There were not a lot of big changes in the 2015 AHA PALS recommendations. Nevertheless I did want to touch briefly on a few issues raised in the update, which you should all read. You can check out the full pdf here.
Fluid restriction in sepsis?
You may recall a paper from NEJM in 2011 that initially randomized children with severe hypotension in Uganda, Kenya, or Tanzania to albumin, saline or no fluids. Along the way the investigators noted that in this population of children, 57% of which had malaria, that fluid resuscitation was associated with increased 48 hour mortality.
- Saline bolus vs. control: RR=1.44 (95% CI, 1.09 to 1.90) P=0.01
- Albumin bolus vs. saline bolus: RR=1.01 (95% CI, 0.78 to 1.29) P = 0.96
- Any bolus vs. control: RR=1.45 (95% CI, 1.13 to 1.86) P = 0.003
Additionally, the 4-week mortality was 12.2%, 12.0%, and 8.7% in the three groups, respectively (P=0.004 for the comparison of bolus with control).
So does this mean we should fluid restrict in sepsis now? Well, not so fast. A resource limited setting is kind of hard to define – but generally includes places without access to mechanical ventilation and/or inotropic drugs. Also, how does one paper refute what we’ve learned about aggressive fluid resuscitation in sepsis? In the 2015 update the authors provided a handy table that summarizes the evidence from a number of perspectives.
So, what does this mean for us in the ED? Well, if the child is in shock, and that shock is hypovolemic and/or distributive then the first treatment is fluids. Both crystalloids and colloids can be used – most important is that they are isotonic. Give 20mL/kg boluses, continue to reassess for their effect – specifically with regard to hemodynamic parameters both measured directly and indirectly. These signs include, but are not limited to:
- Heart rate
- Capillary refill
- Jugular venous pulsations
- Lung findings and work of breathing
- Blood pressure
Though not explicitly mentioned in the AHA PALS paper, use of ultrasound to assess the IVC can also guide further fluid resuscitation. In general, if you work somewhere where you have access to mechanical ventilation and inotropes bolus up to 60mL/kg and beyond if needed, use vasopressors (epinephrine or norepinephrine depending on your access) to restore oxygen delivery (via better perfusion) to essential tissues.