What is the recommended bolus calculation for a pediatric patient?

Recommended Fluid Bolus Calculation for Pediatric Patients

For pediatric patients requiring fluid resuscitation, administer isotonic crystalloid (0.9% NaCl) boluses of 20 mL/kg, which can be repeated up to 60 mL/kg in the first hour based on clinical response. 1

Initial Fluid Selection and Administration

• Use isotonic crystalloid solutions (e.g., normal saline or lactated Ringer's) as the first-choice fluid for initial resuscitation in pediatric patients 1
• Calculate the initial fluid bolus based on the child's weight at 20 mL/kg 1
• Administer fluid boluses rapidly using either:
  • Pressure bag maintained at 300 mmHg 2
  • Manual push-pull system 2
  • Avoid gravity-based administration as it delivers fluid too slowly to meet resuscitation goals 2

Fluid Administration Technique

• For shock states, deliver each 20 mL/kg bolus over 5-10 minutes 1, 3
• For children with septic shock, consider administering each 20 mL/kg bolus over 15-20 minutes to potentially reduce the risk of requiring mechanical ventilation 3
• For children weighing >40 kg, be aware that achieving the recommended rapid infusion rates may be more challenging 2

Monitoring Response and Additional Boluses

• Reassess the patient after each fluid bolus to evaluate response and prevent fluid overload 4
• Look for positive response indicators including:
  • ≥10% increase in systolic/mean arterial blood pressure
  • ≥10% reduction in heart rate
  • Improvement in mental status, peripheral perfusion, and urine output 4
• Continue fluid administration with additional 20 mL/kg boluses as long as there is hemodynamic improvement without signs of fluid overload 1, 4
• Watch for signs of fluid overload including development of increased work of breathing, rales, gallop rhythm, or hepatomegaly 1

Special Considerations for Different Clinical Scenarios

• For hypovolemic shock: Administer up to 60 mL/kg in the first hour if needed, with repeated 20 mL/kg boluses 1
• For septic shock: Consider administering up to 40-60 mL/kg in the first hour, titrated to response 1, 3
• For gastroenteritis with dehydration: Consider using 5% dextrose in normal saline for the 20 mL/kg bolus to help reduce ketosis, though this may not affect hospitalization rates 5
• For trauma patients: Use 20 mL/kg boluses of isotonic crystalloid and involve a qualified surgeon early 1

Intravenous Access Considerations

• If peripheral IV access cannot be established quickly, use intraosseous (IO) access for fluid administration 1
• Central venous access may be used but be aware that resistance in longer catheters may make rapid bolus administration more difficult 1

Pitfalls to Avoid

• Avoid using hypotonic solutions for initial resuscitation as they can worsen hyponatremia 1
• Don't use etomidate for sedation during intubation in patients with septic shock as it's associated with higher mortality rates 1
• Don't rely on gravity-based fluid administration during acute resuscitation as it delivers fluid too slowly 2
• Avoid delaying fluid resuscitation while waiting for central access; use peripheral or IO access immediately 1