Septic shock resuscitation and vasoactive support — formative SAQs

1. Shock despite a normal blood pressure

"This infant is in decompensated septic shock in evolution. Children compensate for circulatory failure by raising heart rate and vascular tone, so blood pressure is maintained until relatively late; a normal reading never excludes shock." The first 60 seconds: declare the concern, call the senior paediatric and resuscitation teams, name a leader, allocate roles, and bring age- and weight-appropriate equipment and monitoring. Stabilisation precedes diagnosis. ^{[5] [1]}

2. First-hour circulatory, antimicrobial and glucose management

I secure the airway and give high-flow oxygen because the infant is in failure, supporting ventilation if it is ineffective. I establish intravenous or intraosseous access and send a point-of-care gas, lactate, glucose, culture and core bloods. I restore the circulation with crystalloid aliquots of 10 to 20 mL per kilogram, stating the expected response before each and reassessing after each; the first-hour total is a ceiling, not a target. I give broad-spectrum antibiotics within the first hour at weight-appropriate doses, taking cultures first only when this does not delay treatment. The bedside glucose is dangerously low, so I correct it immediately through the local hypoglycaemia pathway and recheck, because hypoglycaemia worsens neurological outcome. ^{[1] [5]}

3. Diagnosis and next step after refractory boluses

Shock persisting after two or three reassessed boluses is fluid-refractory septic shock. The cold, mottled phenotype with weak pulses and a narrow pulse pressure is cold shock, so I start an adrenaline infusion at 0.05 to 0.1 microgram per kilogram per minute and titrate to perfusion endpoints, arranging central access and intensive care. I do not keep driving fluid toward a target. ^{[1] [6]}

4. Reassessment and escalation

After every action I return to airway, breathing, circulation and consciousness, and I judge the trend against the improvement I predicted. Endpoints are stronger pulses, warmer skin, capillary refill under 2 seconds, normal interaction, a mean arterial pressure appropriate for age, a falling lactate and urine output above 1 mL per kilogram per hour. I call retrieval and intensive care in parallel with resuscitation, before local support is exceeded, and I prepare escort, monitoring and a contingency for deterioration or transport delay. ^[1]