Recently the society of critical care medicine (SCCM) has published evidence-based guideline of management of pediatric septic shock and multi-organ dysfunction in children [1]. This guideline is an update to the previously published version in the year 2017 [2] and the scope of guideline includes all term neonates (>37 wks) till end of childhood up to 18 year. Due to complex and different pathophysiology of shock in preterms, the guideline has not particularly looked for evidence pertaining to shock in preterm neonates. In general, the words ‘suggested for’ or ‘suggested against’ have been used to denote ‘a weak recommendation’ emerging from very ‘low to low-quality evidence’ for or against certain practice, respectively; while the words ‘recommended for’ or ‘recommended against’ have been used to denote ‘strong recommendation’ for or against certain practice arising from ‘moderate to high quality evidence’. However, some of the recommendations in all the above mentioned categories have also emerged as best practice statement, based on the consensus opinion of experts when adequate evidence is not available.

KEY CHANGES

As compared to previously published guideline the current guideline is more extensive and detailed which covers supportive and ancillary management of pediatric septic shock which were henceforth not covered in the previous version. These include details of evidence-based recommendation on antimicrobial therapy, source control of infection, nutrition, ventilation, prophylaxis against bedsore, deep vein thrombosis and ulcer. As compared to previous guidelines, the current guideline has de-emphasized the role of lactate in hemodynamic monitoring. Similarly, it promotes restrictive fluid up to 40 mL/kg (previously up to 60 mL/kg) and each bolus of 10-20 mL/kg (previously 20 mL/kg) during resuscitation in settings where there is no support of intensive care facility to avoid fluid overload. As is the case in many health care facilities in lower-middle income countries, where prevalence of malnutrition in children is very high, unsupervised administration of high volume of fluid can actually increase mortality. Hence the current guideline has been more conservative in these scenario. Further, it has set a time frame of 3 hour for initiation of antibiotics in children with sepsis but without septic shock. In light of recent emerging evidence the guideline has replaced epinephrine or nor-epinephrine in place of dopamine as first choice inotrope. However, its applicability in resource-limited setting may remain an issue where these two drugs are not easily available and dopamine may have to be used as first line drug in these situations. As the recent guideline has not mentioned exact cut-off of blood pressure for hypotension, normal range of blood glucose or hemoglobin level cutoff for transfusion in unstable children, for point of care issues related to these topics, the readers still have to either refer the previous version or other published guideline. The summary of 2020 surviving sepsis campaign guideline in contrast with 2017 guideline has been provided in Table I.

THE WAY FORWARD

The current version addressed practical issues pertaining to pediatric septic shock management, which can be applicable to resource-limited setting as well. Supportive aspects in management of septic shock such as ventilation, antibiotic stewardship, and nutrition are addressed compared to previous guidelines that concentrated more on first hour management. Like with any other International guidelines, the current guideline also needs to be adapted to local clinical practice cautiously in the light of experience, clinical acumen and judgment for its maximum benefit/utilization.

Contributors: TS, AS: both equally contributed in collection of literature and drafted the manuscript; KMG: provided critical inputs in the manuscript. All authors approved the final version.

Funding: None; Competing interest: None stated.

REFERENCES

1. Weiss SL, Peters MJ, Alhazzani W, Agus MS, Flori HR, Inwald DP, et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-associated Organ Dysfunction in Children. Intensive Care Med. 2020;46:10-67.

2. Davis AL, Carcillo JA, Aneja RK, Deymann AJ, Lin JC, Nguyen TC, et al. American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Crit Care Med. 2017;45:1061-93.

3. American Academy of Pediatrics. Pediatric Advanced Life Support (PALS) Provider Manual. American Heart Association; 2015.

4. Pediatric Acute Lung Injury Consensus Conference Group. Pediatric Acute Respiratory Distress Syndrome: Consensus Recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med. 2015;16:428-39.