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Fluid Choice and Blood Products

Early fluid administration is more important than type of fluid1-3

Fluids

Bolus amount

Considerations

Cautions

Refs

Noraml saline

20-30 mL/kg

First line

 

1

Lactated ringers

20-30 mL/kg

Alternative first line

Risk of increased ICP (slightly hypotonic)and microthromboses (Ca2+ can activate clotting cascade) Avoid/use with caution if hyperkalemia, AKI, or known kidney disease

7, 8

5% albumin

( > 44 wks CGA)

10-20 mL/kg

Consider if:

Poor response to crystalloid 60 mL/kg

Albumin < 3 mg/dL
Chloride > 110 mEq/L

 

4, 5, 6

 

Blood products

Fluids

Considerations

Cautions

Refs

PRBC

Consider if:

Hgb < 10 and ongoing shock with sScvO2 < 70%, lactate > 4 mmol/dL

Patients not in shock may tolerate lower Hgb (target=7 gm/dL)

Monitor for anaphylaxis

1, 2, 12

FFP

Consider if:

Invasive procedure and INR/PTT elevated or DIC with active bleeding

 

1, 10

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, 10, 11


References for fluid resuscitation

  1. Dellinger et al, CCM, 2008 (Surviving Sepsis Campaign)

  2. Rivers et al, NEJM, 2001

  3. Han et al, Pediatrics, 2003

  4. Vincent & Gottin, Minerva Anestesiol, 2011

  5. Finfer et al, NEJM, 2004 (SAFE Study)

  6. Dubois et al, CCM, 2006

  7. Tommasino et al, CCM, 1988

  8. Kiraly et al, J Trauma, 2006

  9. Hartog et al, Anesth Analg, 2011

  10. Gajic et al, CCM, 2006

  11.     Church et al, PCCM, 2009

  12.     Karam, PCCM, 2011

  13.     Carcillo et al, JAMA, 1991

 

Fluid choices: Adverse affects and cost

Agent

Potential adverse effects

Cost

Normal saline

Hyperchloremic metabolic acidosis

$

Lactated ringers

Metabolic alkalosis, hyperkalemia, increased ICP, microthrombosis

$

Albumin 5%

Allergic reactions, intraventricular hemorrhage (neonates)

$$$$

Courtest of CM Pharmacy Department

 

Reconceptualized from: http://www.chop.edu/clinical-pathway/icu-clinical-pathway-infants-28-days-and-children-severe-sepsisseptic-shock-fluid-0

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.