A 3-year-old (14 kg) with septic shock has received 60 mL/kg crystalloid over 30 minutes. BP remains 62/38 mmHg, CRT 5 seconds, lactate 6.8 mmol/L. CVP is 4 mmHg. What is the next most appropriate step?

• A Administer hydrocortisone 2 mg/kg IV
• B Start norepinephrine infusion via peripheral IV
• C Start dopamine infusion via central line
• D Additional 20 mL/kg crystalloid bolus ✓

Explanation

Fluid-refractory shock is defined after 60 mL/kg without improvement. Before starting vasoactive drugs, the child should receive additional boluses up to 100-120 mL/kg total if no signs of fluid overload. CVP of 4 mmHg suggests ongoing hypovolemia. Epinephrine or norepinephrine is started after 60-100 mL/kg fluids fail. Central access is preferred but peripheral vasopressors can be used temporarily in emergencies.

Reference: Surviving Sepsis Campaign International Guidelines, 2020 ed.

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Written and medically reviewed by the StethoPrep medical team.