Circulation
1 min to attain IV access
If unable to get IV in 1 min, consider IO access
60ml/kg IVF over the first hour
Consider vasopressors if not fluid responsive
Consider steroids if not fluid responsive
Airway
Consider early intubation, especially in fluid refractory shock
Ketamine for sedation is drug of choice
Hypotensioncan still occur in septic patients
Typical paralytic agents
Breathing
CPAP can buy time for fluid resus prior intubation
Glucose
Ensure euglycemia
1 min to attain IV access
If unable to get IV in 1 min, consider IO access
60ml/kg IVF over the first hour
Consider vasopressors if not fluid responsive
Consider steroids if not fluid responsive
Consider early intubation, especially in fluid refractory shock
Ketamine for sedation is drug of choice
Hypotensioncan still occur in septic patients
Typical paralytic agents
Hypotensioncan still occur in septic patients
CPAP can buy time for fluid resus prior intubation
Ensure euglycemia
Cap refill <2 sec
Normal BP
Normal pulses, similar central and peripheral
Warm extremities
UOP >1 mL/kg/hr
Normal mental status
Compared to adults, pediatric<unk> patients have normal lactate ore often
Controversial but surviving<unk> campaign no longer recommends trending lactate in pediatric patients
Ampicillin 50mg/kg q8h + gentamicin 2.5mg/kg q24h + acyclovir
If gram-negative strongly suspected replace gentamicin with cefotaxime or ceftazadine
Have better CNS penetration
If gram-negative strongly suspected replace gentamicin with cefotaxime or ceftazadine
Have better CNS penetration
Have better CNS penetration
Treatment will differ by local protocols
Extended-spectrum penicillin (e.g. Ppiperacillin-tazobactam]]) ± aminoglycoside ± vancomycin
OR
3rd or 4th generation cephalosporin ± aminoglycoside ± vancomycin
OR
Carbapenem ± aminoglycoside ± vancomycin
If vasopressors needed for septic shock, follow recommendations:
Normotensive shock with impaired perfusion: dopamine
Warm shock (vasodilated with poor perfusion or low BP): norepinephrine
Cold shock (vasoconstricted with poor perfusion or low BP): epinephrine
Consider epinephrine and perhaps norepinephrine over dopamine as a 1st line vasopressor
Dopamine may be associated with increased mortality in pediatrics, which has been demonstrated in adult literature as well
RTC trial in 2015 from Brazil, without other larger RTCs or multi-center trials to corroborate information
Normotensive shock with impaired perfusion: dopamine
Warm shock (vasodilated with poor perfusion or low BP): norepinephrine
Cold shock (vasoconstricted with poor perfusion or low BP): epinephrine
Dopamine may be associated with increased mortality in pediatrics, which has been demonstrated in adult literature as well
RTC trial in 2015 from Brazil, without other larger RTCs or multi-center trials to corroborate information
Sepsis 
THE MISFITS [1]
Tumor lysis syndrome
Trauma
Hemorrhagic shock
Heart
Toxic shock syndrome
Congenital heart disease