Pediatric Shock Care

Pediatric Septic Shock Care: Fluid Therapy

Last Full Review: Surviving Sepsis Campaign 2020

Hypovolemia in septic shock is the result of capillary leak, vasodilation, and fluid losses, leading to decreased cardiac output and reduced organ perfusion. Fluid resuscitation corrects hypovolemia.

 

Evidence Summary

The Surviving Sepsis Campaign (SSC) review (Weiss et al. 2020, e52) included three randomized controlled trials (RCTs) (Santhanam et al. 2008, 647; Sankar et al. 2017, e435; Inwald et al. 2019, 426) of different volume resuscitation strategies for 316 children with septic shock in advanced care settings and found no difference in mortality between the restrictive and liberal fluid resuscitation groups. The suggestion of “up to 40 milliliters per kilogram (mL/kg)” was included for care in low-resource settings on the basis on the Fluid Expansion as Supportive Therapy (FEAST) study (Maitland et al. 2011, 2483) of children with severe hypotension. It was noted that the World Health Organization recommends isotonic crystalloid over 30 to 60 minutes, followed by an additional 10 mL/kg over 30 minutes if there is no improvement and no signs of fluid overload, cardiac failure, or neurologic deterioration. No pediatric RCTs compared balanced/buffered crystalloids to 0.9% saline, however two observational studies in a total of 30,532 children with sepsis (Weiss et al. 2017, 304; Emrath et al. 2017, 1177) found that of 2,100 who received only balanced/buffered crystalloids for the first 72 hours of hospitalization and 28,432 who received normal saline, the use of balanced/buffered crystalloid was associated with lower mortality (OR, 0.79; 95% CI, 0.65–0.95). Recommendations from SSC for fluid therapy are tiered by settings based on availability of ICU care.

In healthcare systems with availability of intensive care, the SSC suggests administering up to 40 to 60 mL/kg in bolus fluid (10 to 20 mL/kg per bolus) over the first hour, titrated to clinical markers of cardiac output and discontinued if signs of fluid overload develop, for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction (Weiss et al. 2020, e52).

In healthcare systems with no availability of intensive care and in the absence of hypotension, a strong recommendation is made against bolus fluid administration while starting maintenance fluids (Weiss et al. 2020, e52).

In healthcare systems with no availability of intensive care, if hypotension is present, SSC suggests administering up to 40 mL/kg in bolus fluid (10 to 20 mL/kg per bolus) over the first hour, titrated to clinical markers of cardiac output and discontinued if signs of fluid overload develop (Weiss et al. 2020, e52).

The SSC suggests using balanced/buffered crystalloids, rather than 0.9% saline, for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction (Weiss et al. 2020, e52).

Insights and Implications

Similar results are being identified for outcomes in adults with sepsis suggesting that resuscitation with crystalloid containing high chloride concentrations (i.e., 0.9% normal saline) is associated with hyperchloremic acidosis, systemic inflammation, acute kidney injury, coagulopathy, and mortality as compared with use of balanced, buffered crystalloids such as lactated Ringer’s and Plasma-Lyte (Semler et al. 2018, 829).

Pediatric Septic Shock Care: Ventilation

Last Full Review: Surviving Sepsis Campaign 2020

Pediatric patients with fluid-refractory and catecholamine-resistant septic shock may progress to respiratory failure or may benefit from early mechanical ventilation. The Surviving Sepsis Campaign (SSC) review evaluated evidence related to management of respiratory failure and sepsis-induced pediatric acute respiratory distress syndrome (Weiss et al. 2020, e52).

 

Evidence Summary

Etomidate is used as a sedative for tracheal intubation in patients with unstable hemodynamics, but there are concerns noted by SSC regarding the effect of the drug on adrenal function in adults (Weiss et al. 2020, e52). There are no randomized controlled trials (RCTs) comparing etomidate with other sedatives in the pediatric population with or without sepsis. A recent small observational study of children with meningococcal sepsis or septic shock intubated with etomidate as compared with any other combination of sedatives reported an association with higher mortality after use of etomidate (pooled OR, 4.51; 95% CI, 1.82–11.16) (den Brinker et al. 2005, 5110). Additional studies from the adult population were used to inform the treatment recommendation for etomidate (Weiss et al. 2020, e52).

The SSC review authors performed a meta-analysis of three observational studies (Wolfler et al. 2015, 418; Dohna-Schwake et al. 2011, 1114; Pancera et al. 2008, 533) that evaluated the association of noninvasive mechanical ventilation with mortality in a pediatric intensive care unit population. Unadjusted estimates found noninvasive ventilation to be associated with a decreased risk of death (RR, 0.21; 95% CI, 0.09–0.47) (Weiss et al. 2020, e52).

Pooled data from two RCTs (Curley et al. 2005, 229; Kornecki et al. 2001, 211) in pediatric acute respiratory distress syndrome (PARDS) patients showed an RR of 0.99 (95% CI, 0.36–2.69) for mortality with prone compared with supine positioning and with no reported serious adverse events. The recommendation for consideration of prone positioning as a potentially lifesaving strategy is additionally supported by RCTs in adults (Weiss et al. 2020, e52).

A weak recommendation based on low quality of evidence is made by SSC against the use etomidate when intubating children with septic shock or other sepsis-associated organ dysfunction (Weiss et al. 2020, e52).

A weak recommendation based on very low quality of evidence is made by SCC for a trial of noninvasive mechanical ventilation (over invasive mechanical ventilation) in children with sepsis-induced PARDS without a clear indication for intubation and who are responding to initial resuscitation (Weiss et al. 2020, e52).

A weak recommendation based on low of quality evidence is made by SCC, suggesting a trial of prone positioning in children with sepsis and severe PARDS (Weiss et al. 2020, e52).

Insights and Implications

Noninvasive mechanical ventilation with continuous positive airway pressure or bi-level positive airway pressure ventilation is a means of reducing the work of breathing and increasing oxygenation and thus avoiding intubation in sepsis-induced PARDS. Although there are no RCTs comparing noninvasive ventilation with mechanical ventilation in children and infants with sepsis, the meta-analysis by SSC, (Weiss et al. 2020, e52) while very low-certainty evidence, suggests benefit from noninvasive ventilation. It is emphasized that patients with noninvasive ventilation should be monitored closely and should not have evidence of ongoing or worsening end-organ dysfunction.

The prone position is of particular interest during the COVID-19 pandemic, and when combined with high-flow nasal cannula, has been found to help avoid intubation, especially in patients with moderate PARDS and baseline saturation of peripheral oxygen greater than 95% (Ding et al. 2020, 28).

Pediatric Septic Shock Care: Vasoactive Medications

Last Full Review: Surviving Sepsis Campaign 2020

Vasoactive medications, such as norepinephrine and epinephrine, are useful in septic shock unresponsive to fluid therapy. The Surviving Sepsis Campaign (SSC) evaluated the choice of vasoactive medications in children with septic shock (Weiss et al. 2020, e52).

 

Evidence Summary

The SSC review (Weiss et al. 2020, e52) identified two randomized controlled trials (RCTs) comparing epinephrine with dopamine in children with fluid-refractory septic shock, (Ventura et al. 2015, 2292; Ramaswamy et al. 2016, e502) both showing that epinephrine was associated with a lower risk of mortality (RR, 0.63; 95% CI, 0.40–0.99). Although norepinephrine has not been studied in children with septic shock, one RCT of norepinephrine compared with saline in mechanically ventilated children did not show a difference in mortality between groups (Piva et al. 2014, 208). However, improved blood pressure and higher urine output suggested improved perfusion compared with saline.

Three RCTs (Choong et al. 2009, 632; Baldasso et al. 2007, S137; Yildizdas et al. 2008, 511) evaluating vasopressin-receptor agonists in children and others in adults informed the SSC recommendation on use of vasopressin (Weiss et al. 2020, e52).

A weak recommendation, based on low-quality evidence, is made by SSC that suggests using epinephrine, rather than dopamine, in children with septic shock. SSC also suggests, based on very low quality of evidence, using norepinephrine, rather than dopamine, in children with septic shock (Weiss et al. 2020, e52).

The SSC is unable to issue a recommendation for a specific first-line vasoactive infusion for children with septic shock. However, in the practice of SSC panel members, they select either epinephrine or norepinephrine as the first-line vasoactive infusion guided by clinician preference, individual patient physiology, and local system factors (Weiss et al. 2020, e52).

A weak recommendation is made by SSC (low-certainty evidence) that suggests either adding vasopressin or further titrating catecholamines in children with septic shock who require high-dose catecholamines (Weiss et al. 2020, e52).

Insights and Implications

Data from adult trials comparing norepinephrine with dopamine show a lower mortality rate and lower incidence of arrhythmias with norepinephrine than dopamine and contribute to the recommendations for children and infants with septic shock (Avni et al. 2015, e0129305). There is insufficient data to recommend epinephrine or norepinephrine as the initial vasoactive agent, and SSC panel members surveyed were split on which agent they use, depending on presence or absence of myocardial dysfunction and low cardiac output or the need to increase systemic vascular resistance (Weiss et al. 2020, e52). There was no consensus on the optimal threshold for initiating vasopressin, and the decision is left to clinician preference.

Pediatric Hemorrhagic Shock Care 

Last Full Review: ILCOR 2020

The management of pediatric hemorrhagic shock was previously reviewed by the American Red Cross Scientific Advisory Council and updated management was provided by the American College of Surgeons in the latest Advanced Trauma Life Support Program. These recommendations have not changed since the last review. 

 

Evidence Summary 

An International Liaison Committee on Resuscitation scoping review in 2020 sought to identify evidence about the effectiveness of graded volume resuscitation (restrictive volume resuscitation and permissive hypotension) for traumatic hemorrhagic shock (Maconochie et al. 2020, S140). Retrospective studies from trauma registries were identified, with only one study that assessed the volume of fluid administered for traumatic injuries in the prehospital setting. No studies reported on survival at 30 days; there was a suggestion from these studies of a possible advantage to using limited volume resuscitation (Maconochie et al. 2020, S140).

Insights and Implications 

The main goal of fluid resuscitation is to restore intravascular volume to reverse cellular hypoxia and ischemia before irreversible end-organ damage occurs. Monitoring of patient response to fluid resuscitation should be ongoing. Always assess the child or infant after each fluid bolus and discontinue fluid administration if clinical signs or symptoms of hypervolemia develop. Packed red blood cells or whole blood may be indicated in combination with isotonic crystalloids for volume resuscitation in hemorrhagic shock, to optimize hemoglobin concentration and hence oxygen delivery in shock. 

Pediatric Cardiogenic Shock Care 

Last Full Review: ILCOR 2020

Children and infants who remain in shock despite adequate fluid resuscitation or who cannot tolerate ongoing aggressive fluid therapy (e.g., those in cardiogenic shock) are candidates for other supportive (namely, vasoactive) therapies. 

 

Evidence Summary 

An evidence update was completed by the International Liaison Committee on Resuscitation (ILCOR) in 2020 on the topic of vasoactive drugs for cardiogenic shock in the first hours of treatment (Maconochie et al. 2020, S140). Insufficient evidence was identified to consider a systematic review of change in recommendations. The ILCOR recommendation states that the catecholamine dose for inotropic support in cardiogenic shock must be titrated for each individual because there is wide variability in the clinical response to vasoactive drugs (Maconochie et al. 2020, S140). It is reasonable to use epinephrine, levosimendan, dopamine, or dobutamine for inotropic support in infants and children with cardiogenic shock. Milrinone may be beneficial for the prevention and treatment of low cardiac output following cardiac surgery. There are insufficient data to support or refute the use of norepinephrine in pediatric cardiogenic shock (Maconochie et al. 2020, S140).

The management of pediatric cardiogenic shock was previously reviewed by the American Red Cross Scientific Advisory Council. These recommendations have not changed since the last review. 

Insights and Implications 

The central physiologic abnormality in cardiogenic shock is decreased cardiac output. In most cases, this decrease is due to impaired contractility of the heart. Children and infants in cardiogenic shock may be hypo-, normo- or hypervolemic. Therefore, fluid resuscitation should be carried out with caution, starting with smaller-than-usual boluses of 5 to 10 milliliters per kilogram (ml/kg) and closely monitoring response and for signs of pulmonary edema and signs of worsening perfusion.