Management of Septic Shock in Children

Paediatric septic shock is a frequently occurring disease condition that is associated with high morbidity and mortality (Watson et al, 2003). Shock is an acute, complex state of circulatory dysfunction resulting in failure to deliver oxygen (DO2) and nutrients to meet metabolic demands (VO2) which are usually increased during shock. If left untreated, multiple organ failure and ultimately death will occur (Smith et al, 2006). This strongly points out the importance of early recognition and aggressive treatment of children with shock. Comparable to adults, such an approach – termed early-goal directed therapy (EGDT) – has been shown to significantly reduce mortality in paediatric septic shock. Paediatric studies have pointed out that the risk of death showed a two-fold increase with each hour delay in the reversal of shock (Carcillo et al, 2009; Han et al, 2003; Inwald et al, 2009; Rivers et al, 2001). Hypovolaemic shock and septic shock are the most common forms of shock in children. Hypovolaemic shock is characterized by a decrease in intravascular blood volume to such an extent that effective tissue perfusion cannot be maintained. In children hypovolaemic shock is mainly caused by fluid and electrolyte loss due to vomiting and diarrhea or acute haemorrhage. Septic shock is actually a combination of distributive shock (i.e. a decreased total vascular resistance and maldistribution of blood flow in the microcirculation) and relative as well as a absolute hypovolaemia. Furthermore, impairment of myocardial fuction may occur with symptoms of cardiogenic shock. The great majority of children with septic shock will not be presented in hospitals with PICU facilities. Furthermore, from a pathophysiologic perspective paediatric shock does not resemble adult septic shock. This strongly suggests that every physician that could be faced with these children needs to understand how to recognize paediatric shock and have basic knowledge of the principles of primary management. This chapter summarizes the pathophysiology, clinical manifestations and primary management of paediatric septic shock.