Pediatric Sepsis Resuscitation

Initial Fluid Resuscitation

The Dutch Pediatric Society and the American College of Critical Care Medicine recommend isotonic saline or crystalloid as the first-choice fluid for initial resuscitation in neonates and children with hypovolemia, due to no proven mortality benefit of colloids over crystalloids, potential infection hazards with biological colloid products, risk of anaphylactic reactions with colloids, and significantly higher cost of colloids compared to crystalloids 1, 2, 3
The initial bolus should be 20 mL/kg over 5-10 minutes, with subsequent boluses of 20 mL/kg if signs of shock persist, and children may require 40-60 mL/kg in the first hour, with each bolus given over 5-10 minutes and reassessed after each bolus for clinical response 2, 3, 4
The maximum volume of fluid administration should be up to 200 mL/kg in the first hour in severe cases, titrated to clinical response 2

Continue boluses while monitoring for signs of fluid overload, such as increased work of breathing, rales, gallop rhythm, and hepatomegaly, and monitor parameters to assess response to fluid resuscitation, including capillary refill ≤2 seconds, normal pulses with no differential between peripheral and central pulses, warm extremities, urine output >1 mL/kg/h, normal mental status, normal blood pressure for age, ScvO2 >70% (when available), and cardiac index >3.3 L/min/m² (when available) 2, 5, 6, 3
Clinical markers of cardiac output, including heart rate, blood pressure, capillary refill time, level of consciousness, and urine output, should be used to titrate fluid administration 5, 1, 6, 3

Synthetic colloids may be considered when large amounts of fluids are required (e.g., in refractory septic shock) due to longer intravascular retention, and blood products, such as packed red blood cells, may be considered in neonates with hemoglobin <12 g/dL 1, 2
Advanced hemodynamic variables, such as cardiac output/cardiac index, systemic vascular resistance, and central venous oxygen saturation (ScvO2), should be used when available, and trends in blood lactate levels and signs of fluid overload, such as hepatomegaly and rales, should be monitored 5, 6, 3

If shock persists despite adequate fluid resuscitation, initiate vasopressors promptly, with options including peripheral inotrope (low-dose dopamine or epinephrine) while establishing central access, central epinephrine (0.05-0.3 μg/kg/min) for cold shock, and norepinephrine for warm shock, with a target mean arterial pressure (MAP) of 65-70 mmHg 2, 7, 8
Norepinephrine is the first-line vasopressor for patients not responding adequately to fluid resuscitation, and peripheral administration of vasopressors should be considered until central access is established 7, 8, 3

Delayed fluid resuscitation, relying solely on blood pressure as an endpoint for resuscitation, excessive fluid administration, delayed recognition of need for surgical intervention, and failure to initiate vasopressors when fluid resuscitation is inadequate should be avoided 3, 7, 9
Relying solely on blood pressure as an endpoint for resuscitation, delayed recognition of fluid overload, inappropriate fluid choice, inadequate monitoring, and failure to consider specific disease states are common pitfalls in fluid resuscitation that should be avoided, and fluid overload should be avoided in patients with generalized peritonitis, as excessive fluid can lead to gut edema, increased intra-abdominal pressure, abdominal compartment syndrome, and acute respiratory distress syndrome 6, 3, 7