Sepsis — Fluid Choice and Blood Products — Clinical Pathway: Emergency Department, Inpatient and PICU

Sepsis Clinical Pathway — Emergency Department, Inpatient and PICU

Fluid Choice and Blood Products

Early Fluid Administration is More Important Than Type of Fluid1-3

If in ED, consider PRoMPT Bolus Eligibility

Fluids Bolus Amount Considerations Physiological Effects Cautions Refs
Normal Saline 20-30 mL/kg FIRST LINE Hyperchloremic metabolic acidosis   1,2
Lactated Ringers 20-30 mL/kg ALTERNATIVE FIRST LINE
Balanced/buffered fluids
e.g., LR suggested by SSCG		 Metabolic alkalosis, hyperkalemia, increased ICP, microthrombosis
  • Risk of increased ICP (slightly hypotonic) and microthrombosis (Ca2+ can activate clotting cascade)
  • Avoid/use with caution if hyperkalemia, AKI, known kidney disease, or mitochondrial/metabolic disease
 1,8, 9

Blood Products

Fluids Considerations Cautions Refs
PRBC
  • Consider if:
    • Hgb < 7 and ongoing shock, severe hypoxemia or hemorrhage
  • Per SSCG, not routinely recommended if Hgb > 7
 Monitor for anaphylaxis 1, 2, 3, 13
FFP
  • Consider if:
    • Invasive procedure and INR/PTT elevated or DIC with active bleeding
   1, 2, 11
Platelets
  • Consider if:
    • Platelet < 10 k or
    • Platelet < 50 K with bleeding, invasive procedure or ARDS
  • Recommend to administer over at least 30 minutes
  • Do not push platelets for volume resuscitation due to risk of hypotension
 1, 1, 11, 12

References for Fluid Resuscitation

  1. Weiss et al, PCCM, 2020 (Surviving Sepsis Campaign Guidelines  )
  2. Dellinger et al, CCM, 2008 (Surviving Sepsis Campaign)
  3. Rivers et al, NEJM, 2001
  4. Han et al, Pediatrics, 2003
  5. Vincent & Gottin, Minerva Anestesiol, 2011
  6. Finfer et al, NEJM, 2004 (SAFE Study)
  7. Dubois et al, CCM, 2006
  8. Tommasino et al, CCM, 1988
  9. Kiraly et al, J Trauma, 2006
  10. Hartog et al, Anesth Analg, 2011
  11. Gajic et al, CCM, 2006
  12. Church et al, PCCM, 2009
  13. Karam, PCCM, 2011
  14. Carcillo et al, JAMA, 1991