What is the proper fluid resuscitation dose in pediatric (peds) patients, is 30 milliliters per kilogram (ml/kg) appropriate?

From the Guidelines

The appropriate fluid resuscitation dose for pediatric patients is typically 20 ml/kg of isotonic crystalloid solution, which can be repeated up to 60 ml/kg if needed based on reassessment, as a 30 ml/kg bolus is generally considered too aggressive for initial resuscitation in most pediatric patients. This recommendation is based on the most recent and highest quality study available, which suggests administering up to 40–60 mL/kg in bolus fluid (10–20 mL/kg per bolus) over the first hour, titrated to clinical markers of cardiac output and discontinued if signs of fluid overload develop, for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction 1.

Key Considerations

• The initial fluid volume should be 10–20 ml/kg, with repeated doses based on individual clinical response 1.
• Children can rapidly develop fluid overload, which may lead to complications such as pulmonary edema, making a cautious approach essential.
• In cases of severe shock or specific conditions like sepsis, higher volumes may be required, but this should be done with careful monitoring.
• Crystalloids, rather than albumin, are suggested for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction 1.
• Balanced/buffered crystalloids, rather than 0.9% saline, are suggested for the initial resuscitation of children with septic shock or other sepsis-associated organ dysfunction 1.

Monitoring and Adjustments

• After each 20 ml/kg bolus, the child should be reassessed for signs of improved perfusion, including heart rate, capillary refill, mental status, blood pressure, and urine output.
• The need for fluid administration should be guided by frequent reassessment of clinical markers of cardiac output, serial blood lactate measurement, and advanced monitoring, when available 1.
• Signs of fluid overload, such as clinical signs of pulmonary edema or new or worsening hepatomegaly, should limit further fluid bolus therapy.

From the Research

Proper Fluid Resuscitation in Pediatric Patients

The proper fluid resuscitation dose in pediatric patients is a critical aspect of managing septic shock and other conditions. According to the available evidence:

• The American College of Critical Care Medicine guidelines suggest administering 20 mL/kg of bolus intravenous fluid within 5 minutes 2.
• A study comparing balanced versus unbalanced fluid resuscitation in critically ill children found that the ideal choice of crystalloid remains to be determined, but balanced fluids like Ringer's lactate may be associated with more favorable outcomes 3.
• Research on hypertonic versus normal saline as initial fluid bolus in pediatric septic shock found that both were equally effective in restoring hemodynamic stability 4.
• Early fluid resuscitation in pediatric septic shock is crucial, with rapid administration of fluids in excess of 40 mL/kg in the first hour associated with improved survival 5.
• The use of hypotonic fluids for pediatric patients in ED and prehospital settings is not recommended, as it can contribute to fatal outcomes 6.

Key Findings

• The recommended initial fluid bolus for pediatric septic shock is 20 mL/kg 2.
• Fluid resuscitation should be tailored to the individual patient's needs, with ongoing assessment of hemodynamic stability and adjustment of fluid administration as needed.
• Balanced fluids like Ringer's lactate may be a better choice than unbalanced fluids like 0.9% saline, but more research is needed to determine the optimal fluid choice 3.
• Hypertonic saline may be a promising fluid for resuscitation of septic shock, but more studies are needed to confirm its efficacy 4.
• Rapid fluid resuscitation is critical in pediatric septic shock, with improved survival associated with administration of fluids in excess of 40 mL/kg in the first hour 5.
• Hypotonic fluids should be avoided in pediatric patients due to the risk of fatal outcomes 6.

Fluid Resuscitation Dose

• The initial fluid bolus dose for pediatric septic shock is typically 20 mL/kg 2.
• However, the total fluid dose may vary depending on the patient's response to initial resuscitation and ongoing hemodynamic stability.
• Some studies suggest that administration of fluids in excess of 40 mL/kg in the first hour may be associated with improved survival 5.
• The dose of 30 mL/kg mentioned in the question is not specifically supported by the available evidence, but it may be within the range of acceptable doses depending on the individual patient's needs.