Max 1000 mg/dose · Duration: 5–20 min · 10–20 mL/kg over 5–20 min (calculator: mL = 10–20 × weight kg) — reassess perfusion immediately after; repeat only if shock persists (SSC pediatric 2020, AAP PALS, WHO ETAT, NICE NG84)
• **Initial bolus:** **10–20 mL/kg** isotonic crystalloid over **5–20 min** (calculator: mL = 10–20 × weight kg per bolus) — SSC pediatric and PALS recommend 10–20 mL/kg with reassessment between boluses; NICE NG84 uses 20 mL/kg over 15 min for shocked gastroenteritis (SSC 2020, AAP PALS 2024, WHO ETAT 2022, NICE NG84).
• **Repeat boluses:** give additional **10–20 mL/kg** only if **shock/poor perfusion persists** after each bolus — **reassess clinically** (HR, CRT, BP, mental status, urine output, lung exam) before every repeat; do NOT give blind serial boluses without reassessment (SSC pediatric, AAP PALS, ERC).
• **Cumulative first-hour maximum:** up to **40–60 mL/kg** cumulative crystalloid in the **first hour** with reassessment — document total volume given; beyond this without improvement = **fluid-refractory shock** → start **vasopressors** (epinephrine or norepinephrine per PALS) and treat underlying cause; avoid ongoing fluid overload (SSC pediatric 2020, AAP PALS, WHO ETAT).
• **NOT for routine dehydration:** uncomplicated moderate dehydration **without shock** — **no empiric bolus**; use dehydration card for isotonic maintenance + deficit over 24–48 h (ESPGHAN 2014, WHO 2022, NICE NG84). For **sepsis antibiotics and source control**, see sepsis/infection cards — this card covers volume resuscitation only.
• **Balanced vs 0.9% NaCl:** balanced crystalloids (Plasma-Lyte, Hartmann's) acceptable alternative to 0.9% NaCl at **same volumes** — may reduce hyperchloremic acidosis with large volumes; local formulary availability determines choice (SSC pediatric, pediatric critical care evidence, WHO).
Max 1000 mg/dose · Duration: 5–20 min · Same 10–20 mL/kg volumes as 0.9% NaCl (calculator: mL = 10–20 × weight kg) — Plasma-Lyte or Hartmann's/Ringer lactate per formulary (SSC pediatric, pediatric evidence)
• Balanced crystalloids: acceptable first-line alternative to 0.9% NaCl for shock boluses — identical volume principles; consider in prolonged resuscitation or hyperchloremia concern (SSC pediatric, pediatric critical care).
• Fluid-refractory shock: persistent poor perfusion after **40–60 mL/kg** in first hour — start **vasopressor infusion** (epinephrine or norepinephrine per PALS), obtain central access, treat cause; **do NOT** continue large-volume boluses without hemodynamic response (SSC 2020, AAP PALS, WHO ETAT).
• Sepsis pathway: bolus is one component — **early broad-spectrum antibiotics** and source control are concurrent priorities; see infection/sepsis cards for antimicrobial therapy (SSC pediatric 2020, AAP).
• Dehydration without shock: use **dehydration card** for isotonic maintenance + deficit replacement over 24–48 h — **no routine bolus** (ESPGHAN 2014, WHO 2022, NICE NG84).
• Hemorrhagic shock: prioritize **blood products** over repeated crystalloid — trauma team activation; crystalloid bolus only as bridge (ATLS, ERC, PALS).
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Clinical notes
• Bolus indications: give isotonic crystalloid bolus for **shock** or **poor perfusion** (prolonged CRT, weak pulses, cool extremities, altered mental status ± hypotension) — septic shock, hypovolemic shock, anaphylactic shock (after adrenaline), hemorrhagic shock (with blood products); **NOT** for uncomplicated dehydration without perfusion compromise — use dehydration card (SSC pediatric 2020, ESPGHAN, WHO ETAT, AAP PALS, NICE).
• Reassess after each bolus: check **HR, CRT, BP, mental status (AVPU), peripheral perfusion, urine output, and lung auscultation** before every repeat bolus — clinical response guides next step; absence of improvement after adequate volume = fluid-refractory shock (SSC pediatric, AAP PALS, ERC, WHO ETAT).
• Signs of fluid overload: **hepatomegaly**, **new/worsening rales/crackles**, **gallop rhythm**, **jugular venous distension**, **worsening respiratory distress**, **hypertension** (in some contexts), **widening pulse pressure** — stop boluses and reassess for cardiogenic or fluid-refractory shock; consider echo and PICU (SSC pediatric, AAP PALS, pediatric critical care).
• Fluid-refractory shock: after **40–60 mL/kg** cumulative crystalloid in first hour without adequate perfusion, start **vasopressors** (epinephrine or norepinephrine per PALS) rather than continuing blind fluid boluses — treat underlying cause (sepsis, hemorrhage, cardiac); document fluid balance (SSC pediatric 2020, AAP PALS, WHO ETAT, ERC).
• PICU consult: fluid-refractory shock, need for vasopressor/inotrope infusion, suspected cardiogenic shock, signs of fluid overload, altered consciousness not improving, need for invasive monitoring, or complex resuscitation — early PICU/anesthesia involvement (SSC pediatric, AAP PALS, NICE, WHO ETAT).
• Surviving Sepsis Campaign — International guidelines for management of septic shock and sepsis-associated organ dysfunction in children (fluid resuscitation) (2020)
• AAP — Pediatric Advanced Life Support (PALS) shock and fluid resuscitation (2024)
• ERC — European Resuscitation Council Guidelines (pediatric life support and shock) (2021)
+ 4 more
• WHO — Emergency Triage Assessment and Treatment (ETAT) — shock management (2022)
• WHO — Pocket Book of Hospital Care for Children (IV fluid resuscitation) (2022)
• NICE NG84 — Intravenous fluid therapy in children with gastroenteritis (shock bolus) (2017)
• ESPGHAN / NASPGHAN — Acute gastroenteritis (no routine bolus without shock) (2014)
