Secure two vascular access sites.
Intraosseous (IO) access should be secured when intravenous (IV) access has not been achieved after two attempts. In situations where rapid IV access may be difficult, IO access should occur concurrently with IV attempts to minimize delay to vascular access.

Rapid administration of normal saline boluses of 20 mL/kg over 5-10 minutes.
Give boluses via push-pull technique (i.e. filling large syringe with normal saline from IV bag and pushing through IV tubing) or rapid/Level 1 infuser (patient must be ≥ 20 kg with large bore IV, at least 22 gauge or larger to use rapid infuser)².
- A regular IV pump is NOT sufficient.
Boluses may need to be repeated up to 60 mL/kg or more.
Titrate fluids to therapeutic endpoints (see Page 2).
Carefully monitor for signs of fluid overload (i.e. crackles on auscultation, hepatomegaly) or signs of cardiogenic shock (i.e. murmur, persistent shock despite fluid resuscitation).

High flow O₂ using 10-15 Lpm via non-rebreather mask.
Check for and correct low glucose (common in infants) and low calcium (see your PedsPac Dosing Binder or contact your local pediatric referral centre for guidance). If glucose ≤ 2.6 mmol/L, give 5mL/kg D10W rapid push IV, then start D10W IV @ 5mL/kg/hr (MAX 250 mL/hr). Recheck bedside glucose in 5 minutes.

Broad spectrum antibiotics should be administered within 1 hour of recognition of sepsis.
Antibiotics should NEVER be delayed to obtain cultures.
Children < 3 months – Ampicillin (75 mg/kg/dose) + Cefotaxime (100 mg/kg/dose, MAX 2 g/dose).
Children > 3 months – Ceftriaxone (100 mg/kg/dose, MAX 2 g/dose) IV q24h + Vancomycin if suspect meningitis (15 mg/kg/dose, MAX 1 g/dose) IV q6h.

If signs of shock persist (abnormal perfusion and/or hypotension) despite resuscitation with 40 mL/kg of isotonic fluids, prepare inotrope infusion, as indicated below, and administer if no improvement after total 60 mL/kg of fluids.
- For cold shock (↓ perfusion, ↓ pulses): epinephrine (0.05 mcg/kg/min IV, titrate up by 0.02 mcg/kg/min to effect).
- For warm shock (↑ pulse pressure, bounding pulses): norepinephrine (0.05 mcg/kg/min IV, titrate up by 0.02 mcg/kg/min to effect).
- Dopamine (10 mcg/kg/min IV) may be started initially if readily available and there is any delay with administering epinephrine or norepinephrine.

Normalization of capillary refill (<2 seconds), pulses, pulse pressure (diastolic BP should be 2/3 systolic BP), mental status, urine output (>1 mL/kg/hr).

Identification of the source of infection should NEVER delay resuscitation and administration of antibiotics.
Blood culture, urine culture (via catheter) and chest x-ray are standard investigations.
CSF culture may be considered in patients who are hemodynamically stable with no altered LOC or focal neurological signs that may suggest the need for head imaging prior to lumbar puncture.