Shock

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    Last updated: September 2023

     

    Shock is a condition of widespread reduced tissue perfusion and inadequate oxygen delivery. Prolonged shock can result in cellular dysfunction and irreversible organ failure. Mortality is high without early diagnosis and treatment.

    Clinical features

    Shock should be suspected in patients with:

    • Sign(s) of hypotension: weak pulse, low or declining blood pressure (BP) a Citation a. Hypotension is based on systolic blood pressure (SBP) in adults: SBP < 90 mmHg or decrease in SBP ≥ 40 mmHg from baseline or mean arterial pressure MAP < 65 mmHg. Shock is often accompanied by hypotension but may also occur with normal or elevated BP. , narrow pulse pressure
    • Acute onset of signs of tissue hypoperfusion:
      • Skin: pallor, mottled skin, sweating, cold extremities or lower limb temperature gradient b Citation b. Run the back of the hand from the toe to the knee. A notable temperature change from the cold foot to the warm knee is a positive temperature gradient, indicating distal hypoperfusion. , capillary refill time (CRT) ≥ 3 seconds
      • Lungs: tachypnea, dyspnoea
      • Heart: tachycardia, which often occurs before BP decreases
      • Kidney: oliguria (urine output < 0.5 to 1 ml/kg/hour) or anuria
      • Brain: thirst, anxiety, agitation, confusional state, apathy, altered mental status

     

    In children, accurate BP measurement is difficult, and hypotension is a very late sign of shock. Therefore, critically ill children c Citation c. Critically ill-appearing child: weak grunting or crying, drowsy and difficult to arouse, does not smile, disconjugate or anxious gaze, pallor or cyanosis, general hypotonia. should be treated for shock if they present at least one of the following signs: lower limb temperature gradient b Citation b. Run the back of the hand from the toe to the knee. A notable temperature change from the cold foot to the warm knee is a positive temperature gradient, indicating distal hypoperfusion. , CRT ≥ 3 seconds, weak radial pulse or severe tachycardia d Citation d. Children under 1 year: > 180 bpm; Children 1 to 5 years: > 160 bpm; Children 5 years and over: > 140 bpm. [1] Citation 1. Houston KA, George EC, Maitland K. Implications for paediatric shock management in resource-limited settings: a perspective from the FEAST trial. Crit Care. 2018;22(1):119.
    https://doi.org/10.1186/s13054-018-1966-4
    .

     

    Clinical features may vary according to the type of shock [2] Citation 2. Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med. 2014;40(12):1795-1815. 
    https://doi.org/10.1007/s00134-014-3525-z
    :
     

    Type Specific clinical features Risk factors

    Distributive

    Severe vasodilation and increased capillary permeability resulting in maldistribution of blood flow

    Anaphylaxis: likely when either of the following 2 criteria develop within minutes to hours [3] Citation 3. Cardona V, Ansotegui IJ, Ebisawa M, et al. World allergy organization anaphylaxis guidance 2020. World Allergy Organ J. 2020;13(10):100472. Published 2020 Oct 30.
    https://doi.org/10.1016/j.waojou.2020.100472
    :

    • Involvement of skin and/or mucous membranes (e.g. generalised urticaria, itching, flushing, swollen lips/tongue/uvula) AND ≥ 1 of the following:
      • respiratory symptoms (wheeze, dyspnoea);
      • low BP or symptoms of end-organ dysfunction (hypotonia, incontinence);
      • severe gastrointestinal symptoms (abdominal pain, repetitive vomiting).
    • Hypotension, bronchospasm or laryngeal involvement (stridor, vocal changes, odynophagia) after exposure to known or probable allergen for that patient.

    Recent exposure to an allergen (e.g. food, sting, medicine) or history of anaphylaxis

     

     

    Septic shock: signs of infection, fever or hypothermia, altered mental status, dyspnoea, persisting hypotension despite fluid resuscitation [4] Citation 4. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810.
    https://doi.org/10.1001/jama.2016.0288

    Infection, recent surgery, immunodeficiency

    Cardiogenic

    Cardiac pump failure

    Ischaemia: chest pain, dyspnoea

    Arrhythmia
    Murmur of valvular heart disease

    History of cardiac disease, advanced age

    Acute heart failure: see Heart failure in adults, Chapter 12.

    History of cardiac disease, viral illness, immunodeficiency

    Hypovolaemic

    Direct blood/fluid loss or fluid sequestration into the extravascular space resulting in decreased intravascular volume
    Haemorrhagic: external bleeding, signs and symptoms of internal bleeding, hypotension (a) Citation a. In children and young adults with hypovolaemic shock, BP may be maintained initially, but subsequently declines rapidly if fluid loss is not replaced. Trauma, recent surgery, obstetric haemorrhage
    Non-haemorrhagic: dry mouth, absence of tears, sunken eyes/fontanelle, low jugular venous pressure (JVP), altered mental status Profuse diarrhoea and/or vomiting, intestinal obstruction

    Obstructive

    Obstruction to blood flow to, or from, the heart or great vessels

    Pulmonary embolism (PE): chest pain, tachycardia, tachypnoea, hypoxia 

    Deep vein thrombosis (DVT): leg pain, swelling, warmth

    Recent surgery or immobilisation, cancer, history of PE or DVT
    Tension pneumothorax: decreased breath sounds, raised JVP, weak radial pulse, tracheal deviation Trauma, invasive medical procedure
    Cardiac tamponade: pulsus paradoxus (b) Citation b. Pulsus paradoxus is measured by taking the patient's BP during both expiration and inspiration. It is defined as a decrease of > 10 mmHg in the SBP during inspiration compared with expiration. , raised JVP, narrow pulse pressure, muffled heart sounds Trauma, immunodeficiency

    Management

    • Attend to the patient immediately even if the type of shock is not known. Call for help. Move to critical care unit if possible.
    • Assess and manage A (airway), B (breathing), and C (circulation) according to Basic Life Support (see below). If anaphylaxis is suspected, immediately go to specific management.  
    • Take a rapid history to try to determine underlying cause.
    • Monitor:
      • urine output hourly (insert a urinary catheter)
      • HR, RR, BP, temperature, CRT, SpO2, and level of consciousness
    • Perform the following tests:
      • haemoglobin and blood glucose level
      • malaria rapid diagnostic test in endemic area: see Malaria, Chapter 6
      • blood culture (if available) and blood group
    • In children, administer ceftriaxone IV e Citation e. For IV administration of ceftriaxone, dissolve only in water for injection. : one dose of 80 mg/kg. Reassess need for further antibiotic treatment according to underlying cause.
    • Treat pain: see Pain, Chapter 1.

     

    Primary objective of shock management is to restore adequate tissue perfusion, demonstrated by:

    • Returning vital signs, CRT, SpO2, mental status, etc. to normal.
    • Maintaining mean arterial pressure (MAP) f Citation f. MAP = diastolic BP (DBP) + 1/3 (SBP-DBP). A patient with BP 90/60 has a MAP = 60 + 1/3 (90-60) = 70. > 65 mmHg in adults (or higher if patient has pre-existing hypertension).
    • Maintaining urine output > 0.5 to 1 ml/kg/hour.

     

    After initial management:

    • Take a more detailed history.
    • Perform a comprehensive physical examination.
    • In case of dehydration: see Dehydration, Chapter 1.
    • In case of blunt thoracic or abdominal trauma, perform POCUS g Citation g. POCUS should only be performed and interpreted by trained clinicians. : (e)FAST exam to evaluate for pneumothorax or free fluid in pleural, pericardial and/or peritoneal spaces. Refer to surgeon as required.

     

    On-going care:

    • Re-evaluate patient’s condition and response to treatment every 10 minutes until patient is stable.
    • Perform a second comprehensive physical examination.
    • Initiate nutritional support adapted to patient's needs as soon as possible and reassess regularly. Patients have high protein and energy requirements. Enteral route is preferred. 

    Basic Life Support

    1) Manage airways and breathing

    • Lay the patient on their back. However:
      • if spinal trauma is suspected, do not move the patient;
      • in case of anaphylaxis, the patient may prefer a sitting position.
    • In case of altered mental status:
      • be prepared with mask and bag if needed for ventilation;
      • remove any airway obstruction (e.g. secretions, foreign body);
      • open airway: stand at head of bed, place one hand on the forehead and gently tilt the head back. Simultaneously, place the fingertips of the other hand under the chin and lift the chin. If suspicion of spinal trauma, do not move the neck. Instead, place heels of both hands on patient’s parietal areas, and use index and middle fingers of both hands to push the angle of mandible anteriorly (jaw thrust)
      • if needed, insert an oropharyngeal airway.
    • Auscultate lungs to assess ventilation.
    • Administer 10 to 15 litres/minute of oxygen with mask to maintain SpO2 > 94%.
    • If SpO2 remains ≤ 94% with oxygen, see If resources allow.

     

    2) Maintain circulation

    • Control bleeding:
      • apply direct manual pressure and/or compression/haemostatic dressing to the wound;
      • in case of massive life-threatening bleeding from an extremity (e.g. leg) not controlled by direct pressure: apply a windlass tourniquet h Citation h. The patient should receive surgery within 1 hour of the application of a windlass tourniquet. After 1 hour, there is a risk of ischaemic injury of the limb. If surgery is not possible and the tourniquet is required to save the patient’s life, it should be left in place. Any tourniquet that has been applied for more than 6 hours should be left in place until arrival at a facility capable of providing definitive surgical care. [5] Citation 5. Richey SL. Tourniquets for the control of traumatic hemorrhage: a review of the literature. World J Emerg Surg. 2007;2:28. Published 2007 Oct 24.  
        https://doi.org/10.1186/1749-7922-2-28
        .
    • Insert 2 peripheral IV lines (catheters 20-22G in children and 14-18G in adults) or an intraosseous (IO) needle.
    • Administer Ringer lactate (RL) i Citation i. Crystalloids should be used. Colloids (e.g. modified fluid gelatin, albumin) are not recommended. , glucose 5%-Ringer lactate (G5%-RL) j Citation j. Remove 50 ml of RL from a 500 ml RL bottle or bag, then add 50 ml of 50% glucose to the remaining 450 ml of RL to obtain 500 ml of 5% glucose-RL solution. , and/or blood, following specific management described below. Reassess before giving additional fluid therapy. Monitor for fluid overload k Citation k. In case of fluid overload: sit the patient up, reduce the infusion rate to a minimum and administer furosemide IV (0.5 mg/kg in children; 40 mg in adults). Monitor the patient closely over 30 minutes and assess for underlying cardiorespiratory or renal disease. Once the patient is stabilised, reassess the necessity of continuing IV fluids. If IV fluids are still required, re-start at half the previous infusion rate and monitor closely. , especially in patients at risk, e.g. severely malnourished children; patients with severe malaria, heart disease, severe anaemia; older patients.  
    • Maintain normal body temperature.
    • If unable to maintain BP, see If resources allow.

    Anaphylaxis

    • Remove exposure to causal agent.
    • Administer epinephrine (adrenaline) IM into the mid-anterolateral thigh. Use undiluted solution and a 1 ml syringe graduated in 0.01 ml [6] Citation 6. Emergency treatment of anaphylaxis. Guidelines for healthcare providers. Rescuscitation Council UK. Updated 2021 [Accessed May 31 2023].
      https://www.resus.org.uk/sites/default/files/2021-05/Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf
      :
      • Children under 6 months: 0.1 to 0.15 ml
      • Children 6 months to 5 years: 0.15 ml
      • Children 6 to 12 years: 0.3 ml
      • Children over 12 years l Citation l. If small or prepubertal children, administer 0.3 ml of epinephrine. and adults: 0.5 ml

    Repeat after 5 minutes if no or poor clinical improvement (up to a total of 3 IM injections). 

    • Monitor HR, BP, CRT and clinical response.
    • In case of stridor, administer nebulized epinephrine: 0.5 mg/kg/dose (max. 5 mg) in 5 ml of 0.9% sodium chloride over 10 to 15 minutes
    • If SpO2 is < 94%, ventilate with bag mask.
    • Administer a bolus of RL:
      • Children: 10 ml/kg as quickly as possible
      • Adults: 500 ml as quickly as possible

    Repeat bolus once if signs of poor perfusion persist after 15 minutes.

    • If shock persists after 3 IM injections of epinephrine, in particular if unable to maintain BP, see If ressources allow.
    • After initial treatment with epinephrine and IV fluids, some patients (e.g. patients requiring continuing treatment after 2 doses of epinephrine IM or patients with ongoing asthma or shock) may benefit from a short course of corticosteroid therapy. When the patient is stable, prednisolone PO : 1 to 2 mg/kg (max. 50 mg) once daily in the morning for 3 to 5 days. Use an IV corticosteroid only if the patient cannot take oral treatment.

    Septic shock

    Look for source of infection. If possible, take specimens for culture before starting antibiotic treatment.

    • Fluid therapy:
      • Children and adolescents under 15 years: G5%-RL solution as maintenance fluids (see Appendix 1)
      • Adolescents 15 years and over and adults: one bolus of 250 to 500 ml of RL as quickly as possible
    • Antibiotic treatment:
      • Start antibiotics according to the suspected origin of infection within 1 hour of presentation [7] Citation 7. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. 
        https://doi.org/10.1007/s00134-021-06506-y
        (see tables below).
      • If source is unknown, administer a broad-spectrum antibiotic to cover gram-positive, gram-negative, and anaerobic bacteria. If possible, take into account local epidemiology (rates and types of resistance). Differentiate community acquired sepsis and nosocomial sepsis as pathogens and rates of resistance may be different. Simplify the antibiotic treatment (to narrower spectrum) whenever possible.
      • Reassess treatment daily:
        • If culture results are available: adapt treatment accordingly.
        • If improvement after 24 to 48 hours: change to oral route, however some foci (e.g. meningitis) require prolonged IV treatment.
        • If no improvement after 48 to 96 hours: consider resistant pathogen m Citation m. For example: methicillin-resistant Staphylococcus aureus (MRSA), pseudomonas species, and gram-negative bacteria with extended-spectrum beta-lactamase (ESBL) activity. , in particular in patients with immunodeficiency or recent (in the last month) hospitalisation or antibiotic use and adapt treatment accordingly.
    • Other measures to control infection:
      • If suspected catheter-related infection, insert a new catheter in another site and remove the suspected catheter.
      • Drain soft-tissue abscess (see Cutaneous abscess, Chapter 10); irrigate and debride traumatic wounds. Refer to surgeon if needed for debridement, drainage, relieving obstruction, etc.
    • Treatment of fever: see Fever, Chapter 1.

     

    Origin  Antibiotics Alternatives (c) Citation c. Only if first-line antibiotic is not available or in allergic patients.
    Cutaneous
    staphylococci, streptococci (d) Citation d. For necrotising infections, see Necrotising infection of skin and soft tissues, Chapter 10.

    cloxacillin

    (+ vancomycin if risk factors for MRSA (e) Citation e. Risk factors for MRSA: prior MRSA infection, recent hospitalisation or antibiotic use, recurrent skin infection, chronic wounds, invasive device, settings with high rates of MRSA. )

    cefazolin (f) Citation f. Do not administer if severe beta-lactam allergy

    (or vancomycin if risk factors for MRSA (e) Citation e. Risk factors for MRSA: prior MRSA infection, recent hospitalisation or antibiotic use, recurrent skin infection, chronic wounds, invasive device, settings with high rates of MRSA. )

    Pulmonary
    pneumococci, H. influenzae

    ceftriaxone + azithromycin
    (+ gentamicin if risk factors for MDR gram negative bacteria (g) Citation g. Risk factors for multiresistant (MDR) gram negative bacteria: recent hospitalisation in intensive care unit or antibiotic use. )
    clindamycin + ciprofloxacin + doxycyline
    Intestinal or biliary
    enterobacteria, anaerobic bacteria, enterococci

    ceftriaxone + metronidazole
    (+ gentamicin if risk factors for MDR gram negative bacteria (g) Citation g. Risk factors for multiresistant (MDR) gram negative bacteria: recent hospitalisation in intensive care unit or antibiotic use. )

    (+ ampicillin if biliary source)

    clindamycin + ciprofloxacin
    Gynaecological
    streptococci, gonococci, anaerobic bacteria, E. coli
    ceftriaxone + metronidazole + azithromycin clindamycin + gentamicin + azithromycin
    Urinary
    enterobacteria, enterococci
    ceftriaxone
    (+ amikacin if risk factors for pseudomonas (h) Citation h. Risk factors for pseudomonas: immunodeficiency, recent hospitalisation or antibiotic use, burns or presence of invasive device.
     
    )

    meropenem

    (+ amikacin if risk factors for pseudomonas (h) Citation h. Risk factors for pseudomonas: immunodeficiency, recent hospitalisation or antibiotic use, burns or presence of invasive device.
     
    )

    Central nervous system See Bacterial meningitis, Chapter 7.
    Other or undetermined

    ampicillin + gentamicin in children

    ceftriaxone

    or cloxacillin + amikacin in children

    ceftriaxone
    (+ amikacin if risk factors for pseudomonas (h) Citation h. Risk factors for pseudomonas: immunodeficiency, recent hospitalisation or antibiotic use, burns or presence of invasive device.
     
    ) in adults
    clindamycin + ciprofloxacin in adults
    Antibiotics Children over 1 month Adults
    amikacin IM or slow IV injection over 3 minutes 15 mg/kg (max. 1.5 g) once daily 15 mg/kg once daily

    ampicillin IV infusion over

    30 minutes

    50 mg/kg (max. 2 g) every 8 hours

    2 g every 6 to 8 hours

    (2 g every 4 hours for meningitis)

    azithromycin PO (by NGT)
                           

    10 to 20 mg/kg (max. 500 mg) once daily

    500 mg to 1 g once daily

    cefazolin slow IV injection over 3 minutes or IV infusion over 30 minutes

    25 mg/kg (max. 3 g) every 12 hours

    2 g every 8 hours

    ceftriaxone slow IV injection over 3 minutes or IV infusion over 30 minutes 80 mg/kg (max. 4 g) once daily (100 mg/kg, max. 4 g, once daily for meningitis) 2 g once daily (2 g every 12 hours for meningitis)
    ciprofloxacin PO (by NGT) 15 to 20 mg/kg (max. 750 mg) every 12 hours 500 to 750 mg every 12 hours

    ciprofloxacin IV infusion over

    60 minutes

    10 mg/kg (max. 400 mg) every 8 hours 400 mg every 8 to 12 hours
     

    clindamycin IV infusion over

    30 minutes

    10 mg/kg (max. 600 mg) every 8 hours 600 to 900 mg every 8 hours

    cloxacillin IV infusion over

    60 minutes

    25 to 50 mg/kg (max. 2 g) every 6 hours 2 g every 6 hours
    doxycycline PO (by NGT)

    4.4 mg/kg (max. 200 mg) on D1 then 2.2 mg/kg (max. 100 mg) every 12 hours

    200 mg on D1 then 100 mg every 12 hours
    gentamicin IM or slow IV injection over 3 minutes 7.5 mg/kg once daily
     
    5 mg/kg once daily

    meropenem IV infusion over

    15 or 30 minutes

    20 mg/kg (max. 2 g) every 8 hours

    2 g every 8 hours

    metronidazole PO (by NGT) 10 mg/kg (max. 500 mg) every 8 hours 500 mg every 8 hours

    metronidazole IV infusion

    over 30 minutes

    10 mg/kg (max. 500 mg) every 8 hours 500 mg every 8 hours

    vancomycin IV infusion over

    60 to 240 minutes

    15 mg/kg (max. 500 mg) every 6 hours  15 to 20 mg/kg (max. 2 g) every 12 hours

     

    Cardiogenic shock

    • Administer RL with extreme caution and monitor closely for signs of fluid overload:
      • Adults: 100 to 250 ml over 30 minutes
      • Subsequent fluid administration should be based on thorough patient assessment, including urinary output, mental status and SpO2.
    • Vasopressors are often required to maintain BP, see If resources allow.
    • In case of acute heart failure, see Heart failure in adults, Chapter 12.
    • Arrhythmias should be managed according to Advanced Life Support techniques as appropriate and where available.

    Hypovolemic non-haemorrhagic shock

    • Administer RL:
      • Children under 1 year: 30 ml/kg over 1 hour then 70 ml/kg over 5 hours
      • Children/adolescents 1 to 14 years: 30 ml/kg over 30 minutes then 70 ml/kg over 2.5 hours
      • Adolescents 15 years and over and adults: 250 to 500 ml as quickly as possible (to be repeated once if required) then adjusted to patient’s condition, providing up to 70 ml/kg over 2.5 hours

    Hypovolaemic haemorrhagic shock

    In order to prevent the “lethal trauma triad” of hypothermia, acidosis and coagulopathy:

    • Determine blood group and if needed transfuse, as quickly as possible:
      • Children under 20 kg: 20 ml/kg of whole blood
      • Children 20 kg and over and adults: an adult unit of whole blood

    Repeat if needed.

    • If blood is not immediately available, administer a bolus of RL with caution (i.e. minimize the use of RL) while waiting for blood:
      • Children: 20 ml/kg as quickly as possible
      • Adults: 250 to 500 ml as quickly as possible

    When blood is available, stop RL and administer blood only.

    • Warm the patient (blankets, warm room, warm IV fluids).
    • In case of trauma presenting within 3 hours, administer tranexamic acid slow IV (over 10 minutes):
      • Children: 15 mg/kg (max. 1 g)
      • Adults: 1 g

    Then immediately start a second dose, administered by IV infusion over 8 hours.

    Obstructive shock

    The management described up to this point will provide only temporary stabilization. Treat the cause or refer for aetiological treatment:

    • Pulmonary embolism: anticoagulation +/- thrombolysis.
    • Tension pneumothorax: needle decompression/finger thoracostomy, followed by insertion of chest tube.
    • Cardiac tamponade: pericardial tap.

     

     

    If ressources allow:

    • Manage airways and breathing:
      • complete airway obstruction: endotracheal intubation or cricothyroidotomy
      • respiratory failure: non-invasive or invasive mechanical ventilation
    • Maintain circulation:
      • If unable to achieve management objectives (in particular BP) using fluid therapy (and no signs of fluid overload are present) or, in the case of anaphylaxis, if shock persists after 3 IM epinephrine injections, vasopressors-inotropes (see below) can be used in the following conditions:
        • close monitoring in a critical care unit;
        • a large peripheral IV catheter n Citation n. When using a peripheral vein, monitor infusion site closely for signs of extravasation, in particular in young children. (proximal forearm or above), a central venous catheter or an IO line dedicated to the infusion;
        • use of an electric syringe or pump to control flow rate o Citation o. If no system to control volume delivery and flow rate (e.g. syringe pump), an infusion using an infusion bag and standard paediatric giving set can be considered in extreme situations as a temporary measure. However, it is important to consider the risks related to this type of administration (accidental bolus or insufficient dose). The infusion must be constantly monitored to prevent any, even small, change from the prescribed rate.
           
          ;
        • intensive monitoring of drug administration, particularly during syringe changes.
      • All infused volumes must be accounted for when recording fluid balance.

     

    These protocols are for peripheral IV administration. Titrate according to patient's clinical situation. Refer to management objectives (including BP) under Management.

     

      Norepinephrine (NEP) tartrate (i) Citation i. 2 mg of NEP tartrate = 1 mg of NEP base. Epinephrine (EPN) (adrenaline)
    Indication Children: 2nd choice
    Adults: 1st choice
    Children: 1st choice
    Adults: 2nd choice

    Preparation of

    diluted solution (j) Citation j. 0.9% sodium chloride or 5% glucose or RL can be used for dilution.

    Children:

    Add 1 ml (2 mg) of NEP tartrate  to 39 ml of 0.9% NaCl to obtain a 0.05 mg/ml (50 micrograms/ml) solution.

    Children:

    Add 2 ml (2 mg) of EPN to 38 ml of 0.9% NaCl to obtain a 0.05 mg/ml (50 micrograms/ml) solution.

    Adults:

    Add 2 ml (4 mg) of NEP tartrate  to 38 ml of 0.9% NaCl to obtain a 0.1 mg/ml (100 micrograms/ml) solution.

    Adults:

    Add 4 ml (4 mg) of EPN to 36 ml of 0.9% NaCl to obtain a 0.1 mg/ml (100 micrograms/ml) solution.

    Starting

    rate (k) Citation k. The infusion rate is calculated as follows: [desired dose (microgram/kg/min) x weight (kg) x 60 min] ÷ concentration (microgram/ml).

    0.1 microgram/kg/minute

    Rate for

    increasing (k) Citation k. The infusion rate is calculated as follows: [desired dose (microgram/kg/min) x weight (kg) x 60 min] ÷ concentration (microgram/ml).  

    Increase by 0.05 micrograms/kg/minute every 10 minutes for the first hour, then every hour. Max. 1 microgram/kg/minute.

    Rate for

    decreasing (k) Citation k. The infusion rate is calculated as follows: [desired dose (microgram/kg/min) x weight (kg) x 60 min] ÷ concentration (microgram/ml).  

    Taper down doses when management objectives are attained. Do not stop abruptly. Decrease by 0.05 micrograms/kg/minute every hour.
    • Ongoing care: measure serum potassium, magnesium, calcium and phosphate levels and correct any abnormalities. Additional investigations (e.g. X-rays, other laboratory tests) may be indicated, depending on aetiology suspected.

     

    Footnotes
    • (a)Hypotension is based on systolic blood pressure (SBP) in adults: SBP < 90 mmHg or decrease in SBP ≥ 40 mmHg from baseline or mean arterial pressure MAP < 65 mmHg. Shock is often accompanied by hypotension but may also occur with normal or elevated BP.
    • (b) Run the back of the hand from the toe to the knee. A notable temperature change from the cold foot to the warm knee is a positive temperature gradient, indicating distal hypoperfusion.
    • (c)Critically ill-appearing child: weak grunting or crying, drowsy and difficult to arouse, does not smile, disconjugate or anxious gaze, pallor or cyanosis, general hypotonia.
    • (d)Children under 1 year: > 180 bpm; Children 1 to 5 years: > 160 bpm; Children 5 years and over: > 140 bpm.
    • (e)For IV administration of ceftriaxone, dissolve only in water for injection.
    • (f)MAP = diastolic BP (DBP) + 1/3 (SBP-DBP). A patient with BP 90/60 has a MAP = 60 + 1/3 (90-60) = 70.
    • (g)POCUS should only be performed and interpreted by trained clinicians.
    • (h)The patient should receive surgery within 1 hour of the application of a windlass tourniquet. After 1 hour, there is a risk of ischaemic injury of the limb. If surgery is not possible and the tourniquet is required to save the patient’s life, it should be left in place. Any tourniquet that has been applied for more than 6 hours should be left in place until arrival at a facility capable of providing definitive surgical care.
    • (i)Crystalloids should be used. Colloids (e.g. modified fluid gelatin, albumin) are not recommended.
    • (j)Remove 50 ml of RL from a 500 ml RL bottle or bag, then add 50 ml of 50% glucose to the remaining 450 ml of RL to obtain 500 ml of 5% glucose-RL solution.
    • (k)In case of fluid overload: sit the patient up, reduce the infusion rate to a minimum and administer furosemide IV (0.5 mg/kg in children; 40 mg in adults). Monitor the patient closely over 30 minutes and assess for underlying cardiorespiratory or renal disease. Once the patient is stabilised, reassess the necessity of continuing IV fluids. If IV fluids are still required, re-start at half the previous infusion rate and monitor closely.
    • (l)If small or prepubertal children, administer 0.3 ml of epinephrine.
    • (m)For example: methicillin-resistant Staphylococcus aureus (MRSA), pseudomonas species, and gram-negative bacteria with extended-spectrum beta-lactamase (ESBL) activity.
    • (n)When using a peripheral vein, monitor infusion site closely for signs of extravasation, in particular in young children.
    • (o)If no system to control volume delivery and flow rate (e.g. syringe pump), an infusion using an infusion bag and standard paediatric giving set can be considered in extreme situations as a temporary measure. However, it is important to consider the risks related to this type of administration (accidental bolus or insufficient dose). The infusion must be constantly monitored to prevent any, even small, change from the prescribed rate.
       
    • (a)In children and young adults with hypovolaemic shock, BP may be maintained initially, but subsequently declines rapidly if fluid loss is not replaced.
    • (b)Pulsus paradoxus is measured by taking the patient's BP during both expiration and inspiration. It is defined as a decrease of > 10 mmHg in the SBP during inspiration compared with expiration.
    • (c)Only if first-line antibiotic is not available or in allergic patients.
    • (d)For necrotising infections, see Necrotising infection of skin and soft tissues, Chapter 10.
    • (e) Risk factors for MRSA: prior MRSA infection, recent hospitalisation or antibiotic use, recurrent skin infection, chronic wounds, invasive device, settings with high rates of MRSA.
    • (f)Do not administer if severe beta-lactam allergy
    • (g) Risk factors for multiresistant (MDR) gram negative bacteria: recent hospitalisation in intensive care unit or antibiotic use.
    • (h) Risk factors for pseudomonas: immunodeficiency, recent hospitalisation or antibiotic use, burns or presence of invasive device.
       
    • (i)2 mg of NEP tartrate = 1 mg of NEP base.
    • (j)0.9% sodium chloride or 5% glucose or RL can be used for dilution.
    • (k) The infusion rate is calculated as follows: [desired dose (microgram/kg/min) x weight (kg) x 60 min] ÷ concentration (microgram/ml).
    References