Pediatric Fluid Bolus Dosing
The standard initial fluid bolus for pediatric patients requiring fluid resuscitation is 20 mL/kg of isotonic crystalloid, not 30 mL/kg. 1, 2
Initial Bolus Dose
- Administer 20 mL/kg of isotonic crystalloid (0.9% normal saline or lactated Ringer's) as the initial fluid bolus for pediatric patients in shock or requiring fluid resuscitation 3, 1, 2
- Each 20 mL/kg bolus should be delivered over 5-10 minutes 1, 2
- The 30 mL/kg figure mentioned in the question is not supported by current guidelines and exceeds standard recommendations
Reassessment and Repeat Boluses
- Reassess the patient immediately after each 20 mL/kg bolus to determine need for additional fluid versus transition to inotropic support 1, 2
- Children commonly require 40-60 mL/kg total in the first hour (meaning 2-3 boluses of 20 mL/kg each) 1, 4
- Up to 60 mL/kg can be administered in the first hour based on clinical response and absence of fluid overload signs 1, 2
- Some children may require up to 200 mL/kg during initial resuscitation in severe shock states, though this is uncommon 1
Signs of Positive Response
Look for these indicators after each bolus to guide further fluid administration: 4
- Heart rate reduction
- Improved mental status and clearing sensorium
- Return of peripheral pulses with capillary refill ≤2 seconds
- Normal skin color and warm extremities
- Increased blood pressure to normal for age
- Increased urine output (goal >1 mL/kg/h)
Critical Stop Points - When to Cease Fluid Boluses
Immediately stop fluid administration if any of these signs of fluid overload develop: 1, 2
- New onset rales/crackles on lung auscultation
- Hepatomegaly
- Increased work of breathing or worsening hypoxemia
- Gallop rhythm on cardiac examination
Transition to Inotropic Support
- If shock persists after 40-60 mL/kg of fluid without signs of fluid overload, initiate inotropic support (dopamine or epinephrine) rather than continuing fluid boluses 1, 4
- Fluid-refractory shock requires vasopressor/inotrope therapy, not additional fluid 1
- Delaying inotropic support in fluid-refractory shock significantly increases mortality 1
Hemodynamic Stability Definitions in Pediatrics
For pediatric patients, hemodynamic stability is defined as: 3
- Systolic blood pressure of 90 mmHg plus twice the child's age in years
- Lower limit of normal is 70 mmHg plus twice the child's age in years
- Positive response to fluid resuscitation demonstrated by the clinical signs listed above
Common Pitfalls to Avoid
- Do not use 30 mL/kg as the initial bolus dose - this exceeds guideline recommendations and may lead to fluid overload 1, 2
- Do not rely on blood pressure alone as children maintain blood pressure through vasoconstriction and tachycardia until cardiovascular collapse is imminent 1
- Do not continue fluid boluses in the presence of hepatomegaly or rales - this mandates immediate cessation and initiation of inotropic support 1
- Do not use hypotonic solutions for initial resuscitation as they can worsen hyponatremia 2
- Do not delay fluid administration while attempting central access - use peripheral or intraosseous access immediately 2