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Septic shock in resource limited settings 
Septic shock webinar Take home message from Dr Karthik webinar 
1. Appropriate Antibiotics should be given as soon as possible in septic shock (within one hour), but no more than 3 hours 
2. Use of Fluids 
A. Volume 20 ml/kg over 20-30 minutes in shock with normal Bp ( compensated shock) 
20 ml/kg over 15- 20 minutes in hypotensive shock 
B. Choice of fluids Normal saline or Plasmalyte Plasmalyte may hold an edge if available ( Lancet 2019 paper ) and SCCM 2020 guideline preference
3. Reassessment after first fluid bolus : 
Clinical plus Echocardiography if available is the best tool for reassessment after first bolus 
Functional Echo helps in managing further in such patients Max fluids given may be 40 ml/kg . After that multiple hemodynamic monitoring tools may be required to decide on fluids further . 
4. Depending on SVR and cardiac function assessed using advanced hemp dynamic monitoring, further Vasoactive support can be decided
Categorising shock into cold and warm shock clinically and titrations vasoactives is to be avoided in settings where intensive care is feasible 
Adrenaline is the preferred vasoactive agent over dopamine ( Karthik PCCM publication ) in fluid refractory Vasoconstrictive shock
Noradrenaline is to be initiated in vasodilator shock . 
Both can be started through a peripheral cannula . They have used till dose of 0.26 ug/kg/minute through peripheral cannula in resuscitation phase . 
Use of other agents like vasopressin and milrinone is decided on case to case basis 
5. Refractory septic shock requires more research work to decide on further path . ECMO can be one promising option . ESPNIC pediatric refractory shock definition needs to be validated in our setting 
6. Stress dose steroids can be given after catecholamine resistant shock . Dose is 5 mg/kg stat max of 100 mg , followed by 2 mg/kg/dose 6 hourly ( maintenance max of 100 mg/day) . 
In patients at risk of adrenal insufficiency , hydrocortisone should be given after fluid resuscitation . 
7. In sub set of septic shock kids , steroids may be harmful . It’s difficult to identify them clinically 
8. HAT therapy in pediatric septic shock requires more literature. 
Individual contribution of micronutrients supplementation is difficult to identify in septic shock . 
9. Adherence to Bundle care is the right approach for successful outcome
10. TAMOF – PLEX offer proven benefit in improving organ functions and mortality–
Ankit Mehta
MD Pediatrics
FIAP critical care ( PGIMER, Chandigarh )
DM Pediatric critical care