Septic shock is divided into warm shock and cold shock.

For cold shock, the use of adrenaline (0.05-0.3 mcg/kg/min) is recommended as the first line. Dopamine can be used in a dose not higher than 10 mcg/kg/min as an alternative

For warm shock, the use of norepinephrine at 0.03-0.05 mcg/kg/min is recommended. The

Vasopressin indicated for refractory shock.

In pediatric septic shock we have two main hemodynamic scenarios according to the clinical findings; those are warm shock and cold shock.

We talk about warm shock when we find in addition to hypotensive patient the following sings and symptoms: vasodilation, bounding pulses, pink extremities and rapid capillary refill.

The standard of care for warm shock is the use of Norepinephrine.

If the patient remains hypotensive, we have asses the volemic status to begin a second medication. If euvolemic, we should start Vasopressin, but if the patient is hypovolemic the agent of choice is Epinephrine or Dobutamine.

In te other hand, Cold shock is characterized by weak pulses, cold extremities and prolonged capillary refill. The first line of treatment in this scenario is Epinephrine.

If shock persist, we have to asses the blood pressure status. If hypotensive, norepinephrine should be added; but if normotensive, a vasodilator like milrinone is a good option, or dobutamine if you want to cardiac contractility.

Epinephrine can be started for cold shock, dopamina (5 - 9 mcg/kg/mn) if epinephrine not available and norepinephrine can be titrated for warm shock (dopamina > 10 mcg/kg/min) if norepinephrine not avalaible

SHOCK WITH LOW CARDIAC INDEX, NORMAL BLOOD PRESSURE AND HIGH SYSTEMIC VASCULAR RESISTANCE: MILRINONE

Shock with low cardiac index, low blood pressure and low systemic vascular resistance : norepinephrine can be added to/or substituted for epinephrine.once

Shock with high cardiac index and low systemic vascular resistance when titration of norepinephrine and fluids does not resolve hypotension, then low dose vasopressin, angiotensin o terlipressin

Vassoactive agents

First line for hypodynamic shock, Low doses of epinephrine

Powerful inotropic and chronotropic effects

Problems, on systemic vascular resistance and response to endocrine stress

At lower doses, Greater β2-adrenergic effects in the peripheral vasculature

Small α-adrenergic effect vascular resistance falls, in the skeletal muscles and in the skin, this redirects blood flow away from the splanchnic circulation even though blood pressure and CO increase

Continuous shock and hot shock, With rapid capillary refill, hot extremities, low diastolic pressure and delimiting pulses

Use Low doses, first line for hypotensive hyperdynamic shock refractory to fluid.

Systemic vascular resistance low, Norepinephrine alone

Norepinephrine with dobutamine

Intrinsic vasodilatory action to counteract the excessive vasoconstriction of norepinephrine.

Nore at higher doses of literature, Induces significant adverse effects

Initial vasoactive infusion in patients with hot shock, vasodilation and low systemic vascular resistance

Vasoactive selection in pediatric septic shock is based on clinical features the patient’s presentation.

Cold or hypodynamic Shock, characterized by low cardiac output and high systemic vascular resistance, the use of Epinephrine 0.05-0.3 mcg/kg/min as a firts line or Dopamine 5-9 mcg/kg/min if Epinephrine is no available, Low doses of Dopamine stimulates vascular dopaminergic receptors and increases cardiac contractility.

Warm or hyperdynamic shock, with high cardiac output and low systemic vascular resistance, use of Norepinephrine 0.5-0.3 mcg/kg/min or Dopamine >10 mcg/kg/min if Epinephrine is no available. This aggents are appropriate to increase SVR.

adult literature with pediatric potentials:

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