Overview
Definition:
Septic shock in pediatrics is a life-threatening condition characterized by circulatory, cellular, and metabolic abnormalities associated with sepsis, leading to persistent hypotension despite adequate fluid resuscitation
It is defined by the presence of sepsis with signs of hypoperfusion and a requirement for vasopressors to maintain a mean arterial pressure (MAP) ≥ 65 mmHg or an absence of hypotension with a decreased level of consciousness and elevated lactate level (>2 mmol/L).
Epidemiology:
Pediatric septic shock is a significant cause of morbidity and mortality in critically ill children, with incidence rates varying from 1-50 cases per 100,000 children per year
Neonates and infants have a higher risk
Despite advances in care, mortality rates remain high, ranging from 10-30% in developed countries and significantly higher in resource-limited settings.
Clinical Significance:
Early recognition and appropriate management of pediatric septic shock are crucial for improving outcomes
Vasopressor choice and escalation strategies significantly impact patient survival and reduce the risk of multi-organ dysfunction
Understanding the roles and differences between epinephrine and norepinephrine is paramount for pediatric residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Fever or hypothermia
Lethargy or irritability
Poor feeding or vomiting
Tachypnea or grunting respirations
Decreased urine output
Mottled skin or cyanosis
Altered mental status.
Signs:
Hypotension (MAP < 65 mmHg or age-adjusted hypotension)
Tachycardia or bradycardia (in neonates)
Poor peripheral perfusion (e.g., prolonged capillary refill time > 2 seconds, cold extremities)
Decreased urine output (<0.5 mL/kg/hr)
Altered mental status (lethargy, confusion, coma)
Mottled skin, petechiae, or purpura
Signs of respiratory distress.
Diagnostic Criteria:
Sepsis-3 criteria are adapted for pediatrics: Suspected or proven infection plus ≥ 2 of the following: altered mental status, tachypnea (respiratory rate > 2 standard deviations above normal for age), or hypotension (systolic blood pressure < 70 mmHg + (2 x age in years) in children < 10 years, or <90 mmHg in children ≥ 10 years)
Septic shock is defined as Sepsis-3 criteria plus need for vasopressors to maintain MAP ≥ 65 mmHg or serum lactate > 2 mmol/L despite adequate fluid resuscitation.
Diagnostic Approach
History Taking:
Focus on duration and nature of fever
Recent infections (e.g., otitis media, pneumonia, UTI, meningitis)
Immunization status
Recent antibiotic exposure
Presence of underlying comorbidities (e.g., congenital heart disease, immunosuppression).
Physical Examination:
Assess airway, breathing, circulation (ABC)
Vital signs including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation
Assess capillary refill time, skin perfusion, and presence of rash
Perform a thorough neurological assessment for altered mental status
Evaluate for signs of focal infection.
Investigations:
Complete blood count (CBC) with differential to assess for leukocytosis or leukopenia
Blood cultures (minimum 2 sets) before antibiotics
C-reactive protein (CRP) or procalcitonin to support infection diagnosis
Lactate level to assess tissue hypoperfusion
Blood gas analysis (venous or arterial) for acid-base status and oxygenation
Electrolytes, glucose, BUN, creatinine to assess organ function
Liver function tests and coagulation profile
Chest X-ray if pneumonia suspected
Urine analysis and culture if UTI suspected
Lumbar puncture if meningitis suspected.
Differential Diagnosis:
Hypovolemic shock (e.g., dehydration, hemorrhage)
Cardiogenic shock (e.g., myocarditis, congenital heart disease)
Obstructive shock (e.g., tension pneumothorax, cardiac tamponade)
Anaphylactic shock
Neurogenic shock
Adrenal insufficiency.
Management
Initial Management:
Immediate resuscitation with intravenous fluids: administer a bolus of 20 mL/kg isotonic crystalloid (e.g., Normal Saline or Lactated Ringer's) over 5-20 minutes, repeat as needed for signs of hypoperfusion, aiming for improved heart rate, perfusion, and mental status
Secure airway and provide oxygenation
Establish central venous access for monitoring and drug administration
Monitor urine output, vital signs, and lactate levels closely.
Medical Management:
Vasopressor therapy is initiated if hypotension persists despite adequate fluid resuscitation (MAP < 65 mmHg or significantly reduced perfusion)
First-line vasopressor: **Norepinephrine** is generally preferred in pediatric septic shock due to its balanced alpha and beta-adrenergic effects, providing both vasoconstriction and some inotropic support
Start infusion at 0.05-0.1 mcg/kg/min and titrate to achieve target MAP
**Epinephrine** is considered as a second-line agent or if norepinephrine is insufficient, particularly if there is concern for myocardial dysfunction
It has stronger beta-adrenergic effects, providing significant inotropic and chronotropic support, along with vasoconstriction
Start infusion at 0.05-0.1 mcg/kg/min and titrate
If cardiogenic component is suspected, dopamine or dobutamine may be added or used
Antibiotics should be administered as soon as possible after cultures are obtained, covering broad-spectrum coverage for suspected pathogens.
Surgical Management:
Rarely indicated directly for septic shock management, but surgical source control is crucial if a specific infected focus is identified (e.g., abscess drainage, removal of infected necrotic tissue, debridement of infected devices).
Supportive Care:
Mechanical ventilation may be required for respiratory failure
Nutritional support (enteral feeding preferred) should be initiated early
Glucose control and management of electrolyte imbalances are important
Consider stress ulcer prophylaxis and deep vein thrombosis prophylaxis
Close monitoring in an intensive care unit setting is essential.
Complications
Early Complications:
Multi-organ dysfunction syndrome (MODS), including acute kidney injury, hepatic dysfunction, and respiratory failure (ARDS)
Disseminated intravascular coagulation (DIC)
Hypoglycemia or hyperglycemia
Electrolyte disturbances
Myocardial dysfunction.
Late Complications:
Post-intensive care syndrome (PICS), including neurocognitive deficits, weakness, and psychological issues
Chronic organ damage
Increased susceptibility to infections.
Prevention Strategies:
Prompt and adequate fluid resuscitation
Early administration of broad-spectrum antibiotics
Judicious use and timely escalation of vasopressor therapy
Strict adherence to sepsis protocols
Close monitoring of vital signs and organ function
Prompt source control when indicated.
Prognosis
Factors Affecting Prognosis:
Severity of illness at presentation (e.g., degree of hypotension, organ dysfunction)
Time to initiation of effective resuscitation and antibiotics
Presence of underlying comorbidities
Development of MODS
Response to vasopressor therapy
Age of the child (neonates and infants often have worse outcomes).
Outcomes:
Outcomes vary widely, with mortality rates ranging from 10-30% in developed countries
Survivors may experience long-term sequelae
Early and aggressive management improves the chances of survival and reduces the risk of long-term complications.
Follow Up:
Close follow-up is essential for survivors to assess for neurodevelopmental deficits, growth, and recovery of organ function
Rehabilitation services may be beneficial for children with significant PICS
Regular clinic visits with pediatric critical care specialists and relevant subspecialists are recommended.
Key Points
Exam Focus:
Norepinephrine is typically the first-line vasopressor in pediatric septic shock due to its balanced adrenergic effects
Epinephrine is often considered second-line or if myocardial dysfunction is a concern
Sepsis-3 criteria and pediatric adaptations are key for diagnosis
Early recognition and aggressive fluid resuscitation are cornerstones of management.
Clinical Pearls:
Remember age-adjusted hypotension criteria for diagnosis
Dosing of vasopressors is weight-based and requires careful titration to target MAP
Continuous infusion pumps are mandatory for accurate and safe vasopressor administration
Always consider and address the underlying source of infection.
Common Mistakes:
Delayed recognition of septic shock
Inadequate fluid resuscitation before or during vasopressor initiation
Incorrect choice or titration of vasopressors
Failure to obtain cultures before antibiotics
Missing a treatable source of infection.