What is the recommended dose and rate of normal saline (NS) bolus for a 7-year-old child weighing 23 kg with ruptured appendicitis, fever, tachycardia, and hypotension?

Fluid Resuscitation for Pediatric Septic Shock with Ruptured Appendicitis

Administer 20 mL/kg boluses of normal saline (460 mL for this 23 kg child), given rapidly over 5-15 minutes, with mandatory reassessment after each bolus, and be prepared to give up to 40-60 mL/kg total (920-1380 mL) in the first hour if intensive care is available. 1, 2

Initial Bolus Strategy

• Start with 20 mL/kg (460 mL) as the first bolus, which is the standard pediatric resuscitation dose for septic shock 1, 2, 3
• Administer this bolus rapidly over 5-15 minutes using either a pressure bag at 300 mmHg or manual push-pull technique 4
• Gravity administration is inadequate for acute resuscitation and should not be used 4

Sequential Bolus Administration

• After the first 20 mL/kg bolus, immediately reassess for clinical markers of cardiac output: heart rate, blood pressure, capillary refill time, mental status, and urine output 1, 2
• If signs of shock persist (ongoing tachycardia, hypotension, poor perfusion), give a second 20 mL/kg bolus (another 460 mL) 1, 2
• Continue with additional 10-20 mL/kg boluses as needed, up to a total of 40-60 mL/kg in the first hour 1, 2
• For this 23 kg child, the maximum first-hour volume would be 920-1380 mL total 1, 2

Fluid Type Selection

• Use 0.9% normal saline as the initial resuscitation fluid 2, 3
• Balanced/buffered crystalloids (Ringer's lactate) are preferred when available, as they reduce the risk of acute kidney injury compared to normal saline 1, 2
• Avoid albumin for initial resuscitation due to cost and lack of outcome benefit 1
• Never use starches or gelatin in pediatric septic shock 1

Critical Reassessment Protocol

Stop fluid boluses immediately if any signs of fluid overload develop: 1, 2

• New or worsening hepatomegaly
• Clinical signs of pulmonary edema (increased work of breathing, crackles, oxygen desaturation)
• Worsening respiratory status

Rate of Administration

• Administer each 20 mL/kg bolus over 5-15 minutes to achieve rapid hemodynamic improvement 1, 4
• The 2002 ACCM guidelines recommend completion within 5 minutes when possible, which is feasible for children under 40 kg using pressure bags or push-pull systems 4
• For this 23 kg child, a 5-minute administration is achievable and appropriate 4

Common Pitfalls to Avoid

• Do not use maintenance fluid rates for resuscitation - this child needs rapid boluses, not slow infusions at 65 mL/hour 3, 5
• Do not stop after one bolus - most children with septic shock require 2-3 boluses (40-60 mL/kg total) to achieve hemodynamic stability 1, 2
• Do not exceed 60 mL/kg total in the first hour without advanced hemodynamic monitoring, as volumes beyond this are associated with worse outcomes 2
• Do not delay bolus administration to calculate exact volumes - round to practical volumes (460 mL ≈ 500 mL is acceptable) 3

Special Considerations for Ruptured Appendicitis

• This child has septic shock from an intra-abdominal source requiring urgent source control (appendectomy) 1
• Aggressive fluid resuscitation is essential before surgical intervention 1
• The presence of fever, tachycardia, and "soft BP" (hypotension) indicates severe septic shock requiring immediate intervention 1, 2
• For a 7-year-old, hypotension is defined as systolic BP <84 mmHg (70 + [2 × 7]) 3

Monitoring During Resuscitation

• Establish continuous vital sign monitoring including heart rate, blood pressure, and oxygen saturation 3
• Measure lactate levels to guide resuscitation adequacy 1
• Expect heart rate to decrease by approximately 6 beats per minute and lactate to decrease by 0.2 mmol/L with effective fluid resuscitation 6
• Consider advanced hemodynamic monitoring (cardiac output, ScvO2) if available to guide further therapy 1

After Initial Resuscitation

• Once hemodynamic stability is achieved, transition to maintenance fluids at 65 mL/hour for this 23 kg child (calculated as 40 + 20 + 3 mL/hour) 5
• Continue to replace ongoing losses from fever, surgical drains, or continued sepsis 5
• Broad-spectrum antibiotics must be administered within the first hour alongside fluid resuscitation 1