ICU Pathway for the Evaluation/Treatment of Infants > 28 Days and Children with Severe Sepsis/Septic Shock

Fluid Choice and Blood Products

Early fluid administration is more important than type of fluid1-3

Fluids Amount Considerations Cautions Refs
Normal Saline 20 mL/kg boluses FIRST LINE   1
5% albumin
( > 44 wks CGA)
10-20 mL/kg Consider if:
  • Poor response to crystalloid
    60 mL/kg
  • Albumin < 3 mg/dL
  • Chloride > 110 mEq/L
  4,5,6
Lactated Ringers 20 mL/kg Consider if:
  • pH < 7.2
  • Chloride > 110 mEq/L
Risk of increased ICP (slightly hypotonic) and microthromboses (Ca2+ can activate clotting cascade) 7,8

Blood Products

Fluids Amount Considerations Cautions Refs
PRBC   Consider if:
  • Hgb < 10 and ongoing shock with sScvO2 < 70%, lactate > 4 mmol/dL
  • Patients not in shock may tolerate lower Hgb (target=7 gm/dL)
Monitor for anaphylaxis 1,2,12
FFP Infusion, NOT bolus Consider if:
  • Invasive procedure and INR/PTT elevated or DIC with active bleeding
  1,10
Platelets   Consider if:
  • Platelet < 10 k or
  • Platelet < 50 K with bleeding, invasive procedure or ARDS
  1,10,11

FLUID CHOICES: ADVERSE AFFECTS AND COST

Agent Potential adverse effects Cost (per 250 mL)
Normal saline Hyperchloremic metabolic acidosis $0.50
Lactated Ringers Metabolic alkalosis, hyperkalemia, increased ICP, microthrombosis $2
Albumin 5% Allergic reactions, intraventricular hemorrhage (neonates) $50
Hespan© (6% hetastarch 600/0.75 in 0.9% sodium chloride) Coagulopathy, renal toxicity, pruritus, anaphylaxis,
(possible increased mortality in sepsis)
Data is not sufficient to recommend synthetic colloids in pediatric septic shock
$5

Courtesy of Susan Warrington, PharmD

REFERENCES for Fluid Resuscitation

  1. Dellinger et al, CCM, 2008 (Surviving Sepsis Campaign)
  2. Rivers et al, NEJM, 2001
  3. Han et al, Pediatrics, 2003
  4. Vincent & Gottin, Minerva Anestesiol, 2011
  5. Finfer et al, NEJM, 2004 (SAFE Study)
  6. Dubois et al, CCM, 2006
  7. Tommasino et al, CCM, 1988
  8. Kiraly et al, J Trauma, 2006
  9. Hartog et al, Anesth Analg, 2011
  10. Gajic et al, CCM, 2006
  11. Church et al, PCCM, 2009
  12. Karam, PCCM, 2011
  13. Carcillo et al, JAMA, 1991