• ALT 2× upper limit of normal for age
TABLE 10.3
RECOMMENDED LABORATORY TESTING IN SUSPECTED SEPSIS
Source testing • Blood culture
• Urinalysis, urine culture
• Consider other cultures based on suspected source (e.g.,
lumbar puncture, drainage of abscess, or fluid collection)
• CXR and other focused radiologic studies
• Influenza and other viral testing
• Consider procalcitonin, C-reactive protein as biomarkers for
presence of infection
Perfusion
• Lactate
• Base deficit
• Central venous oxygen saturation (ScvO2 )
Respiratory
Hematologi c
Renal
Hepatic

• Blood gas if clinically indicated
• Complete blood count
• Coagulation studies (PTT, PT/INR, fibrinogen, d-dimer)
• Serum creatinine
• Transaminases (ALT, AST)
• Bilirubin
• Albumin

There have been efforts to determine whether additional laboratory testing
including white blood cell count, immature neutrophils, C-reactive protein (CRP),
and procalcitonin may have predictive value for sepsis in children with

compensated shock. Increased procalcitonin has been associated with an
increased likelihood of bacterial infection and septic shock. While these
biomarkers may suggest a patient is more likely to require treatment for bacterial
sepsis, optimal thresholds and their clinical utility have yet to be demonstrated
rigorously. Increasing evidence shows that both venous and arterial lactate levels
in the ED are associated with risk of organ dysfunction in pediatric sepsis and risk
of death at the time of pediatric intensive care unit (PICU) admission. While the
optimal cutoff remains to be defined, lactate ≥2 mmol/L is worrisome and
associated with worse outcome.


Neonates With Shock. Very young infants (<28 days) can present with shock
from a variety of causes, and are mentioned separately here due to challenges in
shock recognition and differences in treatment in this vulnerable population.
Neonates with shock can decompensate very rapidly. They certainly can present
in a similar fashion to older children with the signs and symptoms described
above, but also can present in a decompensated state with hypothermia, apnea,
and bradycardia. A broad differential diagnosis should be maintained including
sepsis, undiagnosed congenital heart disease (Chapter 73 Septic-Appearing Infant
), metabolic disease, and trauma (accidental or nonaccidental).

PRINCIPLES OF SHOCK MANAGEMENT
The mainstays of shock treatment are rapid recognition of the compensated or
uncompensated shock state, rapid reversal of shock, and identification and
treatment of the underlying etiology of shock. Important aspects of shock reversal
include assessment of airway patency and adequacy of breathing, provision of
supplemental oxygen, establishment of vascular access, restoration of the
circulating blood volume, support of the cardiac and vascular system with
appropriate vasoactive agents when necessary, and frequent reassessment of the
patient’s response. The management strategies discussed in the following sections

apply to all shock types, with additional discussion at the end of the section for
type-specific management recommendations.

Vascular Access
Intravenous (IV) access should be established immediately, preferably with two
large-bore peripheral IVs. If peripheral IV access cannot be obtained within the
first 5 minutes of shock recognition, intraosseous access should be established
until more definitive vascular access can be obtained. Central venous access
should be strongly considered if the patient has fluid-refractory shock (e.g.,
remains in shock despite rapid administration of at least 60 mL/kg of fluid
resuscitation) or if vasoactive agents are initiated. For those in refractory shock,
central venous access also allows for monitoring of important goal-directed
therapy targets, such as ScvO2 . Arterial blood pressure monitoring with an intraarterial catheter is also recommended for children in fluid-refractory shock. An
arterial catheter provides continuous monitoring of the arterial blood pressure to
aid in titration of fluid resuscitation and vasoactive infusions and facilitates
monitoring of arterial blood gases to follow acidosis and lactate to guide
resuscitation. Although central venous access and arterial access are more
commonly established following transfer to definitive care in the PICU, advanced
vascular access could be obtained in the ED setting if immediate transfer to


definitive care is not feasible and there is a provider available experienced in the
placement of these devices in children in shock.

Volume Resuscitation
Several studies of pediatric shock have shown decreased mortality with early and
aggressive fluid resuscitation, and the current recommendation is to administer
fluid in 20-mL/kg boluses pushed over 5 to 10 minutes, with reassessment of
perfusion and vital signs, as well as for signs of hepatomegaly and rales, during
and after each fluid bolus. Fluid boluses totaling up to and over 60 mL/kg should

be administered if the child remains in shock, with a goal of delivering at least 60
mL/kg in the first 20 to 60 minutes if shock persists and signs of fluid overload
(hepatomegaly, rales) do not manifest. Ongoing fluid resuscitation should be
reconsidered if hepatomegaly or signs of pulmonary edema develop. In addition,
caution should be taken with rapid fluid resuscitation in neonates <30 days of
age, patients with severe malnutrition or anemia, and in patients with known or
suspected cardiac or renal disease or suspected cardiogenic shock. For these
patients, smaller boluses of 5 to 10 mL/kg are prudent with frequent reassessment
to determine clinical response. The recent FEAST trial in sub-Saharan Africa,
which is discussed in more detail below, has called into question the paradigm of
aggressive fluid resuscitation in pediatric septic shock. Further trials of smallervolume fluid boluses and earlier vasoactive infusion support are ongoing to
further clarify the optimal role of fluid resuscitation in pediatric septic shock.
Fluid should be administered via IV push or a rapid infuser system to achieve
the time goals set by the American College of Critical Care Medicine. IV push
delivery may be facilitated by attaching a large syringe with a three-way stopcock
to the IV tubing from the IV fluid bag, creating a so-called “push–pull system”
that allows the user to rapidly draw up fluid into the syringe and then administer
via IV push without repeatedly disconnecting and reconnecting the syringe to the
patient’s IV. In larger patients >50 kg, a pressure bag or rapid infuser may be used
to rapidly administer large volumes of fluid through a large gauge peripheral IV
over the goal of 5 minutes.
The optimal fluid choice for resuscitation remains a matter of debate. While
Maitland et al. showed reduction in mortality in shock related to malaria with
albumin versus crystalloid resuscitation and the adult SAFE study showed a trend
toward improved survival in subgroup analysis of patients with septic shock
receiving albumin versus crystalloid, many other studies have shown no
differences in outcome with a colloid versus crystalloid resuscitation strategy.
Furthermore, the SAFE study showed worse outcomes in the subgroup analysis of
patients with traumatic brain injury who received colloid resuscitation. Therefore,



IV crystalloids are generally considered first-line fluids except for children with
hemorrhagic shock and dissociative shock. In terms of crystalloid solution choice,
several interventional trials in adults show decreased mortality and decreased
kidney injury with preferential use of balanced fluids for resuscitation rather than
0.9% saline, though additional confirmatory trials are ongoing. In children with
septic shock, several studies demonstrate an association of increased mortality
with hyperchloremia, which can be seen in the setting of large-volume saline
resuscitation. However, retrospective pediatric studies comparing balanced fluids
to 0.9% saline have reported conflicting results and 0.9% saline has the relative
benefits of low cost and universal compatibility compared to Plasma-Lyte and
lactated Ringer’s (LR), respectively. Until further data become available, use of
crystalloids (either 0.9% saline or balanced fluids such as LR or Plasma-Lyte) is
generally more common than colloids for initial fluid resuscitation due to their
availability, ease of administration, and low cost. There is evidence supporting a
risk of kidney injury with the use of synthetic colloids, such as hydroxyethyl
starch, and its use is currently not recommended by the Surviving Sepsis
Campaign.
The use of blood products for volume expansion is another important
consideration, especially in hemorrhagic shock. The Advanced Trauma Life
Support guidelines recommend resuscitation with crystalloid and blood products
for classes III and IV hemorrhagic shock (see Chapter 7 A General Approach to
the Ill or Injured Child for more details on trauma). Based on early studies of
adult septic shock and subsequent pediatric studies red blood cell (RBC)
transfusion has typically been recommended to maintain a goal hemoglobin >10
g/dL and an ScvO2 >70% for children with fluid-refractory septic shock during
the early stages of resuscitation. However, while RBC transfusion can increase
blood oxygen content, adverse effects can occur (e.g., transfusion-related acute
lung injury, immune suppression, or circulatory overload). RBCs also tend to
aggregate and obstruct the microcirculation in states of systemic inflammation

and endothelial activation (as with sepsis), and transfused RBCs may be less
efficient at delivering oxygen to vital organs due to a reduction in 2,3diphosphoglycerate content and other changes during storage. Data from two
adult randomized trials recently demonstrated that a hemoglobin threshold of 7 to
7.5 g/dL before transfusion provided similar outcomes as a higher hemoglobin
threshold. Consequently, recent consensus guidelines for RBC transfusion in
children were unable to reach consensus regarding the optimal transfusion
threshold for critically ill children with unstable nonhemorrhagic shock.