Sepsis and Septic Shock in Children
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Direct answer
Sepsis in children is life-threatening organ dysfunction caused by a dysregulated host response to infection, and septic shock is sepsis with severe cardiovascular dysfunction, such as hypotension, raised lactate or the need for vasoactive support. The core approach is early recognition, cultures, antibiotics and a rapid crystalloid bolus, completed as an hour-one bundle. Organ dysfunction is judged against age-specific norms, because normal heart rate and blood pressure vary widely through childhood.
What you must remember
- Sepsis: suspected or proven infection with organ dysfunction, judged against age-appropriate normal values.
- Septic shock: sepsis with cardiovascular dysfunction, needing vasoactive drugs to maintain perfusion despite adequate fluid.
- Early markers: tachycardia, prolonged capillary refill, altered mental state, mottling, weak pulses and falling urine output, with hypotension a late sign.
- Hour-one bundle: measure lactate, obtain cultures, start broad-spectrum antibiotics within the hour, give an isotonic crystalloid bolus and start vasoactives if hypotension persists.
- Fluid bolus: rapid isotonic crystalloid, typically 10 to 20 mL/kg, reassessed after each bolus for response and for signs of overload.
- Vasoactive choice: cold shock with poor output favours epinephrine, and warm vasodilatory shock favours norepinephrine, although books differ on the first-line agent.
- Refractory shock: hydrocortisone is considered for catecholamine-resistant shock, with evidence in children still limited.
A stepwise approach to the first hour
A 3-year-old with fever, mottled legs and a capillary refill of four seconds has a normal-looking blood pressure. The steps below follow the bundle in order.
- Recognise and call for help. Mottling, prolonged capillary refill and altered sensorium indicate shock even when blood pressure is preserved.
- Secure access and draw samples. Establish two IV or intraosseous routes, and take blood culture and lactate without delaying treatment.
- Give antibiotics within the hour. Use broad-spectrum cover per local guidelines, and narrow later according to culture.
- Bolus isotonic crystalloid. Give 10 to 20 mL/kg boluses over minutes, reassessing after each for response and for crackles, hepatomegaly or hypoxia.
- Escalate vasoactives if needed. Start epinephrine or norepinephrine according to the cold or warm picture, using a peripheral line if central access is delayed.
Completing each element within the hour matters more than the exact order, so teams should work in parallel rather than one step at a time. Reassessment after every intervention keeps fluid, drugs and oxygen matched to the child's response.
Where the exam tries to catch you
Three mistakes recur on this topic.
- Trap: waiting for hypotension before calling it shock Correct: children compensate with tachycardia and vasoconstriction, so poor perfusion and altered mental state define shock before blood pressure falls.
- Trap: giving fluids without reassessment Correct: boluses can cause pulmonary oedema, so the child is reviewed after each one.
- Trap: delaying antibiotics until cultures return Correct: cultures are drawn first, but antibiotics start within the hour without waiting for results.
Frequently asked questions
What is septic shock in children?
Septic shock in children is sepsis with cardiovascular dysfunction that persists despite adequate fluid resuscitation and needs vasoactive drugs. It is recognised by hypotension or poor perfusion, although in children these may be late signs.
What is the hour-one bundle in paediatric sepsis?
The hour-one bundle in paediatric sepsis includes measuring lactate, obtaining blood cultures, starting broad-spectrum antibiotics and giving a rapid isotonic crystalloid bolus. Vasoactive support is added if hypotension persists, all within about an hour of recognition.
Why is normal blood pressure no reassurance in childhood sepsis?
Normal blood pressure does not exclude sepsis in children, because they maintain it through tachycardia and vasoconstriction until late decompensation. Capillary refill, pulse quality, mental state and urine output are better early markers.
Which vasoactive drug is used in paediatric septic shock?
Epinephrine and norepinephrine are the main vasoactive drugs in paediatric septic shock, with the choice guided by whether the shock is cold or warm. Books differ on the first-line agent, so local protocol and haemodynamic assessment guide the decision.