What is the protocol for administering boluses in the first 3 hours?

Fluid Bolus Administration in the First 3 Hours

Administer 30 mL/kg of crystalloid fluid within the first 3 hours for patients with sepsis or septic shock, using balanced crystalloids like Lactated Ringer's solution as the preferred fluid type. 1, 2

Calculating the Initial Bolus

• Calculate the total volume by multiplying patient weight (in kg) by 30 mL to determine the total crystalloid needed within 3 hours 1, 2
• For a 70 kg patient, this equals 2,100 mL (approximately 2 liters) to be administered over the 3-hour window 1
• Use actual body weight for most patients, but consider ideal or adjusted body weight for patients with severe obesity (BMI >40) to avoid excessive fluid administration 3

Fluid Type Selection

• Balanced crystalloids (Lactated Ringer's or Plasmalyte) are preferred over normal saline as first-line fluids to reduce the risk of hyperchloremic metabolic acidosis 2, 4
• Limit normal saline to 1-1.5 L maximum if used, due to adverse metabolic effects 4

Administration Strategy

Initial Rapid Bolus Approach

• Start with a rapid bolus of 500-1000 mL administered over 15-30 minutes for adults with signs of hypoperfusion 2
• For septic patients specifically, one protocol uses 20 mL/kg bolus over the first 2 hours, followed by 2-3 mL/kg/hour for the remainder of the first 24 hours 1
• Reassess hemodynamic status after each bolus before administering additional fluid 2, 4

Dividing the Total Volume

• The 30 mL/kg can be given as repeated boluses rather than as a continuous infusion, allowing for reassessment between boluses 1, 2
• Administer 500-1000 mL boluses and repeat based on response, rather than giving the entire calculated volume at once 2

Reassessment Parameters After Each Bolus

Evaluate the following clinical markers to determine if additional fluid is needed: 2, 4

• Heart rate and blood pressure (target MAP ≥65 mm Hg) 1
• Respiratory rate and work of breathing 2
• Skin perfusion and capillary refill time 2
• Urine output (target >0.5 mL/kg/hour) 2, 5
• Mental status changes 4
• Serum lactate levels if available (aim for 20% reduction if elevated) 1, 2

When to Stop Fluid Administration

Discontinue further boluses when: 2, 4

• No improvement in tissue perfusion occurs after a bolus 2, 4
• Signs of fluid overload develop (pulmonary edema, jugular venous distension, new or worsening respiratory distress) 1, 2
• Hemodynamic parameters stabilize (MAP ≥65 mm Hg, improved perfusion markers) 4

Special Populations

Elderly or Cardiac Dysfunction

• Use smaller boluses of 250-500 mL administered over 15-30 minutes with more frequent reassessment 2
• Monitor closely for signs of volume overload as these patients tolerate aggressive fluid resuscitation poorly 2

Acute Pancreatitis

• Aggressive fluid administration (>10 mL/kg/hour) is associated with increased complications including abdominal compartment syndrome and pulmonary edema 1, 5
• Consider a more conservative approach with 10 mL/kg bolus over 2 hours, then 1.5 mL/kg/hour 1

Common Pitfalls to Avoid

• Do not order continuous fluids without specifying reassessment intervals, as this leads to fluid overload 4
• Do not use normal saline exclusively throughout the resuscitation period 4
• Do not delay vasopressor initiation if the patient remains hypotensive despite initial fluid resuscitation—consider earlier vasopressor use rather than continuing aggressive fluid administration 2, 4
• The 30 mL/kg is a starting point, not a mandatory target—some patients will require more fluid, while others (particularly those with severe illness) may experience worse outcomes with aggressive fluid administration 6