Paediatric septic shock with cold shock pattern — FFICM MCQ

Correct answer: C — Start vasoactive support and involve senior PICU team urgently

The correct answer is C, start vasoactive support and involve senior PICU team urgently. This child has fluid refractory septic shock: after 40 ml/kg of balanced crystalloid he remains mottled, has weak pulses, capillary refill of 5 seconds, hypotension below the 5th centile, a lactate of 6.5 mmol/L, and now basal crackles suggesting early fluid intolerance or evolving pulmonary oedema. NICE guidance on meningococcal septicaemia in under 16s states that if shock persists despite fluid resuscitation, adrenaline or noradrenaline infusion should be started and further management discussed with a paediatric intensivist. Continuing large volume fluid in this setting risks worsening pulmonary oedema without correcting the underlying vasoplegia and myocardial dysfunction of septic shock, so escalation to vasoactive drugs and senior input is the safe, guideline directed step. Why the other options are wrong: A, unlimited crystalloid until capillary refill normalises: this child already has basal crackles after boluses, indicating fluid is not being tolerated; further unrestricted fluid risks pulmonary oedema and does not address the fluid refractory nature of the shock. C, use adult NEWS2 thresholds to guide treatment: NEWS2 is validated for adults only and paediatric physiology (age specific heart rate, blood pressure and respiratory rate centiles) makes adult early warning thresholds invalid and potentially dangerous in a 7-year-old. D, delay antibiotics until lumbar puncture: in suspected meningococcal sepsis, antibiotics must be given immediately on clinical suspicion; lumbar puncture is contraindicated in shock and any delay in antibiotics increases mortality. E, discharge because fever has settled: the child has ongoing decompensated shock with a markedly elevated lactate and hypotension; fever resolution is irrelevant and discharge would be grossly unsafe. Key point: persistent shock after 40 ml/kg fluid in paediatric sepsis, especially with signs of fluid intolerance, mandates vasoactive drugs and senior PICU involvement rather than further fluid boluses.

Reference: NICE. Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management (CG102), recommendations 1.4.30-1.4.32 on fluid resuscitation and vasoactive therapy for shock. https://www.nice.org.uk/guidance/cg102/chapter/1-guidance