Paediatric inotropes and haemodynamic support in septic shock

NHS Tayside ED Guidance
NHS Tayside
  • In the shocked child,early and aggressive fluid resuscitation is fundamental to reducing mortality1.
  • When a volume replacement of 60ml/kg has been reached or there is evidence of volume overload (hepatomegaly, lung crepitations), circulation should be supported with inotropes and the child intubated and ventilated2.
  • Ideally Inotropes should be delivered via a central line. Placement of central access in a child can be very challenging without general anaesthesia and appropriate skills.
  • A number of inotropes can be delivered safely via a peripheral cannula or preferably intraosseous route as an interim measure. These should be delivered via a syringe driver.

The inotropes that can be used are:

  1. Adrenaline (1st line inotrope, can be commenced via peripheral access.)
  2. Nor Adrenaline (warm shock, fluid refractory).

The majority of children will be in cold shock on presentation. Warm shock is most often related to hospital acquired central venous line infection3.

A drug calculator can be found on the Scottish Paediatric Retrieval Service Website4

 

Infusion drug Route Formulation Dose Dilution Infusion rate
Adrenaline

IV cannula

IO needle

central line

 1:1000 (1mg/ml) 0.01-1mcg/ml/min 0.3mg/kg in 50ml of 5% glucose 1ml/hr = 0.1mcg/kg/min (range 0.1-1mcg/kg/min)
Nor-adrenaline

IO

central line

 1:1000 (4mg/4ml) 0.01- 1mcg/kg/min 0.3mg/kg in 50ml of 5% glucose 1ml/hr = 0.1mcg/kg/min (range 0.1-1mcg/kg/min)

Haemodynamic support of paediatric and neonatal septic shock visual pathway

Haemodynamic support of paediatric and neonatal septic shock visual pathway.

Haemodynamic support of paediatric and neonatal septic shock Q & A algorithm

Haemodynamic support of paediatric and neonatal septic shock Q & A algorithm

References

1. APLS (2012). The paediatric emergency medicine resource, 5th edition.

2. NICE (2015). Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management.

3. Brierley J, Peters MJ. (2008) Distinct hemodynamic patterns of septic shock at presentation to pediatric intensive care. Pediatrics, 122: 752-759.

4. Scottish Paediatric Retrieval Service Website.