Pediatric Septic Shock
Introduction to Pediatric Septic Shock
Septic shock in pediatrics represents a severe subset of sepsis characterized by profound circulatory, cellular, and metabolic abnormalities associated with a higher risk of mortality than sepsis alone.
Key Points
- Time-critical emergency requiring immediate recognition and intervention
- Leading cause of death in children worldwide
- Mortality rates vary from 10% to 40% depending on resources and setting
- Early recognition and adherence to protocol-driven care significantly improve outcomes
- Different pathophysiology and clinical presentation compared to adults
Pathophysiology
Key Mechanisms
- Inflammatory Response:
- Massive cytokine release (cytokine storm)
- Activation of complement cascade
- Endothelial dysfunction
- Microvascular thrombosis
- Hemodynamic Changes:
- Initial hyperdynamic (warm) phase:
- Increased cardiac output
- Decreased systemic vascular resistance
- Warm extremities
- Late hypodynamic (cold) phase:
- Decreased cardiac output
- Increased systemic vascular resistance
- Poor peripheral perfusion
- Initial hyperdynamic (warm) phase:
Cellular Dysfunction
- Mitochondrial Dysfunction:
- Impaired oxygen utilization
- Cellular energy failure
- Increased lactate production
- Endothelial Injury:
- Capillary leak syndrome
- Tissue edema
- Organ dysfunction
Risk Factors & Epidemiology
High-Risk Populations
- Age-related:
- Neonates and infants < 1 year
- Premature infants
- Adolescents with chronic conditions
- Underlying Conditions:
- Immunocompromised states
- Chronic medical conditions
- Recent surgery or invasive procedures
- Malignancy
- Congenital heart disease
Common Causative Organisms
- Bacteria:
- N. meningitidis
- S. pneumoniae
- Group B Streptococcus (in neonates)
- Gram-negative organisms
- Viruses:
- Influenza
- RSV
- COVID-19
- Fungi:
- Candida species
- Aspergillus (in immunocompromised)
Clinical Presentation
Early Recognition Signs
- Temperature Abnormalities:
- Fever (>38.5°C) or hypothermia (<36°C)
- Temperature instability
- Cardiovascular:
- Tachycardia
- Flash capillary refill
- Bounding pulses (early)
- Wide pulse pressure
- Respiratory:
- Tachypnea
- Increased work of breathing
- Oxygen requirement
Late Signs
- Cardiovascular:
- Hypotension
- Poor peripheral perfusion
- Weak pulses
- Narrow pulse pressure
- Mental Status:
- Lethargy
- Confusion
- Decreased responsiveness
- Organ Dysfunction:
- Oliguria
- Metabolic acidosis
- Elevated lactate
- Coagulopathy
Diagnosis
Initial Workup
- Blood Studies:
- Complete blood count with differential
- Blood cultures (before antibiotics)
- Basic metabolic panel
- Coagulation profile
- Blood gas analysis
- Lactate level
- Inflammatory Markers:
- C-reactive protein
- Procalcitonin
- ESR
- Source Identification:
- Urine culture
- CSF studies if indicated
- Respiratory cultures
- Site-specific cultures based on clinical suspicion
Imaging
- Chest X-ray
- Point-of-care ultrasound
- CT scan (if source identification needed)
- Echocardiogram (if cardiac dysfunction suspected)
Management
First Hour Bundle
- Recognition and Vascular Access:
- Establish IV/IO access within 5 minutes
- Draw blood cultures
- Start continuous monitoring
- Fluid Resuscitation:
- 20mL/kg boluses of crystalloid
- Reassess after each bolus
- Up to 60mL/kg or more if needed
- Consider balanced solutions
- Antimicrobial Therapy:
- Broad-spectrum antibiotics within 1 hour
- Consider local resistance patterns
- Add antifungal if indicated
Ongoing Management
- Hemodynamic Support:
- Vasoactive medications if fluid-refractory
- Epinephrine for cold shock
- Norepinephrine for warm shock
- Consider stress-dose hydrocortisone
- Respiratory Support:
- Oxygen therapy
- Early intubation if needed
- Lung-protective ventilation
- Source Control:
- Identify and control infection source
- Surgical intervention if needed
- Remove infected devices
Complications
Acute Complications
- Organ Dysfunction:
- Acute kidney injury
- Acute respiratory distress syndrome
- Liver dysfunction
- Myocardial depression
- Hematologic:
- DIC
- Thrombocytopenia
- Bleeding complications
- Metabolic:
- Severe acidosis
- Electrolyte imbalances
- Hyperglycemia
Long-term Complications
- Post-sepsis syndrome
- Neurocognitive impairment
- Chronic organ dysfunction
- Growth and development issues
Prognosis & Follow-up
Monitoring Parameters
- Clinical Markers:
- Hemodynamic stability
- Organ function recovery
- Resolution of fever
- Improved mental status
- Laboratory Markers:
- Trending lactate levels
- Inflammatory markers
- Organ function tests
Long-term Follow-up
- Regular developmental assessment
- Monitoring for chronic complications
- Psychological support
- Rehabilitation services if needed