| Initial Resuscitation: Pediatric Specific Considerations |
| 1. Infants anatomically have low pulmonary functional residual capacity and can desaturate very quickly. Supplemental oxygen should be delivered via face mask or nasal cannula or other devices to children with septic shock even if oxygen saturation levels appear normal with peripheral monitoring devices. |
| 2. Peripheral intravenous access is often difficult to obtain in hemodynamically unstable infants and young children. If unable to obtain peripheral intravenous access quickly, early use of intraosseus access is recommended for fluid resuscitation, inotrope infusion and delivery of antibiotics when central venous access is not easily obtainable. If mechanical ventilation is required then cardiovascular instability during intubation may be less likely after appropriate cardiovascular resuscitation. |
| 3. The American College of Critical Care Medicine-Pediatric Life Support (ACCM-PALS) guidelines112 are recommended for the management of septic shock in children. |
| Antibiotics and Source Control |
| 1. Empiric antibiotics should be administered within the first hour of determining that the patient has severe sepsis. Obtaining blood cultures prior to antibiotics is preferred, when possible, but should not delay antibiotic administration. |
| a. The empiric drug choice must be tailored to epidemic and endemic ecologies and consideration for treatment of resistant organisms is essential. |
| b. Clindamycin and anti-toxin therapies for toxic shock syndromes with refractory hypotension are recommended. |
| 2. Early and aggressive source control is essential. Because infants and young children have difficulty communicating the location of their pain, radiologic imaging is an essential part of the workup in children with severe sepsis. |
| Fluid Resuscitation |
| 1. In the industrialized world with access to inotropes and mechanical ventilation, initial resuscitation of hypovolemic shock begins with infusion of isotonic crystalloids (or albumin equivalent) with repeated boluses of up to 20 mL/kg of crystalloids (or albumin equivalent) over 5–10 min, titrated to reversing hypotension, increasing urine output, and attaining normal capillary refill, peripheral pulses, and level of consciousness. |
| a. In a child with hepatomegaly or rales, early inotropic support should be implemented, and fluid resuscitation carefully titrated. |
| 2. In children with compensated shock in resource-limited settings without access to inotropes or mechanical ventilation, fluid boluses may be harmful.92 Blood transfusion should be considered in patients with compensated shock who are profoundly anemic. |
| Extracorporeal Membrane Oxygenation (ECMO) |
| 1. Consider ECMO for refractory pediatric septic shock with respiratory failure. |
| Blood Products and Plasma Therapies |
| 1. Hemoglobin targets are similar in children as in adults. In hemodynamically unstable children in shock on vasopressor infusions, hemoglobin levels of ≥10 g/dL are targeted. In stable critically ill children, a lower hemoglobin target of ≥7.0 g/dL is recommended.113
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| 2. Similar platelet transfusion targets in children as in adults. |
| 3. Consider plasma therapies in children to correct sepsis-induced thrombotic purpura disorders, including progressive disseminated intravascular coagulation, secondary thrombotic microangiopathy, and thrombotic thrombocytopenic purpura. |
