A 6-year-old in septic shock has received 60 mL/kg of isotonic crystalloid, is on norepinephrine plus epinephrine infusions at high dose, and remains hypotensive with cool peripheries. Labs show Na 128 mEq/L, K 5.8 mEq/L, glucose 62 mg/dL, and a random cortisol of 3 microgram/dL. Which single addition to therapy is most indicated?

• A Third vasopressor, vasopressin, at higher escalation
• B Hydrocortisone 50 to 100 mg/m2/day IV ✓
• C Fresh frozen plasma 15 mL/kg
• D Dexamethasone 0.15 mg/kg twice daily

Explanation

Hyponatremia, hyperkalemia, hypoglycemia, and a low random cortisol point to adrenal insufficiency, and hydrocortisone is indicated in catecholamine-resistant shock or proven/suspected steroid deficiency. Hydrocortisone is preferred over dexamethasone because it provides mineralocorticoid activity as well. Escalating further vasopressors ignores the reversible hormonal cause revealed by the electrolyte pattern.

Reference: Surviving Sepsis Campaign Pediatric Guidelines / Nelson Textbook of Pediatrics, 2020 / 21st ed.

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Written and medically reviewed by the StethoPrep medical team.