The type of fluid solution does not seem to influence the ability of fluids to improve perfusion, organ function, and outcome. Dr. McLaughlin recommended using normal saline or lactated Ringer's solution instead of 5% albumin, which has not been shown to be decidedly better than saline.
Titrate to Symptoms
The important point to remember is to titrate to effect, he said. This means that the patient's feet and hands should get warmer, his blood pressure should come up, his heart rate should go down, and his capillary refill time should be more normal – although not necessarily faster or slower because some kids have a really brisk capillary refill rate, he said. Clinicians also should titrate to symptoms, which involves feeling a patient's liver.
“If you're giving fluids to the point you're getting hepatomegaly, then you've probably reached your fluid limit for that patient,” Dr. McLaughlin said. “If you're getting more tachycardia as you give more fluids, that should cause you to pause and … shift your therapy.”
Various inotropes can be used for septic shock, and Dr. McLaughlin recommended that clinicians use the one they are most familiar with. In the general pediatric population, that typically means starting out with dopamine and epinephrine, he said, adding that dobutamine and milrinone “could get you into trouble.”
Antibiotic therapy should address the specific epidemiology of the patient population: ceftriaxone for community-acquired pediatric sepsis; ampicillin with gentamicin or cefotaxime, or cefotaxime for neonates; and ceftazidime with or without vancomycin for patients with neutropenia and central venous access.
“What I see too many times is that patients get assessed, plans get started, and then for an hour and a half no one's gone back to look at that kid again,” Dr. McLaughlin said. “That's not okay. You have to stay on top of these kids because time matters. An hour matters.”
He observed that hospitalists are in a unique position to affect sepsis outcomes because they have early access to patients. He also pointed out that 50% of patients with sepsis have chronic disease, SIRS is present in 7% of hospitalized patients, and sepsis is a quality indicator.