Fluid and Inotropic Targets for Pediatric, Adult, and Geriatric Populations
Initial fluid resuscitation should use isotonic crystalloids with boluses of up to 20 mL/kg in pediatric patients and up to 30 mL/kg in adults, titrated to clinical endpoints, followed by inotropic support when fluid-refractory shock persists. 1
Pediatric Fluid Resuscitation Targets
Initial Fluid Therapy
- Administer isotonic crystalloids as first-line fluid therapy 1
- Initial bolus: 20 mL/kg over 5-10 minutes 1
- May repeat up to total of 60 mL/kg (as three 20 mL/kg boluses) with reassessment after each bolus 1
- For children with severe febrile illness in resource-limited settings (without access to mechanical ventilation/inotropes), fluid boluses should be given with extreme caution as they may be harmful 1
Clinical Endpoints for Fluid Resuscitation
- Reversal of hypotension
- Capillary refill ≤2 seconds
- Normal peripheral pulses with no differential between peripheral and central pulses
- Warm extremities
- Urine output ≥1 mL/kg/hr
- Normal mental status
- Absence of hepatomegaly or rales (signs of fluid overload) 1
Advanced Hemodynamic Targets
- ScvO₂ ≥70%
- Cardiac index between 3.3-6.0 L/min/m² 1
Adult Fluid Resuscitation Targets
- Initial crystalloid bolus: 30 mL/kg for septic shock
- Similar clinical endpoints as pediatric patients
- Avoid excessive fluid administration after initial resuscitation to prevent complications
Geriatric Fluid Resuscitation Targets
- Similar initial approach as adults but with more cautious fluid administration
- More frequent reassessment for signs of fluid overload
- Lower threshold for initiating vasopressors/inotropes
Inotropic Support
Pediatric Inotropic Therapy
- Begin peripheral inotropic support until central access is established in fluid-refractory shock 1
- Hemodynamic states in children are heterogeneous and may change over time 2:
- Low cardiac output/high SVR (58% of cases): Use inotropes ± vasodilators
- High cardiac output/low SVR (20% of cases): Use vasopressors
- Combined cardiac and vascular dysfunction (22% of cases): Use combined inotrope and vasopressor therapy 2
Specific Inotrope/Vasopressor Selection
Cold shock (low cardiac index): Epinephrine is first-line 3
Warm shock (low SVR): Norepinephrine is first-line
Normal BP with low cardiac output and high SVR: Add vasodilators to inotropes 1
Inotrope Dosing
- Epinephrine: 0.05-0.3 mcg/kg/min
- Dopamine: >7 mcg/kg/min increases pulmonary vascular resistance 1
- Milrinone: 50 mcg/kg loading dose followed by 0.5 mcg/kg/min infusion 5
- Vasopressin (for refractory shock): 0.01-0.07 units/minute in septic shock 4
Special Considerations
Fluid Type Selection
- Isotonic crystalloids are recommended as initial resuscitation fluid for all age groups 1
- No significant survival difference between colloids and crystalloids in most settings 1
- Avoid hypotonic fluids in maintenance therapy as they increase risk of iatrogenic hyponatremia 6
Fluid Overload Prevention
- Excessive fluid administration is associated with increased mortality in pediatric patients with multi-organ dysfunction 7
- After initial resuscitation, emphasis should shift to inotropic support rather than continued aggressive fluid administration 7
Monitoring Requirements
- Regular reassessment of clinical parameters after each fluid bolus
- Serial assessments to titrate inotropes/vasopressors to optimal hemodynamic results 1
- Monitor for signs of fluid overload: hepatomegaly, rales, increasing oxygen requirement
Pitfalls and Caveats
Persistent shock despite appropriate fluid therapy should prompt consideration of:
Fluid resuscitation in excess of 60 mL/kg often requires inotropic support 1
Children's hemodynamic states can change rapidly - reassess frequently and adjust therapy accordingly 2
In resource-limited settings, aggressive fluid resuscitation without access to mechanical ventilation and inotropic support may be harmful 1