Pediatric Sepsis and Septic Shock (SSC/Phoenix 2024)

Algorithm Steps

1. ▶

   Start

   Suspected Pediatric Sepsis

   Child with suspected infection and signs of organ dysfunction

   1. ●

      Action

      Recognition: Phoenix Sepsis Criteria

      Identify sepsis using Phoenix Score

      • Sepsis = Phoenix Score ≥2 in child with suspected infection
      • Phoenix Score assesses: Respiratory, Cardiovascular, Coagulation, Neurologic
      • Septic Shock = Sepsis + Cardiovascular dysfunction (CV score ≥1)
      • CV dysfunction: Vasoactive use OR Lactate >5 mmol/L OR MAP low for age
      1. ●

         Action

         First Hour Bundle

         Time-sensitive interventions

         • Obtain IV/IO access (2 large-bore if possible)
         • Draw blood cultures BEFORE antibiotics (do not delay abx)
         • Measure lactate
         • Begin fluid resuscitation
         • Administer broad-spectrum antibiotics within 1 hour
         1. ●

            Action

            Fluid Resuscitation

            Isotonic crystalloid boluses

            • Initial: 10-20 mL/kg balanced crystalloid or NS
            • Reassess after each bolus (exam, HR, BP, cap refill, urine output)
            • Repeat up to 40-60 mL/kg in first hour if needed
            • Watch for fluid overload (rales, hepatomegaly, worsening oxygenation)
            • In resource-limited settings: restrict to 20-40 mL/kg total
            1. ◆

               Decision

               Response to Fluids?

               Assess perfusion after 40-60 mL/kg fluids

               • Signs of adequate perfusion:
               • - Improved cap refill (<2 sec)
               • - Improved mental status
               • - Improving lactate
               • - Adequate urine output
               1. ✓

                  Outcome

                  Perfusion Restored

                  Continue monitoring, ICU admission

                  • Continue supportive care
                  • Complete antibiotic course
                  • Wean vasopressors as tolerated
                  • PICU admission for close monitoring
               2. ●

                  Action

                  Vasopressor Initiation

                  Fluid-refractory shock - start vasopressors

                  • FIRST-LINE: Epinephrine OR Norepinephrine (no preference)
                  • Epinephrine: 0.05-0.3 mcg/kg/min (may use peripherally initially)
                  • Norepinephrine: 0.05-1 mcg/kg/min
                  • Titrate to MAP appropriate for age
                  • Consider central access for prolonged vasopressor use
                  1. ●

                     Action

                     Ongoing Monitoring

                     Continuous reassessment

                     • Serial lactate measurements
                     • Urine output (goal >0.5 mL/kg/hr)
                     • Invasive BP monitoring if on vasopressors
                     • Central venous access for CVP, ScvO2
                     • Point-of-care echo to assess cardiac function
                  2. ◆

                     Decision

                     Assess Shock Phenotype

                     Warm vs Cold Shock

                     • WARM shock: Bounding pulses, flash cap refill, wide pulse pressure
                     • → Norepinephrine preferred
                     • COLD shock: Weak pulses, prolonged cap refill, narrow pulse pressure
                     • → Epinephrine preferred
                     1. ●

                        Action

                        Catecholamine-Resistant Shock

                        Consider additional therapies

                        • Add second vasopressor/inotrope
                        • Consider hydrocortisone if adrenal insufficiency suspected
                        • Stress-dose steroids: Hydrocortisone 1-2 mg/kg (max 100mg) q6-8h
                        • Consider ECMO if available and appropriate
                        • Reassess source control - drainage of abscess?
         2. ⚠

            Warning

            Source Control

            Identify and control infection source

            • Surgical consultation if needed
            • Drain abscesses, debride necrotic tissue
            • Remove infected devices/lines
            • De-escalate antibiotics when culture data available