Journal of Pediatric Critical Care (Feb 2024)
Hemodynamic assessment and management of septic shock in children
Abstract
The three main pathophysiologic contributors to septic shock include varying combinations of hypovolemia (relative > absolute), vasoplegia, and myocardial dysfunction. The three pillars of hemodynamic support include fluid boluses (FBs), vasopressors ± inotropic agents. The three goals of hemodynamic resuscitation include an adequate cardiac output (CO)/clinical perfusion markers, pressure parameters (adequate mean arterial pressure [MAP] and diastolic blood pressure [DBP]) for organ perfusion, and avoiding congestion (worse filling) parameters. Fluid bolus-induced CO improvements are variable (33%–50%) and ill-sustained on account of sepsis-mediated glycocalyx injury. A pragmatic approach is to administer a small bolus (10 mL/kg over 20–30 min) as a test and judge the response based on clinical perfusion markers, pressure parameters, and congestive features. Vasoplegia is characterized by low DBP, which is a major contributor to hypotension in septic shock; furthermore, FBs may exacerbate vasoplegia. A strategy of restricted FB with early low-dose norepinephrine (NE) (0.05–0.1 µg/kg/min) can be helpful. NE has press or effects and also mild inotropy and can be a useful first-line vasoactive even in patients with mild-moderate septic myocardial dysfunction (SMD) to maintain adequate coronary perfusion and DBP while minimizing tachycardia. Severe SMD may benefit from additional inotropy (epinephrine/dobutamine). Except vasopressin, most vasoactive drugs may safely be administered via a peripheral route. The lowest MAP (5th centile for age) may be an acceptable target, provided that end-organ perfusion and organ function (mentation and urine output) are satisfactory. An individualized rather than protocolized approach combining the history, physical examination, laboratory analyses, available monitoring tools, and re-assessments can improve outcomes.
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