Fluid bolus therapy and vasoactive support — branching viva

Probe: "Why not give all the fluid at once?" Because the first-hour ceiling of 40 to 60 mL per kilogram is a maximum to reach through reassessed aliquots, not a single push. The purpose of the aliquot is to give, reassess, and decide. Giving all fluid at once removes the decision point and risks driving the child onto the flat portion of the Starling curve without detecting the signs of overload. [2] [9]

Probe: "What fluid do you choose?" Isotonic crystalloid — either 0.9 per cent sodium chloride or a balanced solution such as Hartmann or Plasma-Lyte. I avoid hypotonic fluids because they do not stay intravascular and can cause hyponatraemia. Albumin is not routinely first-line for the initial bolus. [2] [3]

Probe: "Which vasoactive agent do you start and why?" I choose based on the shock phenotype. This child has cold shock — cool mottled skin, weak pulses, prolonged capillary refill and a narrow pulse pressure. The first-line agent is adrenaline, starting at 0.05 to 0.5 micrograms per kilogram per minute, titrated to clinical response. If the child had warm shock — warm dry skin, bounding pulses, flash capillary refill, wide pulse pressure — I would use noradrenaline at the same dose range. [3] [4]

Probe: "Why not dopamine?" The Surviving Sepsis Campaign 2020 guideline recommends adrenaline or noradrenaline over dopamine for paediatric septic shock. Dopamine is now second-line. I would use it only if adrenaline or noradrenaline were not immediately available. [3]

Probe: "What access do you use?" Central venous access is preferred for vasoactive infusions, but intraosseous access is an acceptable rapid alternative. I do not delay the first vasoactive dose to place a central line — if IO is available now, I start through it and convert when safe. [3] [9]

Probe: "Does FEAST mean you should not give any fluid?" No. FEAST showed harm from bolus fluid in a specific population without intensive care rescue. In a well-resourced setting with PICU access, up-front boluses remain standard for septic shock with rigorous reassessment. Here, without vasoactive rescue on site, I apply a more cautious strategy and prioritise early retrieval. The fluid strategy fits the child and the setting. [1] [3]

Probe: "What is the single most important error to avoid?" Driving toward a fixed fluid volume without measuring the response. The ceiling of 40 to 60 mL per kilogram is a maximum, not a target. Each aliquot is followed by a full reassessment. If the child is not improving, I stop and escalate, even if the ceiling has not been reached. [2] [9]