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Children’s Acute
Transport Service
Clinical Guidelines
Septic Shock
Document Control Information
Author Claire Fraser Author Position ANP
P.Ramnarayan CATS Consultant
Document Owner E. Polke Document Owner Position Service Coordinator
Document Version Version 4 Replaces Version January 2018
First Introduced Review Schedule 2 Yearly
Active Date January 2020 Next Review January 2022
CATS Document Number
Applicable to All CATS employees
Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St
Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great Great
Ormond Street Hospital
Page 1 of 7
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Septic Shock
Septic shock is suspected when children have a change in mental status manifested as
irritability, inappropriate crying, drowsiness, confusion, poor interaction with parents, lethargy,
or becoming unrousable, along with additional features such as tachypnoea and reduced
urine output.
Recognition
Suspected infection
Hypo or hyperthermia (temp <36° or >38.5°) tachycardia
Tachypnoea
Altered mental status
Decreased urine output (<1 ml/kg/hr) other end organ dysfunction
Signs of either cold or warm shock
For recognition of a child at risk refer to the amber and red signs on the Paediatric Sepsis 6
trigger bundle at the end of the guideline.
Cold Shock Warm Shock
Capillary refill >2s Flash capillary refill
Reduced peripheral pulses Bounding peripheral pulses
Cool mottled extremities Warm to edges
Narrow pulse pressure Wide pulse pressure
Hypotension is not required for the clinical diagnosis of shock; however once it is
present in a child with a suspected infection the diagnosis is confirmed. Early signs and
symptoms of shock are as a result of the body’s compensatory mechanisms, while late
signs are indicative of decompensation.
Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St
Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great Great
Ormond Street Hospital
Page 2 of 7
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Normal ranges for age (APLS)
Age(years) Respiratory rate Heart rate Systolic BP (mmHg)
<1 30 - 40 110 - 160 80 - 90
1-2 25 - 35 100 - 150 85 - 95
2-5 25 - 30 95 - 140 85 - 100
5 - 12 20 - 25 80 - 120 90 - 110
> 12 15 - 20 60 -100 100 - 120
There is evidence showing aggressive optimisation of the haemodynamic status
within the first few hours of critical illness reduces subsequent organ failure improving
overall survival. Paediatric septic shock is typically associated with severe
hypovolemia and children frequently respond well to aggressive volume
resuscitation, children are consistently under-resuscitated in the first few hours. For
every hour that a child remains in septic shock the mortality risk doubles.
The first hour of resuscitation – Goals to restore
Normal perfusion
No difference in quality between central & peripheral pulses
Warm extremities
Capillary refill time <2s
Normal range for age heart rate, blood pressure & respiratory rate for age (this may
not be possible if the underlying cause is pneumonia)
Normal mental status
Urine output >1ml/kg/hr
Serum lactate < 2
ScvO2 sats (where available) >70%
Normal glucose and ionized calcium concentrations
Actions in the 1st hour
Maintain or restore a patent airway
High flow oxygen to achieve saturations >95% - intubate if indicated
Obtain secure intravenous or intraosseous access x2
Give high dose broad spectrum antibiotics- avoid ceftriaxone (<1yr) due to risk of
precipitation with calcium administration, use cefotaxime
Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St
Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great Great
Ormond Street Hospital
Page 3 of 7
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Do not waste valuable time - if difficult IV access, site an intraosseous (IO) needle. More than one
is frequently required.
Resuscitate
Signs of shock should be immediately treated
20 mls/kg over 5 minutes. Rapid infusion bolus administered either by push or pressure bag
Use 0.9% Saline or Human Albumin Solution 4.5% (HAS)
Correct hypoglycaemia, give 2 mls/kg of 10% Glucose
Reassess - What are the effects of every fluid bolus?
Have the heart rate, quality of peripheral pulses, CRT, mental state, blood pressure
responded? Multiple fluid boluses may be necessary
Large fluid deficits often exist & initial fluid volumes of 40-60 ml/kg are quite
usual, volumes of 80-100mls/kg may be necessary
Is there evidence of volume overload? (hepatomegaly, crackles, increased work
of breathing or gallop rhythm), fluid is not recommended when rales or
hepatomegaly are present – commence inotropic support
If after 15 minutes of optimal fluid resuscitation (40-60 mls/kg) and there is still evidence of end
organ dysfunction start peripheral or IO Adrenaline at 0.1mcg/kg/min up to 0.5mcg/kg/min.
Refer to CATS at this point if not already done so.
Inotrope choice:
Adrenaline for COLD SHOCK
Noradrenaline for WARM SHOCK
Hydrocortisone Therapy
If in catecholamine resistant shock then IV hydrocortisone should be administered at 1mg/kg
qds (2.5mg/kg in neonates)
Obtain central access
Insert an arterial line for haemodynamic monitoring
Indications for Intubation
Impending cardiovascular collapse
Poor airway reflexes
Depressed level of consciousness -Glasgow Coma Score (GCS) ≤ 8 or AVPU ≤ P worsening
tachypnoea or oxygen requirement
Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St
Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great Great
Ormond Street Hospital
Page 4 of 7
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Fluid refractory shock (≥ 40 mls/kg fluid resuscitation in the first 30 minutes without reversal
of shock)
Management of intubation
Optimal volume replacement prior to intubation
Fluid bolus attached prior to induction drugs
Adrenaline infusion drawn up and attached if not running
Pre oxygenation with 100% O2
A “good fit” ETT (preferably a cuffed ETT). This is necessary to ventilate in the presence of
pulmonary oedema
Ensure the most experienced team members perform the intubation
Anaesthetic / ICU Consultant with Paediatric Consultant support
Use of optimal drugs for induction (refer to CATS intubation checklist)
Modified rapid sequence induction (cricoid pressure)
Inhalational anaesthetics present a significant risk of cardiovascular depression. They
should only be used if the risk of a difficult airway outweighs this. Thiopentone, propofol
& benzodiazepines all carry a similar risk of significant cardiovascular depression.
Once Intubated
End tidal CO2 monitoring is mandatory
Secure ETT – do not cut the ETT
Check appropriate position with CXR (Tip at T2-T3)
Sedate & muscle relax as per CATS guidelines
These children are at risk of acute respiratory distress syndrome (ARDS). A low
tidal volume strategy of 4-7 ml/kg with an initial PEEP of 5 cm/H2O should be
used. PEEP can be titrated up depending on blood gases & evidence of
pulmonary oedema
Stabilisation
Coagulopathy
Consider treatment with 10-20 mls/kg of Fresh Frozen Plasma (FFP)
Low platelet counts in the absence of active bleeding should not be supplemented unless <
20 x106/microlitre
Low fibrinogen is suggestive of DIC give 5-10mls/kg of Cryoprecipitate
Electrolytes
Treat Hypocalcaemia (0.5 mls/kg 10% calcium gluconate)
Treat Hypomagnesaemia 0.5 ml/kg 20% magnesium sulphate (or 1ml/kg 10% magnesium
sulphate)
(This can cause hypotension, give slowly over 30 minutes with additional fluid bolus if
necessary)
Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St
Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great Great
Ormond Street Hospital
Page 5 of 7
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Ongoing Fluid Resuscitation
Fluid shift and hypotension secondary to capillary leak can continue for several days.
Continued fluid administration should be titrated against clinical end points such as, heart rate,
perfusion pressure, cardiac output, urine output, serum lactate and ScvO2 saturations.
Consider Fresh Frozen Plasma for coagulopathy. Consider packed red cells.
Indicators of disease severity
Low neutrophils
Low platelets
Rapid onset (<6 hours)
Rapidly spreading rash
High volume requirement
References:
Davis, A et al., (2017). American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support
of Pediatric and Neonatal Septic Shock. Critical Care Medicine, 45(6), pp.1061-1093.
Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St
Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great Great
Ormond Street Hospital
Page 6 of 7
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1.
Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St
Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great Great
Ormond Street Hospital
Page 7 of 7
Printed copies of this document may not be up to date, obtain the most recent version from www.cats.nhs.uk
Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St
Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great Great
Ormond Street Hospital
Page 8 of 7
