What is the recommended bolus dose of intravenous (IV) fluids for a 15-month-old patient requiring fluid resuscitation?

IV Fluid Bolus Dose for a 15-Month-Old

Administer 20 mL/kg of isotonic crystalloid (0.9% normal saline or lactated Ringer's) as the initial bolus, delivered over 15-20 minutes, with mandatory reassessment after each bolus. 1, 2, 3, 4

Initial Bolus Specifications

• Volume: 20 mL/kg based on actual body weight 1, 2, 3, 4
• Fluid type: Isotonic crystalloid—either 0.9% normal saline or balanced crystalloids like lactated Ringer's solution 1, 2, 3, 4
• Administration time: 15-20 minutes per bolus (NOT 5-10 minutes) 5
  • Delivering boluses over 15-20 minutes reduces the risk of mechanical ventilation by 38% compared to 5-10 minute boluses 5
  • The faster administration (5-10 minutes) increases risk of fluid overload and respiratory compromise 5

Practical Delivery Methods

• Use either a pressure bag (maintained at 300 mmHg) or manual push-pull technique to achieve guideline-adherent delivery 6
• Gravity administration is inadequate for acute resuscitation and should not be used 6
• If peripheral IV access cannot be established quickly, use intraosseous (IO) access immediately rather than delaying resuscitation 3, 4

Mandatory Reassessment After Each Bolus

You must reassess after every single bolus before giving additional fluid. 1, 2, 3, 4

Signs of positive response:

• Increased systolic/mean arterial blood pressure 2, 3, 4
• Decreased heart rate 1, 2, 3
• Improved mental status 2, 3, 4
• Capillary refill ≤ 2 seconds 1, 2
• Improved peripheral perfusion (warm extremities) 1, 2
• Increased urine output (goal >1 mL/kg/hr) 1

Signs requiring immediate cessation (fluid overload):

• Increased work of breathing 1, 2
• New or worsening pulmonary rales/crackles 1, 2, 4
• Development of gallop rhythm 1, 4
• Hepatomegaly 1

Subsequent Boluses

• If shock persists after initial 20 mL/kg bolus, give additional 20 mL/kg boluses with reassessment between each 1, 2, 3, 4
• Total volume in first hour: Up to 40-60 mL/kg can be administered in settings with intensive care availability 1, 2, 3, 4
• Children commonly require 40-60 mL/kg in the first hour for septic shock 1
• Each subsequent bolus should also be delivered over 15-20 minutes 5

Critical Volume Ceiling

Never exceed 60 mL/kg/day of crystalloid resuscitation, as volumes beyond this threshold are associated with significantly worse outcomes 2, 3

Special Considerations for a 15-Month-Old

At 15 months, the average weight is approximately 10-12 kg, meaning:

• Initial bolus: 200-240 mL over 15-20 minutes 1, 2, 3
• Maximum first hour: 400-720 mL (if 40-60 mL/kg needed) 1, 2, 3

Fluid Type Selection Nuance

• Balanced crystalloids (lactated Ringer's) are preferred over 0.9% saline when available, as they reduce the risk of acute kidney injury by 38% and decrease hyperchloremia 7, 3
• However, both are acceptable and effective for initial resuscitation 1, 2, 3, 4
• 5% albumin can be considered as second-line if requiring large crystalloid volumes or refractory shock 1

Common Pitfalls to Avoid

• Do not administer boluses over 5-10 minutes despite older recommendations—this increases mechanical ventilation risk 5
• Do not use gravity administration for acute resuscitation—it delivers inadequate volumes 6
• Do not skip reassessment between boluses—this is the most critical step to prevent fluid overload 1, 2, 3, 4
• Do not use hypotonic solutions for resuscitation—only isotonic crystalloids are appropriate 2