Sepsis — Fluid Resuscitation — Clinical Pathway: Emergency Department, Inpatient and PICU

Sepsis Clinical Pathway — Emergency Department, Inpatient and PICU

Fluid Resuscitation

First Hour

Core Component Considerations
Rapid Crystalloid (NSS or LR)
20 mL/kg bolus
  • Consider patient eligibility for PRoMPT Bolus Study if ED Patient
  • Monitor response to fluids, VS Targets and Clinical Goals Met
  • Check for signs of congestive heart failure (CHF) every 15 minutes
  • Tailor fluid therapy to the individual patient.
  • Consider 5-10 mL/kg boluses q 10-20 minutes in patients with:
    • Known cardiac dysfunction
    • Pulmonary edema
    • Severe anemia
    • Renal dysfunction (creatinine clearance < 60)
  • Refer to Fluid Choice
Rapid Fluid Infusion Techniques < 50 kg Administer via manual syringe (< 5 kg) or push-pull technique Push-Pull Technique Demonstration with 30 mL syringe and macro drip set with 3-way stopcock
≥ 50 kg Pressure Bag or Rapid Infuser
Assess Cardiac Function
  • Consider bedside cardiac ultrasound or echocardiogram to assess for systolic dysfunction, pericardial effusion, and fluid responsiveness.
  • DO NOT DELAY initiation of vasoactive therapy to obtain cardiac function assessment.

Ongoing Therapy

  • Continue rapid volume infusion using crystalloid (NS/LR) as needed, titrate to goal clinical parameters
    • Escalate to the ICU, CAT or CODE team per clinical condition and response to therapy
  • Begin vasoactive infusion if ongoing signs of shock refractory to fluid therapy (40-60 mL/kg)
    • Vasoactive can be started peripherally

Ongoing Monitoring

  • Titrate to goal clinical parameters (e.g., urine output, improvement in perfusion, improved heart rate or blood pressure)
  • Development of pulmonary crackles, hepatomegaly, CVP > 12 (> 15 if on positive pressure ventilation) in absence of hemodynamic improvement with bolus suggests limited benefit of further fluid therapy and may suggest development of heart failure.