Paeds SAQs · acute-care-resuscitation-and-toxicology
Septic shock resuscitation and vasoactive support — formative SAQs
Two MedVellum formative short-answer questions on resuscitating paediatric septic shock: recognising shock from the whole circulation, the first-hour bundle of reassessed fluid aliquots and antibiotics within the hour, choosing adrenaline for cold shock and noradrenaline for warm shock, recognising fluid accumulation injury, and arranging retrieval before local support is exceeded. The marks and timing support transparent self-assessment. They are not an official board format or pass standard.
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Target exams
SAQ 1 — A deteriorating infant in cold septic shock
Question 1 — 10 formative marks; suggested time 15 minutes [1]
A nine-month-old infant presents with two days of fever and reduced feeding, and today is floppy, mottled and barely responsive. Heart rate is 175, central pulses are weak, capillary refill is 4 seconds, respiratory rate is 60 with grunting, and blood pressure is low-normal. Bedside glucose is 2.1 mmol per litre. [1] [5]
- Explain why this child is in shock despite a normal-range blood pressure, and state what you do in the first 60 seconds. (2 marks)
- Outline your first-hour circulatory and antimicrobial management, including fluid aliquot, antibiotic timing and glucose correction. (4 marks)
- After two reassessed boluses the infant remains cold and poorly perfused with a narrow pulse pressure. What is the diagnosis and the next step? (2 marks)
- Describe how you reassess after each intervention and when you escalate to retrieval. (2 marks) [1]
Full-credit answer — SAQ 1
Reveal full-credit answer for SAQ 1
1. Shock despite a normal blood pressure
"This infant is in decompensated septic shock in evolution. Children compensate for circulatory failure by raising heart rate and vascular tone, so blood pressure is maintained until relatively late; a normal reading never excludes shock." The first 60 seconds: declare the concern, call the senior paediatric and resuscitation teams, name a leader, allocate roles, and bring age- and weight-appropriate equipment and monitoring. Stabilisation precedes diagnosis. [5] [1]
2. First-hour circulatory, antimicrobial and glucose management
I secure the airway and give high-flow oxygen because the infant is in failure, supporting ventilation if it is ineffective. I establish intravenous or intraosseous access and send a point-of-care gas, lactate, glucose, culture and core bloods. I restore the circulation with crystalloid aliquots of 10 to 20 mL per kilogram, stating the expected response before each and reassessing after each; the first-hour total is a ceiling, not a target. I give broad-spectrum antibiotics within the first hour at weight-appropriate doses, taking cultures first only when this does not delay treatment. The bedside glucose is dangerously low, so I correct it immediately through the local hypoglycaemia pathway and recheck, because hypoglycaemia worsens neurological outcome. [1] [5]
3. Diagnosis and next step after refractory boluses
Shock persisting after two or three reassessed boluses is fluid-refractory septic shock. The cold, mottled phenotype with weak pulses and a narrow pulse pressure is cold shock, so I start an adrenaline infusion at 0.05 to 0.1 microgram per kilogram per minute and titrate to perfusion endpoints, arranging central access and intensive care. I do not keep driving fluid toward a target. [1] [6]
4. Reassessment and escalation
After every action I return to airway, breathing, circulation and consciousness, and I judge the trend against the improvement I predicted. Endpoints are stronger pulses, warmer skin, capillary refill under 2 seconds, normal interaction, a mean arterial pressure appropriate for age, a falling lactate and urine output above 1 mL per kilogram per hour. I call retrieval and intensive care in parallel with resuscitation, before local support is exceeded, and I prepare escort, monitoring and a contingency for deterioration or transport delay. [1]
SAQ 2 — Fluid-refractory warm shock in a rural hospital
Question 2 — 10 formative marks; suggested time 15 minutes [1]
A seven-year-old in a rural hospital has fever, is flushed and warm with bounding pulses, has a wide pulse pressure and a flash capillary refill, and remains hypotensive after three reassessed boluses. The hospital has monitoring and intravenous access but no paediatric intensive care or vasoactive agents on site. [1] [5]
- Identify the shock phenotype and name the first-line vasoactive agent with its typical infusion range. (2 marks)
- Justify the choice against dopamine as an alternative. (2 marks)
- During the boluses the child develops crackles, hepatomegaly and a rising oxygen requirement. Interpret this and state your action. (3 marks)
- Explain the FEAST lesson and how it applies here, and describe your retrieval plan. (3 marks) [4]
Full-credit answer — SAQ 2
Reveal full-credit answer for SAQ 2
1. Phenotype and first-line vasoactive agent
This is warm shock: vasodilated, flushed, with bounding pulses, a wide pulse pressure and flash capillary refill, indicating low systemic vascular resistance. The first-line agent is noradrenaline (norepinephrine), started at 0.05 to 0.1 microgram per kilogram per minute and titrated to effect, commonly up to around 1.0 microgram per kilogram per minute. Its predominant alpha effect restores vascular tone and blood pressure. [1] [6]
2. Noradrenaline over dopamine
Dopamine is no longer the preferred first-line agent. The Surviving Sepsis Campaign recommends adrenaline or noradrenaline over dopamine, and a meta-analysis of randomised studies found no survival advantage for dopamine over adrenaline in paediatric and neonatal septic shock, with a higher dysrhythmia burden. For this warm, vasodilated phenotype, noradrenaline directly targets the dominant fault of low systemic vascular resistance. [1] [6]
3. Fluid accumulation injury
Bilateral crackles, hepatomegaly and a rising oxygen requirement during fluid resuscitation signal fluid accumulation injury: the leaking circulation cannot hold the volume given. I stop driving fluid toward a target, escalate to the vasoactive agent (noradrenaline for this warm phenotype), arrange central access and intensive care, and reassess perfusion and the fluid balance. The first-hour total was a ceiling, not a target, and the signs now demand that I respect it. [1] [9]
4. The FEAST lesson and the retrieval plan
FEAST found that saline or albumin bolus increased early mortality compared with no bolus in African children with severe febrile illness. Its correct lesson is that a fluid algorithm cannot be transplanted across populations, shock types and rescue resources. Here, in a well-resourced setting with a child in septic shock, I still gave reassessed aliquots, but I watched the response, respected the ceiling and escalated rather than forcing a fixed volume. Because this hospital cannot provide paediatric intensive care or vasoactive agents, I called retrieval and critical care in parallel with resuscitation, before local support was exceeded, and I agreed the destination, the treatment to continue, the escort and equipment, the expected deterioration and the plan if transfer is delayed. [4] [9]
References
- [1]Weiss, Scott L Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026 Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2026.PMID 41869844
- [3]Sanchez-Pinto, L Nelson Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock JAMA, 2024.PMID 38245897
- [4]Maitland, Kathryn Mortality after fluid bolus in African children with severe infection The New England journal of medicine, 2011.PMID 21615299
- [5]Bjorklund, Ashley Pediatric Shock Review Pediatrics in review, 2023.PMID 37777656
- [6]Wen, L The efficacy of dopamine versus epinephrine for pediatric or neonatal septic shock: a meta-analysis of randomized controlled studies Italian journal of pediatrics, 2020.PMID 31937353
- [9]Ali, Ahmed O Restrictive Versus Liberal Fluid Strategy for Initial Resuscitation in Sepsis and Septic Shock: A Systematic Review and Meta Analysis Journal of clinical medicine research, 2026.PMID 41953594