EM · Paediatric sepsis and septic shock
Paediatric sepsis and septic shock (the septic child in the emergency department)
Also known as Paediatric sepsis · Septic shock in children · Paediatric septic shock · Phoenix sepsis criteria · Sepsis six in children
Paediatric sepsis is the dysregulated host response to infection producing life-threatening organ dysfunction, now defined (2024 Phoenix criteria) as suspected infection plus a Phoenix Sepsis Score of 2 or more, with septic shock adding cardiovascular dysfunction. The Fellowship-critical recognition rests on age-specific physiological thresholds — the tachycardia, the tachypnoea, and the hypotension that is systolic below 70 plus 2 times the age in years for a child under 10 and below 90 for a child over 10 — and on the perfusion signs of mottled skin, a capillary refill over 3 seconds and an altered mental state. The management is the first-hour bundle: fluid boluses of 10 to 20 mL per kilogram of balanced crystalloid (titrated, up to 40 to 60 mL per kilogram), early intravenous antibiotics within the hour (ceftriaxone 50 to 75 mg per kilogram; cefotaxime plus ampicillin in the neonate), vasopressors (adrenaline 0.05 to 0.5 mcg per kilogram per minute for cold shock), and intubation for refractory shock. Children differ from adults in the weight-based dosing, the higher heart-rate thresholds and the earlier need for intubation. The differential is meningococcaemia, Kawasaki disease and the serious bacterial illnesses. ACEM-primary, globally tagged.
Checked against its sources on 2 Sept 2026
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- Paediatric fever and serious bacterial illness (the febrile child in the emergency department)
- Sepsis and septic shock — the emergency department approach
- Fluid resuscitation in the emergency department
- Vasoactive drugs in resuscitation
- Meningitis and encephalitis (emergency department diagnosis and management)
- Community-acquired pneumonia
- DKA, HHS and hypoglycaemia
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Red flags
- Hypotension is a late and pre-arrest sign in children — a normal blood pressure does not exclude decompensated shock; recognise the tachycardia, the mottled skin and the delayed capillary refill first
- A systolic blood pressure below 70 plus 2 times the age in years (under 10) or below 90 (over 10) defines decompensated shock and demands immediate fluid resuscitation
- Give the first dose of antibiotics within the first hour — ceftriaxone 50 to 75 mg per kilogram intravenously; cefotaxime plus ampicillin in the neonate
- Reassess after every 10 to 20 mL per kilogram bolus — stop at hepatomegaly, a gallop rhythm or a rising work of breathing; the FEAST trial warns that unmonitored fluid boluses kill
- A child in refractory cold shock needs adrenaline 0.05 to 0.5 mcg per kilogram per minute early — do not chase blood pressure with ever more fluid once the limit is reached
- A non-blanching petechial or purpuric rash with fever is meningococcaemia until proven otherwise — give ceftriaxone immediately and notify public health
Meet the patient
A 3-year-old is carried into the resuscitation bay at 2am, febrile and floppy, with mottled skin and a capillary refill of 5 seconds. Heart rate 170, respiratory rate 42, and a systolic blood pressure of 64 — below the 76 threshold (70 plus 2 times 3) that defines decompensated shock.[1]
The two questions that decide the next hour are the two that decide every paediatric sepsis: is this child in shock? (the age-corrected vitals and the perfusion answer within a minute) and can I deliver the first-hour bundle without delay? (access, fluid, antibiotic, escalate). Hold those two and the rest of the topic slots into place.[1]
References5ShowHide
- [1]Weiss SL, Peters MJ, Alhazzani W, et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med, 2020.PMID 32030529
- [2]Sanchez-Pinto LN, Bennett TD, DeWitt PE, et al. Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock. JAMA, 2024.PMID 38245897
- [3]Schlapbach LJ, Watson RS, Sorce LR, et al. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA, 2024.PMID 38245889
- [4]Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med, 2011.PMID 21615299
- [5]McCrindle BW, Rowley AH, Newburger JW, et al. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association. Circulation, 2017.PMID 28356445