Sepsis, N/IICU — Ongoing Fluid Resuscitation — Clinical Pathway: ICU and Inpatient

Suspected Sepsis Clinical Pathway — N/IICU

Ongoing Fluid Resuscitation

Fluid Resuscitation
  • First Hour
    • Administer initial crystalloid (NS or LR) 10-20 mL/kg bolus over 10-15 minutes
    • Consider smaller volume (5-10 mL/kg) and slower boluses in:
      • Extremely premature infants
      • Known cardiac dysfunction
      • Pulmonary edema
      • Severe anemia
      • Renal dysfunction
    • Repeat boluses up to a total volume of 20-60 ml/kg
    • Begin pressor infusion if poor response to fluid therapy
Monitoring
  • Continue rapid volume infusion as needed, titrate to goal clinical parameters
  • Development of pulmonary crackles or hepatomegaly in absence of hemodynamic improvement with bolus suggests limited benefit of further fluid therapy
Fluid Maintenance
  • D10 1/2 NS at maintenance to provide adequate glucose (target GIR 5-8)
  • Correct electrolyte abnormalities
Blood Products
  • Order:
    • PRBC if Hgb < 10 mg/dL (emergency O negative blood is available on unit)
    • Platelets for platelet count < 25,000 cells per cubic millimeter or per clinical discretion with signs of bleeding
    • FFP if coagulation profile (INR, PT/PTT) abnormal or per clinical discretion with signs of bleeding

Goals for Initial Resuscitation

Parameter Comment Target
Urine Output (UOP) Inadequate urine output is a sign of poor end-organ perfusion > 1 ml/kg/hr
Hemoglobin
  • Hemoglobin is a primary determinant of O2 delivery; thus, anemia should be treated in shock
  • Infants not in shock may tolerate a lower Hgb level
 Hgb ≥ 10 g/dL
Activity Level Lethargy and agitation are signs of poor end-organ perfusion Alert and appropriate for age
Capillary Refill
  • Delayed capillary refill can be seen in cold shock
  • Flash capillary refill can be seen in warm shock
 < 2 sec
Lactate
  • Elevated lactate > 4 mmol/L may be sign of shock with inadequate oxygen delivery
    • Normative data is not available in preterm infants
 < 4 mmol/L or
≥ 10% decrease over 2 hrs