger than three months of age or with psychosis), is suggested for sedation. Etomidate is not recommended unless ketamine is not available or contraindicated. Infants younger than 3 months may receive IV fentanyl 1 to 2 mcg/kg slowly.
Δ Fluid volume should be calculated based upon ideal body weight (eg, 50^th percentile for age). 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), the fluid bolus should be omitted or reduced (eg, 5 to 10 mL/kg given over 15 minutes).
◊ Consultation with an expert in pediatric infectious disease is strongly encouraged for all children with septic shock. Empiric antimicrobial treatment should consist of broad-spectrum antibiotics and, for susceptible patients, antifungal and antiviral agents. Refer to UpToDate topics on recognition and initial resuscitation of septic shock in children for specific regimens.
§ For recommended dosing 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.