Continued...

Therapeutic End points
Therapeutic endpoints are capillary refill of < 2 secs, normal pulses with no differential between peripheral and central pulses, warm limbs, urine output of >1 mL/kg/hr, normal mental status, decreased lactate, and increased base deficit and superior vena cava or mixed venous oxygen saturation of >70%. When employing measurements to assist in identifying acceptable cardiac output in children with systemic arterial hypoxemia such as cyanotic congenital heart disease or severe pulmonary disease, arterial-venous oxygen content difference is a better marker than mixed venous hemoglobin saturation with oxygen. Optimizing preload optimizes cardiac index. As noted above, blood pressure by itself is not a reliable endpoint for resuscitation. Rarely, if a pulmonary artery catheter is utilized, therapeutic endpoints are cardiac index of >3.3 and < 6.0 L/m/meter sq with normal perfusion pressure (mean arterial pressure-central venous pressure) for age. Use of pulmonary artery catheter has declined over the years due to no well-demonstrated therapeutic benefit in patients with septic shock.

Electrolyte balance
An attempt should be made to check and correct common electrolyte problems related to sodium (hyponatremia), potassium and ionized calcium (ionized hypocalcemia).

Steroids
Hydrocortisone therapy should be reserved for use in children with catecholamine resistance and suspected or proven adrenal insufficiency. Patients at risk include children with severe septic shock and purpura (20,21), children who have previously received steroid therapies for chronic illness, and children with pituitary or adrenal abnormalities. There are no strict definitions, but adrenal insufficiency in the case of catecholamine-resistant septic shock is assumed at a random total cortisol level of < 18 µg/dL (496 nmol/L). There is no clear consensus for the role of steroids or best dose of steroids in children with septic shock. A post 30- or 60-min adreno corticotropic hormone (ACTH) stimulation test increase in cortisol of =9 µg/dL (248 nmol/L) also makes that diagnosis. There are two randomized, controlled trials that used shock dose hydrocortisone (25 times higher than the stress dose) in children, both in dengue fever. The results were conflicting (22,23). Dose recommendations vary from 1-2 mg/kg for stress coverage (based on clinical diagnosis of adrenal insufficiency) to 50 mg/kg for empirical therapy of shock followed by the same dose as a 24-hr infusion. Thus dose of steroids remains controversial.

Conclusions:

• Pediatric recommendations for management of severe sepsis in children include a more likely need for endotracheal intubation and mechanical ventilation due to low functional residual capacity.
• Infants and children are recognized to have more difficult intravenous access, therefore necessitating use of intraosseous access as required.
• Early fluid resuscitation based on weight with 40-60 mL kg or higher may be needed.
• Decreased cardiac output and increased systemic vascular resistance tends to be most common hemodynamic profile. Dopamine is recommended as the initial agent for hemodynamic support.
• Pediatric recommendations include greater use of physical examination therapeutic endpoints.
• Issue of high-dose steroids for therapy of septic shock remains unsettled, although recommendation include use of steroids for catecholamine unresponsive shock in presence of a suspected or proven adrenal insufficiency.
• There is greater risk of hypoglycemia with aggressive glucose control.

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Last updated on 01-03-2006 Vol 3 Issue 3 Art # 9

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Khilnani P. Management of Septic Shock.Pediatric Oncall [serial online] 2006 [cited 2006 March 1];3. Art # 9. Available from: