What initial isotonic crystalloid bolus dose and administration guidelines should be used for an 11‑year‑old (≈30‑40 kg) in shock?

Initial Fluid Bolus for an 11-Year-Old in Shock

Administer 20 mL/kg of isotonic crystalloid (normal saline or lactated Ringer's solution) as a rapid bolus over 5-10 minutes, with immediate reassessment after each bolus and repeat dosing up to 40-60 mL/kg total in the first hour if shock persists without signs of fluid overload. 1, 2, 3

Fluid Selection

• Use isotonic crystalloid as first-line therapy—either 0.9% normal saline or balanced crystalloids like lactated Ringer's solution 4, 1, 2
• Balanced/buffered crystalloids are preferred over 0.9% saline when available, though both are acceptable 1
• Do not use colloids (albumin) during initial resuscitation—there is no survival benefit and crystalloids are superior 4

Initial Bolus Dose Calculation

• Calculate 20 mL/kg based on actual body weight (for an 11-year-old weighing 30-40 kg, this equals 600-800 mL) 1, 2, 3
• The 30 mL/kg figure cited in some adult sepsis guidelines does not apply to pediatric patients and may lead to fluid overload 3

Administration Technique

• Deliver each 20 mL/kg bolus over 5-10 minutes using rapid push or pressure bag infusion 4, 1, 2
• If peripheral IV access cannot be established within minutes, immediately place intraosseous (IO) access rather than delaying resuscitation 4, 1, 2

Mandatory Reassessment After Each Bolus

You must reassess immediately after every single bolus before giving additional fluid. 1, 2, 3 Look for:

Signs of Positive Response (Continue Fluid):

• Heart rate decreasing toward normal for age 2, 3
• Improved mental status and alertness 2, 3
• Capillary refill improving to ≤2 seconds 4, 2
• Peripheral pulses strengthening and becoming equal to central pulses 4, 2
• Extremities warming with improved skin color 2, 3
• Blood pressure normalizing (systolic BP should be ≥70 + [2 × age in years] mmHg) 3
• Urine output increasing toward >1 mL/kg/hour 4, 2

Critical Stop Signs (Cease Fluid Immediately):

• New or worsening pulmonary rales/crackles 4, 2
• Development of hepatomegaly 4, 2
• Gallop rhythm on cardiac auscultation 4, 2
• Increased work of breathing 1, 2
• Worsening oxygen saturation 2

Repeat Boluses and Total Volume Limits

• If shock persists after the initial 20 mL/kg bolus, give additional 20 mL/kg boluses with reassessment between each 1, 2, 3
• Children commonly require 40-60 mL/kg total in the first hour (meaning 2-3 boluses of 20 mL/kg each) 4, 1, 2
• Up to 200 mL/kg total may be required in some cases if signs of fluid overload remain absent 4
• This aggressive approach is only appropriate in settings with intensive care availability—in resource-limited settings without ICU access, maximum 40 mL/kg should be given with extreme caution 4, 1

Transition to Vasoactive Support

If shock persists after 40-60 mL/kg of fluid without signs of fluid overload, initiate inotropic support rather than continuing fluid boluses. 4, 2, 3 This is a critical decision point:

• Begin peripheral inotrope infusion (low-dose dopamine or epinephrine) through a second peripheral IV/IO line while establishing central venous access 4, 2
• Once central access is secured, use central dopamine, epinephrine (for cold shock with poor perfusion), or norepinephrine (for warm shock with vasodilation) 4
• Delaying inotropic support in fluid-refractory shock significantly increases mortality 3

Common Pitfalls to Avoid

• Do not rely solely on blood pressure to guide therapy—children maintain blood pressure through compensatory mechanisms until cardiovascular collapse is imminent, so assess perfusion parameters comprehensively 2, 3
• Do not continue fluid boluses without reassessing for overload after each one—this is associated with increased mortality 2, 5
• Do not use hypotonic fluids for shock resuscitation 2
• Do not give maintenance fluids during active resuscitation—use bolus therapy until perfusion normalizes, then transition to maintenance 4
• Do not use etomidate for intubation in septic shock—it is associated with higher mortality due to adrenal suppression 4

Special Considerations

• If the child has underlying cardiac, renal, or hepatic disease, use smaller initial boluses (10 mL/kg) with more frequent reassessment 1
• If pneumonia is present, rales may not indicate fluid overload—proceed with careful monitoring of work of breathing and oxygen saturation 4
• Correct hypoglycemia and hypocalcemia during resuscitation 4

The evidence strongly supports this aggressive but carefully monitored approach in resource-rich settings, 4, 1, 2 though the FEAST trial 6 demonstrated harm from fluid boluses in African children without ICU availability, emphasizing the critical importance of reassessment and access to advanced support.