What is the fluid of choice for pediatric sepsis?

Fluid of Choice for Pediatric Sepsis

Isotonic crystalloids, specifically normal saline, should be the first-line fluid for resuscitation in pediatric sepsis. 1, 2

Initial Fluid Resuscitation Protocol

First-Line Fluid Choice

• Use isotonic crystalloids (normal saline) as the initial fluid of choice 1, 2
• Administer rapid fluid boluses of 20 mL/kg 1, 2
• Deliver via push or rapid infusion device (pressure bag) 1
• Continue boluses while monitoring for signs of fluid overload 1

Volume and Rate

• Children commonly require 40-60 mL/kg in the first hour 1
• May need up to 200 mL/kg in the first hour in severe cases 1
• Each bolus should be given over 5-10 minutes 2
• Reassess after each bolus for clinical response 1, 2

Evidence Supporting Crystalloid Use

The Dutch Pediatric Society guideline explicitly recommends isotonic saline as the first-choice fluid for initial resuscitation in neonates and children with hypovolemia 1. This recommendation is based on:

1. No proven mortality benefit of colloids over crystalloids
2. Potential infection hazards with biological colloid products
3. Risk of anaphylactic reactions with colloids
4. Significantly higher cost of colloids compared to crystalloids

The American College of Critical Care Medicine similarly recommends crystalloid as the fluid of choice in pediatric sepsis 1. Recent evidence also indicates that balanced crystalloids may reduce the risk of acute kidney injury compared to normal saline, though mortality outcomes remain similar 3.

When to Consider Alternative Fluids

• Synthetic colloids: May be considered when large amounts of fluids are required (e.g., in refractory septic shock) due to longer intravascular retention 1
• Blood products: Consider packed red blood cells in neonates with hemoglobin <12 g/dL 1
• Balanced crystalloids: May be preferred over normal saline in patients at risk for hyperchloremic metabolic acidosis, though evidence for mortality benefit is lacking 3

Monitoring Response to Fluid Therapy

Monitor the following parameters to assess response to fluid resuscitation:

• 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)
• Cardiac index >3.3 L/min/m² (when available) 1

Common Pitfalls to Avoid

1. Delayed fluid resuscitation: Begin fluid resuscitation immediately upon recognition of septic shock 2
2. Excessive fluid administration: Monitor closely for signs of fluid overload (increased work of breathing, rales, gallop rhythm, hepatomegaly) 1, 2
3. Relying solely on blood pressure: Use multiple clinical markers to guide resuscitation 2
4. Inappropriate fluid choice: Avoid semi-synthetic colloids which have been associated with renal dysfunction 4
5. Delayed vasopressor initiation: If shock persists despite adequate fluid resuscitation, initiate vasopressors promptly 1, 2

Progression to Vasopressor Support

If the patient remains in shock despite adequate fluid resuscitation:

• Begin peripheral inotrope (low-dose dopamine or epinephrine) while establishing central access 1
• For cold shock: Use central epinephrine (0.05-0.3 μg/kg/min) 1
• For warm shock: Use norepinephrine 1

In summary, isotonic crystalloids remain the first-line fluid choice for pediatric sepsis resuscitation based on current guidelines and evidence. While balanced crystalloids may offer some advantages regarding kidney injury, normal saline is still an appropriate and widely used option. The focus should be on prompt administration, appropriate volume, careful monitoring, and timely escalation to vasopressors when needed.