Do pediatric patients with sepsis require an initial fluid bolus of 30 ml/kg of crystalloids (e.g. normal saline or lactated Ringer's solution) for resuscitation?

Fluid Resuscitation in Pediatric Sepsis

For pediatric patients with sepsis, the recommended initial fluid bolus is 10-20 mL/kg of crystalloids (up to a total of 40-60 mL/kg in the first hour), titrated to clinical response and discontinued if signs of fluid overload develop. 1

Initial Fluid Resuscitation Approach

In Healthcare Systems with ICU Availability:

• Administer crystalloid fluid boluses of 10-20 mL/kg, up to a total of 40-60 mL/kg in the first hour 1
• Each bolus should be given over 5-15 minutes and followed by reassessment 2
• Titrate to clinical markers of cardiac output and discontinue if signs of fluid overload develop 1

In Healthcare Systems without ICU Availability:

• If hypotension is present: Administer up to 40 mL/kg total (10-20 mL/kg per bolus) over the first hour 1
• If hypotension is absent: Avoid bolus fluid administration and start maintenance fluids only 1

Clinical Markers for Assessment and Titration

• Monitor heart rate, blood pressure, capillary refill time, level of consciousness, and urine output 1
• Use serial blood lactate measurements to guide resuscitation 1
• Watch for signs of fluid overload: pulmonary edema or new/worsening hepatomegaly 1

Type of Fluid

• Use crystalloids rather than albumin for initial resuscitation 1
• Balanced/buffered crystalloids (e.g., Ringer's lactate) are preferred over 0.9% saline 1
• Avoid starches (strong recommendation) and gelatins (weak recommendation) 1

Important Considerations and Caveats

Rate of Administration

• Rapid administration is important but should be balanced with monitoring for fluid overload 2
• Recent evidence suggests that excessively rapid fluid administration rates may be associated with increased odds of mortality, intubation, and need for non-invasive positive pressure ventilation 3
• For children weighing >40 kg, achieving very rapid rates may be challenging with standard equipment 2

Volume Considerations

• While the 2015 Pediatric Life Support recommendations suggested an initial bolus of 20 mL/kg 1, the more recent 2020 Surviving Sepsis Campaign guidelines recommend 10-20 mL/kg per bolus 1
• Historical data from 1991 suggested that volumes >40 mL/kg in the first hour were associated with improved survival without increased risk of pulmonary edema 4
• However, more recent evidence has led to more cautious approaches to fluid administration with emphasis on frequent reassessment 3

Advanced Monitoring

• When available, use advanced hemodynamic variables (cardiac output/index, systemic vascular resistance, central venous oxygen saturation) to guide resuscitation 1
• Trends in blood lactate levels should be used in addition to clinical assessment 1

Common Pitfalls to Avoid

• Failing to reassess after each fluid bolus, which may lead to fluid overload 1
• Using bedside clinical signs in isolation to categorize shock as "warm" or "cold" 1
• Delaying fluid resuscitation in hypotensive patients 1
• Administering fluids by gravity alone, which is too slow for effective resuscitation in most cases 2