What is the best choice of fluid for neonates with sepsis?

Best Choice of Fluid for Neonates with Sepsis

Isotonic saline (normal saline) should be the first-choice fluid for initial resuscitation of neonates with septic shock. 1

Initial Fluid Selection and Administration

Primary Fluid Choice

• Isotonic crystalloids (normal saline or lactated Ringer's) are recommended as the first-line fluid for volume resuscitation in neonatal sepsis 1
• There is no evidence of advantage of colloids over crystalloids in septic neonates, and crystalloids are significantly less expensive 1

Fluid Administration Protocol

• Begin with boluses of 20 mL/kg of isotonic saline over 5-15 minutes 1
• Reassess the patient after each bolus for:
  • Adequate blood pressure
  • Heart rate
  • Quality of peripheral pulses
  • Capillary refill
  • Level of consciousness
  • Peripheral skin temperature
  • Urine output 1
• Initial volume resuscitation commonly requires 40-60 mL/kg but can be as much as 200 mL/kg in severe cases 1

Special Considerations

When to Consider Colloids

• When large amounts of fluids are required in sepsis, synthetic colloids may be considered as a second-line option due to their longer duration in circulation 1
• However, there is no evidence that synthetic colloids are superior to crystalloids in improving mortality outcomes 1

Blood Products

• Maintain hemoglobin at a minimum of 10 g/dL in septic shock 1
• Consider blood transfusion if ScvO₂ is <70% to improve oxygen delivery 1
• Fresh frozen plasma may be used to correct coagulation abnormalities but should not be pushed rapidly due to risk of hypotension 1

Monitoring for Fluid Overload

• Watch for signs of fluid overload:
  • New onset rales
  • Increased work of breathing
  • Hypoxemia from pulmonary edema
  • Hepatomegaly
  • Diminishing MAP-central venous pressure 1
• Consider diuretics, peritoneal dialysis, or continuous renal replacement therapy (CRRT) for patients who develop fluid overload 1

Evidence Quality and Controversies

Crystalloid vs. Colloid Debate

• Multiple meta-analyses show no mortality benefit of colloids over crystalloids in various patient categories including sepsis 1
• The SAFE Study subgroup analysis showed a relative risk of death in the albumin group compared to saline of 0.87 (95% CI 0.74-1.02) for patients with sepsis, suggesting a potential but non-significant trend toward benefit with albumin 1

Balanced vs. Unbalanced Crystalloids

• Recent evidence comparing normal saline to balanced solutions (like lactated Ringer's) in sepsis shows no statistically significant difference in mortality rates, hospital length of stay, ICU admission, mechanical ventilation, oxygen therapy, or renal replacement therapy requirements 2

Hypertonic Solutions

• Some studies suggest that hypertonic saline (3%) may require approximately half the volume compared to normal saline for resuscitation, but with similar outcomes in shock reversal time, ICU stay, and mortality 3

Practical Pitfalls to Avoid

1. Delayed resuscitation: Early and aggressive fluid resuscitation is critical for survival in septic shock
2. Inadequate monitoring: Failure to reassess after each fluid bolus can lead to under-resuscitation or fluid overload
3. Overreliance on expensive colloids: No evidence supports routine use of albumin or other colloids as first-line therapy
4. Fluid overload: Excessive fluid administration without monitoring for signs of overload can lead to pulmonary edema and worsened outcomes 4
5. Inadequate hemoglobin maintenance: Failure to maintain adequate hemoglobin levels (≥10 g/dL) in septic shock can compromise oxygen delivery 1

In conclusion, isotonic saline remains the first-choice fluid for resuscitation in neonatal sepsis based on the best available evidence, with consideration for synthetic colloids only when large volumes are required.