Phoenix sepsis criteria, the first-hour bundle from the Surviving Sepsis Campaign paediatric guideline, how much fluid to give (and when not to), vasoactive choice, maintenance fluids, and Indian special cases.
At the bedside
Timed steps- 1
Recognise
0 minSuspected infection plus abnormal perfusion (prolonged capillary refill, cold or mottled peripheries, weak pulses), altered mental state, tachycardia/tachypnoea out of proportion, hypotension, or raised lactate. Phoenix criteria: sepsis = Phoenix Sepsis Score ≥2; septic shock = sepsis with ≥1 cardiovascular point.
- 2
ABC, oxygen, access, glucose
0–5 minHigh-flow oxygen, monitor, IV or IO access (two if possible), bedside glucose (treat <3 mmol/L / 54 mg/dL with 2–5 mL/kg D10), blood gas with lactate, cultures if they do not delay antibiotics.
- 3
Antibiotics
≤1 hSeptic shock: broad-spectrum antibiotics within 1 hour. Sepsis-associated organ dysfunction without shock: within 3 hours after appropriate evaluation. Typical empirical: ceftriaxone (add per local antibiogram; include doxycycline/azithromycin if scrub typhus suspected).
- 4
Fluids — titrate, do not 'pour'
First hourWhere intensive care is available: 10–20 mL/kg boluses of balanced crystalloid, reassessing after each, up to 40–60 mL/kg in the first hour, stopping at signs of fluid overload (crackles, hepatomegaly, worsening work of breathing, rising JVP). Without intensive care and without hypotension: no bolus — start maintenance. Without intensive care but with hypotension: up to 40 mL/kg in the first hour.
- 5
Vasoactive
If no responseAfter 40–60 mL/kg or earlier if overloaded: adrenaline or noradrenaline (rather than dopamine); can be started in dilute form through a good peripheral IV/IO while central access is obtained. Cold shock → adrenaline favoured; warm shock → noradrenaline favoured (individualise).
- 6
Refractory shock
RefractoryHydrocortisone if fluid- and catecholamine-refractory (especially if steroid-dependent or adrenal insufficiency suspected); echo to look for myocardial dysfunction, tamponade, pneumothorax; correct ionised calcium and glucose; source control; refer to PICU/ECMO centre.
- 7
Maintenance fluids
After resuscitationUse isotonic fluid (e.g. Ringer's lactate or 0.9% saline with dextrose) at Holliday–Segar rates (4/2/1 mL/kg/h), often restricted to ~70% in pneumonia, meningitis or SIADH risk; monitor sodium and avoid fluid overload.
Fluid resuscitation in septic shock
Balanced crystalloid / 0.9% saline bolus — paediatric
- Dose
- 10–20 mL/kg over 5–20 min, reassess after each; up to 40–60 mL/kg in the first hour where ICU is available
- Worked example
- 15 kg: 150–300 mL per bolus (push-pull with 50 mL syringe).
Vasoactive for cold/fluid-refractory shock
Adrenaline (epinephrine) — paediatric
- Dose
- 0.05–1 mcg/kg/min
- Range
- 0.05–1 mcg/kg/min
- Preparation
- 0.3 mg/kg in 50 mL: 1 mL/h = 0.1 mcg/kg/min
- Worked example
- 15 kg at 0.1 mcg/kg/min = 1 mL/h of 4.5 mg in 50 mL
Vasoactive for warm shock
Noradrenaline (norepinephrine) — paediatric
- Dose
- 0.05–1 mcg/kg/min
- Range
- 0.05–1 mcg/kg/min
- Preparation
- 0.3 mg/kg in 50 mL: 1 mL/h = 0.1 mcg/kg/min
Empirical antibiotic
Ceftriaxone — paediatric
- Dose
- 50–80 mg/kg once daily (max 2 g); meningitis 100 mg/kg/day (max 4 g)
- Worked example
- 15 kg: 750 mg–1.2 g once daily; meningitis 1.5 g/day.
Catecholamine-refractory shock
Hydrocortisone — paediatric
- Dose
- 2 mg/kg (max 100 mg) bolus, then 1 mg/kg 6-hourly (max 50 mg)
Maintenance fluid (Holliday–Segar '4-2-1')
| Weight | mL/h | Example |
|---|---|---|
| First 10 kg | 4 mL/kg/h | 8 kg → 32 mL/h |
| Next 10 kg (11–20 kg) | +2 mL/kg/h | 15 kg → 40 + 10 = 50 mL/h |
| Each kg above 20 | +1 mL/kg/h | 30 kg → 60 + 10 = 70 mL/h |
Use isotonic fluids with dextrose; many sick children need 60–80% of full maintenance (SIADH risk).
Phoenix cardiovascular points (septic shock if ≥1)
| Component | 1 point | 2 points |
|---|---|---|
| Vasoactive medications | 1 medication | ≥2 medications |
| Lactate (mmol/L) | 5–10.9 | ≥11 |
| MAP for age | Below age-specific threshold (1 point band) | Below lower age-specific threshold (2 point band) |
See the Phoenix paper for the age-specific MAP thresholds and the respiratory, coagulation and neurological components.
Calculators for this topic
References
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Paediatric septic shock — first hour
Step 1 of ~6
SSC-paediatric-based pathway, adapted to whether intensive care is available.
Oxygen, monitor, IV/IO access, glucose, gas + lactate, cultures; antibiotics within 1 h
Based on Weiss SL, Peters MJ, Alhazzani W, et al; Maitland K, Kiguli S, Opoka RO, et al. Educational use; follow local protocol.
Pathophysiology
Children with septic shock more often present with low cardiac output, high SVR ('cold shock') than adults, especially infants and in community-acquired sepsis; adults more often have vasodilated 'warm shock'. Myocardial dysfunction, capillary leak and absolute/relative hypovolaemia coexist, so fluid responsiveness is lost early and overload develops easily.
Evidence
- SSC Paediatric 2020 (77 recommendations): antibiotics within 1 h for shock, 3 h for sepsis without shock; fluid strategy depends on ICU availability; balanced crystalloids; adrenaline or noradrenaline rather than dopamine; hydrocortisone not routinely; measure lactate.
- FEAST (2011): in 3,141 African children with severe febrile illness and impaired perfusion (but not hypotension), 20–40 mL/kg boluses of saline or albumin increased 48-h mortality (10.5–10.6% vs 7.3% without bolus). Mechanisms likely include cardiovascular collapse after transient improvement; the result shaped the 'no bolus without ICU and without hypotension' recommendation.
- Phoenix criteria (2024): derived and validated in >3 million encounters across high- and low-resource settings; replaced the 2005 IPSCC SIRS-based definitions.
Controversies
- Volume of initial fluid in middle-income settings with some ICU capacity (most Indian district hospitals sit between the SSC 'with' and 'without' ICU categories).
- Applicability of FEAST (high malaria and anaemia prevalence) to Indian children.
- Early vasoactive vs further fluids in dengue shock (different pathophysiology: plasma leak).
🇮🇳 India notes
- Dengue shock in children follows WHO/national dengue protocols (graded crystalloid infusion with haematocrit monitoring) rather than generic sepsis boluses — see the tropical and monsoon fevers module.
- Scrub typhus is a common cause of paediatric sepsis with multi-organ dysfunction in India — add doxycycline or azithromycin when suspected (eschar, hepatosplenomegaly, monsoon season).
- Severe acute malnutrition: WHO advises 15 mL/kg over 1 h (Ringer's lactate with 5% dextrose, or half-normal saline with 5% dextrose), reassessing for overload; blood transfusion if no improvement.
- Many paediatric wards lack infusion pumps — use burettes/microdrip sets (60 drops = 1 mL) and calculate drops/min carefully.
References
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