ICU Pathway for the Evaluation/Treatment of Infants > 28 Days and Children with Severe Sepsis/Septic Shock

Fluid Refractory Shock, Warm/Cold and Catecholamine Resistant Shock

Fluid Refractory Shock

Shock persists despite 60 mL/kg fluid resuscitation

Catecholamine Resistant Shock

Warm Shock

Cold Shock

Start Dopamine – starting dose 5 mcg/kg/min
Fellow/Attending may select a first alternative agent

WARM SHOCK COLD SHOCK – LOW BP COLD SHOCK – NORMAL BP
If still hypotensive, titrate NOREPINEPHRINE
Starting dose 0.05 mcg/kg/min

Second line
Add epinephrine or vasopressin
If still hypotensive, titrate EPINEPHRINE
Starting dose 0.05 mcg/kg/min

Second line
Add norepinephrine or dobutamine

If still in shock (i.e., SvO2 < 70%), titrate EPINEPHRINE
Starting dose 0.03 mcg/kg/min

Consider
Milrinone
0.3 mcg/kg/min, no loading dose or
Dobutamine 5 mcg/kg/min

Caution: may cause hypotension

Arterial line, CVL, Foley should be placed for patients on vasoactive infusion for > 1 hour, if not already in place.