Stress-Dose Corticosteroids For patients with septic shock, absolute or relative adrenal insufficiency is a common condition that is frequently associated with refractory shock Stress doses of hydrocortisone (50 to 100 mg/m2/day) are recommended for those with risk factors for adrenal insufficiency (e.g., septic shock with purpura, prior steroid therapy for chronic illness, known pituitary or adrenal abnormalities) Even patients without risk factors may develop critical illness–related corticosteroid insufficiency with an inadequate adrenal response and, although evidence for a clinical benefit is not clear, stress-dose hydrocortisone is currently recommended for children with fluid-refractory, catecholamine-resistant shock without a reversible etiology pending further data from clinical trials ECMO ECMO has been used to support neonates and children with refractory septic shock with reported survival rates of ∼70% for newborns and ∼50% for older children One study suggests that central cannulation via sternotomy may achieve survival rates of 74% for refractory septic shock In cardiogenic shock due to myocarditis, survival rates of 70% have been reported following ECMO Although counterintuitive, due to the need for systemic anticoagulation, ECMO has also been used successfully in hemorrhagic shock in small series In most cases of refractory shock, venoarterial ECMO is preferred over venovenous due to the presence of hemodynamic instability Given the risk of ECMO-related complications, the optimal timing for ECMO cannulation remains unclear CONSIDERATIONS FOR INTENSIVE CARE AND TRANSPORT After initial resuscitation in the ED, ongoing management of children with shock should be transitioned to clinicians with the appropriate critical care and trauma expertise in a setting that has the necessary resources to provide pediatric intensive care Individuals requiring significant fluid resuscitation, vasoactive infusions, noninvasive/invasive mechanical ventilation, or high risk for recurrent hemorrhage should be considered for admission to a PICU Children with shock who present to facilities without the necessary resources to treat shock-associated organ dysfunction (e.g., acute kidney injury requiring dialysis) following the initial resuscitation period should undergo timely transfer to an appropriate facility once cardiopulmonary stability has been achieved Use of a pediatric specialized team is associated with improved patient survival and fewer adverse effects during transport Thus, the use of pediatric specialized teams for transport of children with shock is recommended whenever it is available OUTCOMES