Fluid bolus therapy and vasoactive support — long case

Presentation

A three-year-old weighing 14 kilograms presents to a rural emergency department with fever for 12 hours, poor feeding, lethargy and a purpuric rash. The child is cool and mottled with weak central pulses, a capillary refill of 5 seconds, a heart rate of 175 per minute, a blood pressure of 68/42 mmHg and a reduced conscious state responding to voice. The hospital has intravenous access and crystalloid but no paediatric intensive care or vasoactive agents on site. Retrieval is available but transport time is 90 minutes. [4] [9]

Immediate assessment and first-hour plan

This child is in decompensated septic shock: hypotensive, poorly perfused, with altered consciousness and a purpuric rash suggesting meningococcal disease. I call for senior and retrieval help immediately, name a leader, allocate roles and bring monitoring. I confirm the weight as 14 kilograms for all dose calculations. [4]

Fluid strategy and the FEAST caution

I apply the aliquot-based approach with rigorous reassessment after each bolus. The first-hour ceiling is 40 to 60 mL per kilogram, which I treat as a maximum, not a target. I stop immediately for any sign of overload or no benefit. [2]

In this rural setting, the FEAST evidence is directly relevant. FEAST found that bolus fluid increased mortality in African children with severe febrile illness who did not have access to intensive care rescue. The lesson is not that fluid is universally harmful, but that a fluid algorithm cannot be transplanted without considering the available rescue. Here, without vasoactive agents on site, I am even more vigilant: I give aliquots, reassess after each, and call retrieval early so that vasoactive support can be initiated by the retrieval team if needed. [1] [1]

Transition to vasoactive support

If the child remains in cold shock (cool, mottled, weak pulses, prolonged capillary refill) after 40 mL per kilogram of crystalloid, I start adrenaline at 0.05 to 0.5 micrograms per kilogram per minute. I use central access if immediately available, otherwise intraosseous access. I do not delay the first dose to place a central line. [3]

If the phenotype shifts to warm shock (warm dry skin, bounding pulses, flash capillary refill, wide pulse pressure), I switch to or add noradrenaline at 0.05 to 0.5 micrograms per kilogram per minute. I do not use dopamine as first-line because the Surviving Sepsis Campaign 2020 guideline recommends adrenaline or noradrenaline over dopamine for paediatric septic shock. [3] [4]

Structured handover to retrieval

I hand over a structured summary covering identity and weight, current physiology and trend, the fluid aliquots given with times and responses, the vasoactive agent and dose if started, the shock phenotype, pending results, local limits, the family and safeguarding context, and the next contingency and its owner. I agree with the retrieval team what treatment will continue during transport, what deterioration to expect, and what to do if transport is delayed. [9]

Key examiner questions