Septic shock in the newborn

OSCE stationVivaEarly-onset sepsis

A viva on first-hour resuscitation of a newborn in septic shock, using the newborn-specific ACCM recommendations.

Questions

1. Which ACCM recommendations apply, and how would you get vascular access?

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   • The ACCM 2017 newborn recommendations, which are separate from those for older children.
   • Umbilical arterial and venous catheters are preferred; intraosseous access, particularly in preterm newborns, is not the preferred route.
   • ACCM also recommends a trigger tool, clinician assessment within 15 minutes and activation of a resuscitation bundle within 15 minutes.

2. Describe the first-hour fluid strategy.

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   • Fluid boluses of 10 mL/kg, watching for hepatomegaly and increased work of breathing; up to 60 mL/kg may be needed in the first hour.
   • A 10% dextrose-containing isotonic solution at maintenance rate to prevent hypoglycaemia.

3. The baby remains hypotensive after fluids. What cardiovascular support does ACCM recommend for newborns?

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   • Low-dose dopamine (below 8 µg/kg/min) with dobutamine (up to 10 µg/kg/min) initially.
   • If the response is inadequate, adrenaline 0.05–0.3 µg/kg/min.

4. How would you manage persistent pulmonary hypertension if it develops?

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   • Oxygenate with 100% oxygen and alkalinise (up to pH 7.50) until inhaled nitric oxide is available.
   • Inhaled nitric oxide is the first treatment when available; milrinone and inhaled iloprost are back-up therapies.

5. What endpoints are you aiming for?

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   • Capillary refill of 2 seconds or less; normal pulses with no peripheral–central difference; warm extremities.
   • Urine output above 1 mL/kg/hour; normal mental status and blood pressure for age; normal glucose and calcium.
   • Pre- and post-ductal saturation difference below 5%.

Based on: Davis AL et al. American College of Critical Care Medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock (Critical Care Medicine, 2017).