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

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


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