What is the INITIAL intravenous fluid bolus dose and type recommended for a child in hypovolemic shock?

Explanation

## Initial Fluid Resuscitation in Pediatric Hypovolemic Shock **Key Point:** The gold standard initial bolus is **20 mL/kg of isotonic crystalloid** administered over 15–20 minutes, which can be repeated up to 60 mL/kg if shock persists. ### Fluid Bolus Protocol | Parameter | Recommendation | Rationale | |-----------|----------------|----------| | **Fluid type** | Isotonic crystalloid (0.9% NS or Ringer's lactate) | Restores intravascular volume; balanced electrolytes | | **Initial dose** | 20 mL/kg | Addresses acute hypovolemia without fluid overload | | **Infusion time** | 15–20 minutes | Rapid but controlled; allows reassessment | | **Repeat bolus** | May repeat × 2–3 if shock persists | Up to 60 mL/kg total; then reassess for blood products | | **Monitoring** | Reassess perfusion, HR, BP, urine output after each bolus | Guides need for additional fluids or vasopressors | **High-Yield:** After 40–60 mL/kg of crystalloid without improvement, suspect ongoing hemorrhage or sepsis requiring blood products or vasopressors. Do NOT delay blood transfusion in hemorrhagic shock. ### Why Isotonic Crystalloid? - **Normal saline (0.9%):** Physiologic osmolality; no hyperchloremic acidosis risk - **Ringer's lactate:** Balanced electrolytes; lactate metabolized to bicarbonate (buffering) - **Avoid hypotonic fluids (D5W, 0.45% NS):** Risk of cerebral edema and hyponatremia - **Avoid hypertonic saline (3%):** Reserved for specific settings (cerebral edema, hypernatremia); not first-line for hypovolemic shock **Clinical Pearl:** In hemorrhagic shock, if crystalloid alone is insufficient (>40–60 mL/kg), initiate **massive transfusion protocol** with packed RBCs and fresh frozen plasma (1:1 ratio in pediatrics, moving toward 1:1:1 with platelets). **Mnemonic:** **CRISP** for fluid resuscitation: - **C**rystalloid (isotonic) - **R**apid infusion (15–20 min) - **I**nitial dose 20 mL/kg - **S**hock reassessment after each bolus - **P**rogression to blood products if needed