SSC Children 2026 — Part 2: Source Control, Fluid Therapy & Hemodynamic Management

This section covers source control, fluid resuscitation, and hemodynamic management in pediatric sepsis and septic shock, including emergent source control interventions, intravascular access device removal, fluid bolus volumes and targets, fluid management in settings with and without ICU availability, crystalloid selection, clinical hemodynamic assessment, ScvO2 monitoring, advanced hemodynamic monitoring, and point-of-care ultrasound-guided resuscitation. These recommendations apply to pediatric patients from 37 weeks gestational age at birth through 18 years of age.

1. Source Control

Recommendation 17 — Emergent Source Control

Emergent source control should be achieved as soon as possible after the diagnosis of an infection amenable to source control.

Good practice statement

Change from 2020: No change (carried over).

Rationale: Source control — including drainage of abscesses, debridement of necrotic tissue, removal of infected devices, and definitive management of ongoing contamination — is a fundamental principle of sepsis management. Delays in source control are associated with worse outcomes. The specific intervention and timing should be individualized based on the source of infection, the clinical stability of the patient, and the feasibility of the procedure.

Recommendation 18 — Intravascular Access Device Removal

For children with sepsis or septic shock where an intravascular access device is the confirmed source of infection, we recommend removal of the device after other vascular access has been established, taking into account the pathogen and the risks of the surgical procedure.

Strong recommendation, low certainty evidence

Change from 2020: No change (carried over).

Rationale: Intravascular catheter-related bloodstream infections are a significant cause of sepsis in hospitalized children. Device removal eliminates the ongoing source of infection and is associated with improved outcomes for most pathogens. However, removal must be balanced against the risks of device replacement, the difficulty of establishing alternative vascular access, and the specific pathogen involved. Some organisms (e.g., coagulase-negative staphylococci in the absence of prosthetic material or hemodynamic instability) may be amenable to salvage therapy with systemic and/or lock antimicrobials.

2. Fluid Bolus Therapy

Recommendation 19 — Fluid Bolus Therapy in Septic Shock With ICU Availability

For children with septic shock in settings with ICU availability, we suggest administering up to 40-60 mL/kg of isotonic crystalloid in bolus fluid therapy (10-20 mL/kg per bolus) over the first hour, over no fluid bolus therapy.

Conditional recommendation, low certainty evidence

Change from 2020: No change (carried over).

Rationale: In settings where intensive care monitoring and intervention are available, fluid bolus therapy remains a cornerstone of initial resuscitation for pediatric septic shock. The recommended volume of up to 40-60 mL/kg administered in aliquots of 10-20 mL/kg allows for titration to clinical response. Each bolus should be followed by reassessment of hemodynamic status, and further boluses should be withheld if signs of fluid overload develop (hepatomegaly, pulmonary crackles, worsening respiratory distress, or new/increasing oxygen requirement).

Recommendation 20 — Fluid Bolus Therapy in Sepsis Without Hypotension (No-ICU Settings)

For children with sepsis who do not have hypotension in settings without ICU availability, we strongly recommend against fluid bolus therapy, while starting maintenance fluids.

Strong recommendation, high certainty evidence

Change from 2020: No change (carried over).

Rationale: This recommendation is based on high certainty evidence, primarily derived from the FEAST trial conducted in resource-limited settings in sub-Saharan Africa, which demonstrated increased mortality with fluid bolus therapy compared with maintenance fluids alone in febrile children with impaired perfusion but without hypotension.¹ In settings where mechanical ventilation and vasoactive support are not readily available, the risks of fluid bolus therapy — including pulmonary edema and cardiovascular compromise — may outweigh the potential benefits. Maintenance fluids should be initiated to address ongoing losses and metabolic demands.

Recommendation 21 — Fluid Bolus Therapy in Septic Shock With Hypotension (No-ICU Settings)

For children with septic shock who have hypotension in settings without ICU availability, we suggest administering up to 40 mL/kg of isotonic crystalloid in bolus fluid therapy (10-20 mL/kg per bolus) over the first hour, over no fluid bolus therapy.

Conditional recommendation, low certainty evidence

Change from 2020: No change (carried over).

Rationale: In settings without ICU availability, children with septic shock and documented hypotension face significant mortality risk. Fluid bolus therapy may restore intravascular volume and improve perfusion. The volume ceiling of 40 mL/kg (rather than 40-60 mL/kg in ICU settings) reflects the more limited capacity for monitoring and managing complications of volume resuscitation in non-ICU environments. Each bolus should be followed by careful clinical reassessment.

Recommendation 22 — Reassessment After Each Fluid Bolus

Hemodynamic status should be reassessed after every fluid bolus. Fluid therapy should be titrated to clinical markers of cardiac output and perfusion and discontinued if signs of shock resolve or signs of fluid overload develop.

Good practice statement

Change from 2020: No change (carried over from 2020 remarks).

Rationale: Ongoing reassessment prevents both under-resuscitation and the harms of fluid overload, which include pulmonary edema, prolonged mechanical ventilation, and increased mortality. Clinical markers for reassessment include heart rate, blood pressure, capillary refill time, level of consciousness, urine output, and respiratory status. The decision to continue or discontinue fluid bolus therapy should be made at the bedside after each aliquot.

3. Crystalloid Selection

Recommendation 23 — Crystalloids Over Albumin

For initial resuscitation of children with septic shock, we suggest using crystalloids rather than albumin.

Conditional recommendation, moderate certainty evidence

Change from 2020: No change (carried over).

Rationale: Available evidence does not demonstrate a mortality benefit for albumin over crystalloid solutions in the initial resuscitation of pediatric septic shock. Crystalloids are widely available, less costly, and do not carry the risks associated with human-derived blood products. Albumin may be considered in patients who have received substantial crystalloid volumes and remain hemodynamically unstable, though this practice lacks strong supporting evidence.

Recommendation 24 — Balanced Crystalloids Over 0.9% Saline

For children with sepsis or septic shock, we suggest using balanced/buffered crystalloids rather than 0.9% saline for fluid resuscitation.

Conditional recommendation, very low certainty evidence

Change from 2020: Updated.

Rationale: A meta-analysis of 5 RCTs comparing balanced crystalloids to 0.9% saline in critically ill children demonstrated no mortality difference (RR 1.0; 95% CI 0.82-1.22). However, balanced crystalloids were associated with a lower incidence of acute kidney injury (RR 0.62; 95% CI 0.49-0.80) and a reduced need for renal replacement therapy (RR 0.58; 95% CI 0.39-0.87). These kidney-related outcomes, along with the established physiological rationale for avoiding hyperchloremic metabolic acidosis, support the preferential use of balanced solutions.

Remarks: Balanced crystalloids include lactated Ringer’s solution and Hartmann’s solution. 0.9% saline remains an acceptable choice in specific clinical situations, including hyponatremia and central nervous system infections where concerns about hypotonic solutions and cerebral edema may influence fluid selection.

4. Hemodynamic Assessment & Monitoring

Recommendation 25 — Clinical Assessment of Hemodynamic Status

Resuscitation should be guided by ongoing clinical assessment of hemodynamic status, including heart rate, blood pressure, capillary refill time, extremity temperature, pulse quality, level of consciousness, and urine output.

Good practice statement (new)

Change from 2020: New GPS.

Rationale: Clinical assessment remains the foundation for hemodynamic monitoring and resuscitation guidance in pediatric sepsis. The ANDROMEDA-SHOCK trial in adults demonstrated that a capillary refill time-guided resuscitation strategy was associated with less organ dysfunction at 72 hours compared with a lactate-guided strategy.² While direct pediatric evidence is limited, the clinical assessment parameters listed above are readily available in all settings, do not require specialized equipment, and can be repeated frequently to guide real-time clinical decisions.

Recommendation 26 — MAP Targets

There is insufficient evidence to recommend targeting a mean arterial pressure at the 5th or 50th percentile for age in children with septic shock.

No recommendation (insufficient evidence)

Change from 2020: No change (carried over).

Rationale: Age-appropriate blood pressure targets are a fundamental component of hemodynamic management in pediatric sepsis, but the optimal MAP target remains undefined. No pediatric RCT has compared different MAP targets in septic shock. The panel could not recommend a specific percentile target. Clinicians should use age-appropriate reference ranges and target blood pressures that are associated with adequate perfusion as assessed by clinical examination.

Recommendation 27 — Central Venous Oxygen Saturation

For children with septic shock in whom central venous access is available, we suggest targeting a central venous oxygen saturation (ScvO2) of 70% or greater, over not targeting ScvO2.

Conditional recommendation, very low certainty evidence

Change from 2020: Updated.

Rationale: Two pediatric RCTs enrolling a combined 222 patients suggested a possible reduction in mortality with ScvO2-targeted resuscitation (RR 0.48; 95% CI 0.22-1.03), though the confidence interval crossed the line of no effect. ScvO2 less than 70% indicates an imbalance between oxygen delivery and consumption and may identify patients who would benefit from interventions to augment cardiac output or oxygen-carrying capacity. ScvO2 monitoring requires central venous catheterization and should not delay initiation of resuscitation in patients without existing central access.

Recommendation 28 — Advanced Hemodynamic Monitoring

There is insufficient evidence to recommend advanced hemodynamic monitoring in addition to bedside clinical assessment for children with septic shock.

No recommendation (insufficient evidence)

Change from 2020: Updated.

Rationale: Advanced hemodynamic monitoring technologies — including transpulmonary thermodilution, pulse contour analysis, and echocardiography-derived cardiac output — may provide additional hemodynamic data. However, no RCT has demonstrated that the addition of these technologies to bedside clinical assessment improves outcomes in pediatric septic shock. Their use should be guided by clinical context, institutional expertise, and device availability.

Recommendation 29 — Point-of-Care Ultrasound (POCUS)

For children with septic shock, we suggest using cardiac and lung point-of-care ultrasound (POCUS) to guide resuscitation if local training and resources allow.

Conditional recommendation, low certainty evidence

Change from 2020: New recommendation.

Rationale: A meta-analysis of 2 small pediatric RCTs demonstrated that POCUS-guided resuscitation was associated with shorter time to shock reversal and shorter PICU length of stay compared with standard clinical assessment alone. POCUS can provide real-time information on cardiac function, volume status, and the presence of pleural effusions or pericardial fluid, which may inform fluid and vasoactive medication decisions. Implementation requires adequate training, quality assurance programs, and the availability of ultrasound equipment at the bedside.

Pediatric Sepsis Resuscitation Algorithm

The following text-based algorithm outlines the resuscitation approach for children with probable sepsis or suspected septic shock, based on the guideline recommendations (adapted from Figure 2 of the guideline document).

PEDIATRIC SEPSIS RESUSCITATION ALGORITHM

┌───────────────────────────────────────────────────────────────┐
│              PROBABLE SEPSIS / SUSPECTED SEPTIC SHOCK         │
│                                                               │
│  • Recognize signs of sepsis                                  │
│  • Measure blood lactate                                      │
│  • Obtain blood cultures (do not delay antimicrobials)         │
│  • Start antimicrobials:                                      │
│      Septic shock → within 1 hour                             │
│      Sepsis without shock → within 3 hours (if concern holds) │
└───────────────────────────┬───────────────────────────────────┘
                            │
                            ▼
┌───────────────────────────────────────────────────────────────┐
│                  INITIAL FLUID RESUSCITATION                  │
│                                                               │
│  ICU available:                                               │
│    • Give 10-20 mL/kg isotonic crystalloid bolus              │
│    • Reassess after EACH bolus                                │
│    • Repeat up to 40-60 mL/kg in the first hour              │
│    • Prefer balanced crystalloids over 0.9% saline            │
│                                                               │
│  No ICU + hypotension:                                        │
│    • Give 10-20 mL/kg boluses up to 40 mL/kg in first hour   │
│                                                               │
│  No ICU + NO hypotension:                                     │
│    • DO NOT give bolus fluid → start maintenance fluids only  │
│                                                               │
│  STOP BOLUSES if:                                             │
│    ✓ Shock resolves (HR, BP, CRT, UOP normalize)              │
│    ✗ Signs of fluid overload develop                          │
│      (hepatomegaly, crackles, worsening respiratory distress) │
└───────────────────────────┬───────────────────────────────────┘
                            │
              ┌─────────────┴─────────────┐
              │  Shock persists after      │
              │  initial fluid therapy?    │
              └─────────────┬─────────────┘
                   YES      │
                            ▼
┌───────────────────────────────────────────────────────────────┐
│                    VASOACTIVE MEDICATIONS                     │
│                                                               │
│  • Initiate vasoactive agents (see Part 3)                    │
│  • May start through peripheral IV if central access delayed  │
│  • First-line: epinephrine or norepinephrine (evidence for    │
│    either; no superiority demonstrated)                       │
│  • Consider vasopressin if high-dose catecholamines required  │
└───────────────────────────┬───────────────────────────────────┘
                            │
                            ▼
┌───────────────────────────────────────────────────────────────┐
│                   CONTINUOUS REASSESSMENT                     │
│                                                               │
│  Monitor and reassess frequently:                             │
│    • Heart rate, blood pressure, capillary refill time        │
│    • Extremity temperature, pulse quality                     │
│    • Level of consciousness, urine output                     │
│    • Blood lactate (serial measurements)                      │
│    • ScvO2 ≥70% if central venous access present              │
│    • POCUS if training and resources available                 │
│                                                               │
│  Titrate:                                                     │
│    • Fluids ↔ vasoactives based on clinical response          │
│    • Target resolution of hypoperfusion markers               │
│    • Avoid fluid overload                                     │
│    • Consider source control if indicated                     │
└───────────────────────────────────────────────────────────────┘

Quick Reference: Source Control, Fluids & Hemodynamics

SOURCE CONTROL, FLUIDS & HEMODYNAMICS — AT A GLANCE (Recs 17-29)

1. SOURCE CONTROL
   GPS Emergent source control ASAP for amenable infections          [GPS]
   ✓✓ Remove confirmed infected intravascular device (after          [Strong, low CoE]
      alternative access established)

2. FLUID BOLUS THERAPY
   ✓  Septic shock + ICU available → up to 40-60 mL/kg              [Conditional, low CoE]
      (10-20 mL/kg per bolus) in first hour
   ✓✓ Sepsis, no hypotension, no ICU → NO bolus, maintenance only   [Strong, high CoE]
   ✓  Septic shock + hypotension, no ICU → up to 40 mL/kg           [Conditional, low CoE]
      (10-20 mL/kg per bolus) in first hour
   GPS Reassess after EVERY bolus; stop if shock resolves or         [GPS]
       fluid overload develops

3. CRYSTALLOID SELECTION
   ✓  Crystalloids over albumin for initial resuscitation            [Conditional, moderate CoE]
   ✓  Balanced crystalloids over 0.9% saline                        [Conditional, very low CoE]
      • No mortality difference (RR 1.0)
      • Lower AKI (RR 0.62) and lower RRT need (RR 0.58)
      • 0.9% saline acceptable for hyponatremia, CNS infections

4. HEMODYNAMIC MONITORING
   GPS Guide resuscitation by clinical assessment (HR, BP, CRT,     [GPS]
       extremity temp, pulse quality, consciousness, UOP)
   —  MAP target (5th vs 50th percentile for age)                    [Insufficient evidence]
   ✓  Target ScvO2 ≥70% when central venous access present          [Conditional, very low CoE]
   —  Advanced hemodynamic monitoring beyond clinical assessment     [Insufficient evidence]
   ✓  Use cardiac + lung POCUS if local training/resources allow     [Conditional, low CoE]

KEY: ✓✓ = Strong recommendation ("we recommend")
     ✓  = Conditional recommendation ("we suggest")
     GPS = Good practice statement
     —  = No recommendation / insufficient evidence
     CoE = Certainty of evidence

References