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Hypotension is a late sign
Fluid 20 ml/kg is the first priority even if normal BP.
Aim for 3 boluses over the first hour. 
 

 

 

 

 
Consider early intubation in fluid refractory septic shock (after 3 boluses of 20ml/kg IV NS) or in any compromised airway.
Infants or neonates with severe sepsis may require early intubation.
Intubation and mechanical ventilation increases intrathoracic pressure which reduce venous return and lead to worsening shock.
Therefore, fluid resuscitation must be done first.
 
 

 
Warm shock : A state of low systemic vascular resistance (SVR) and normal or increased cardiac output (CO)
Cold shock : A state of elevated SVR and low cardiac output with cold extremities and delayed capillary refill.
The inability of infants and young children to increase HR and cardiac stroke volume to the same extent as adults.
Consequently, vasoconstriction resulting in “cold shock” is the predominant response to a decrease in cardiac output in pediatric septic shock,
with hypotension manifesting as a relatively late finding in young children. 小兒心臟代償能力不如成人, 周邊只好血管收縮呈現 Cold shock
 
 
Norepinephrine : 周邊血管收縮為主 (強 α1 弱 β1)  (所以用在周邊血管擴張的 Warm shock)
Epinephrine  : α1- and nonselective β-adrenergic agonist (有強心的成分) 
Dopamine : 中劑量是 β effect, High dose 是 α effect
 
  • Dopamine pump: (6*BW) mg in 100mL D5W (1mL/hr = 1 mcg/kg/min [4-20mcg/kg/min])
  • Epinephrine pump: (0.6*BW) mg in 100mL D5W (1mL/hr = 0.1 mcg/kg/min [0.1-1mcg/kg/min])
  • Noreepinephrine pump: (0.6*BW) mg in 100mL D5W (1mL/hr = 0.1 mcg/kg/min [0.1-2mcg/kg/min])
 
ex. 7kg -> 8mg epinephrine in 50mL N/S (1mL/hr=0.33mcg/kg/min))
 

Hemodynamic Shock Types. | Download Table

 

 
The use of hydrocortisone in pediatric septic shock is currently being investigated and its role is unclear.
Consider using hydrocortisone 2mg/kg in any child that has fluid and inotropic resistant septic shock or proven adrenal insufficiency
 
Normal urine output is age-dependent:
Newborn and infant up to 1 year: normal is 2 ml/kg/hour.
Toddler : 1.5 ml/kg/hour.
Older child : 1 ml/kg/hour during adolescence.
Adult : 0.5 ml/kg/hour
 
 

 

Shock

  • Assess for poor perfusion and altered mental status.
  • Begin CABD
  • Monitors: SpO2, BP, ECG
  • Provide oxygen therapy, IV
  • Assess rhythm and possible cause
  • Labs: blood gas, lactate, glucose, CBC, ionized calcium, cultures.
  • Provided repeated IV bolus’ of crystalloids at 20 ml/kg. (Cease bolus’ at indication of fluid in lungs showing repiratory distress or rales. Also, cease bolus’ if hepatomegaly presents.)
     
Additional interventions:
  • Administer antibiotics STAT (for septic shock)
  • Correct hypoglycemia
  • Correct hypocalcemia
  • Vasopressors
  • Administer hydrocortisone if possible adrenal insufficiency.
     
If poor end-organ perfusion continues after fluid administration:
  • Vasopressor therapy
  • Titrate according to need (ScvO2 > 70%)
  • Central line, arterial line may be indicated
  • Warm Shock (vasodilated, hypotensive): administer Norepinephrine 0.1-2 mcg/kg/minute and titrate to BP
  • Cold Shock (vasoconstricted, hypotensive): administer Epinephrine 0.1-1 mcg/kg/minute and titrate to BP
     
Normal BP with poor perfusion:
  • administer dopamine 2-20 mcg/kg/minute
     
If ScvO2 >70% and hypotension:
Likely due to warm shock.
  • Continue IV fluid therapy
  • Continue administering Norepinephrine 0.1-2 mcg/kg/minute, titrate to BP
  • Consider administering Vasopressin 0.2-2 milliunits/kg/minute
     
If ScvO2 <70% and normotension:
  • Transfuse PRBC for a Hgb > 10g/dl
  • Continue IV fluid therapy
  • Attempt to optimize arterial oxygenation
  • Consider administering Milrinone loading dose of 50mcg/kg over 10-60 minutes and then o.25-0.75 mcg/kg/min
  • Consider administering Nitroprusside 0.3-1 mcg/kg/minute then titrate (maximum of 8 mcg/kg/minute)
  • Consider administering Dobutamine 2-20 mcg/kg/minute
     
If ScvO2 <70% and hypotension:
Likely due to cold shock.
  • Transfuse PRBC for a Hgb > 10g/dl
  • Continue IV fluid therapy
  • Attempt to optimize arterial oxygenation
  • Continue administering Epinephrine 0.1-1 mcg/kg/minute and titrate to BP and end-organ perfusion
  • Consider administering Dobutamine 2-20 mcg/kg/minute and titrate
  • Consider administering Norepinephrine 0.1-2 mcg/kg/minute and titrate
 
 

 
心因性休克掐 10 ml/kg 就要考慮升壓藥
 
 
 
 
 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4395852/
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