Pharmacotherapy

Initial Emergency Department Management

• IV fluid resuscitation
  • Initial bolus of 20 mL/kg isotonic crystalloid (normal saline, Lactated Ringer’s) over 30-60 mins
  • May repeat up to 40-60 mL/kg in first 1-2 hours to reverse shock
  • Monitor for fluid overload after shock resolves

• Vasopressors
  • Begin early if fluid refractory shock persists >40 mL/kg
  • First line: Dopamine or Epinephrine
  • Dopamine: Start at 5-10 mcg/kg/min, titrate up to 10-20 mcg/kg/min
  • Epinephrine: Start at 0.05-0.3 mcg/kg/min, titrate up to 0.3-1 mcg/kg/min
  • Target MAP at 5th percentile for age

• Broad spectrum antibiotics
  • Obtain cultures first
  • Begin IV antibiotics within 1 hour of sepsis recognition
  • Cover common bacteria based on source of infection
  • Modify based on culture results when available

• Adjunctive therapies
  • Hydrocortisone if fluid/catecholamine resistant shock
  • Start stress dose hydrocortisone 1-2 mg/kg/dose IV q6-12h
  • Drotrecogin alfa (activated) – recombinant activated protein C, controversial, not currently recommended

ICU Management

• Hemodynamic monitoring and optimization
  • Central venous pressure, ScvO2 monitoring
  • Echocardiography to guide fluid/pressor titration

• Judicious fluids once shock resolves
  • Avoid fluid overload > 10% total body weight

• Multiple vasopressor/inotrope use if needed
  • Epinephrine, norepinephrine, vasopressin, dopamine, milrinone
  • Titrate to optimize blood pressure and perfusion

• Hydrocortisone for refractory shock
  • Up to 50 mg/m2/day continuous infusion

• Mechanical ventilation if respiratory failure
  • Lung protective strategies
  • Neuromuscular blockade for refractory hypoxemia

• Renal replacement therapy for fluid overload/renal failure

• Stress ulcer and VTE prophylaxis

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Key Monitoring Parameters

• Vital signs, mental status, urine output
• Serum lactate level – normalize <2 mmol/L
• Central venous oxygen saturation (ScvO2) – target >70%
• Central venous pressure – target >8 mmHg
• Echocardiography for cardiac function
• Daily fluid balance and cumulative balance