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definitive care is not feasible and there is a provider available experienced in the
placement of these devices in children in shock.

Volume Resuscitation
Several studies of pediatric shock have shown decreased mortality with early and
aggressive fluid resuscitation, and the current recommendation is to administer
fluid in 20-mL/kg boluses pushed over 5 to 10 minutes, with reassessment of
perfusion and vital signs, as well as for signs of hepatomegaly and rales, during
and after each fluid bolus. Fluid boluses totaling up to and over 60 mL/kg should
be administered if the child remains in shock, with a goal of delivering at least 60
mL/kg in the first 20 to 60 minutes if shock persists and signs of fluid overload
(hepatomegaly, rales) do not manifest. Ongoing fluid resuscitation should be
reconsidered if hepatomegaly or signs of pulmonary edema develop. In addition,
caution should be taken with rapid fluid resuscitation in neonates <30 days of
age, patients with severe malnutrition or anemia, and in patients with known or
suspected cardiac or renal disease or suspected cardiogenic shock. For these
patients, smaller boluses of 5 to 10 mL/kg are prudent with frequent reassessment
to determine clinical response. The recent FEAST trial in sub-Saharan Africa,
which is discussed in more detail below, has called into question the paradigm of
aggressive fluid resuscitation in pediatric septic shock. Further trials of smallervolume fluid boluses and earlier vasoactive infusion support are ongoing to
further clarify the optimal role of fluid resuscitation in pediatric septic shock.
Fluid should be administered via IV push or a rapid infuser system to achieve
the time goals set by the American College of Critical Care Medicine. IV push
delivery may be facilitated by attaching a large syringe with a three-way stopcock
to the IV tubing from the IV fluid bag, creating a so-called “push–pull system”
that allows the user to rapidly draw up fluid into the syringe and then administer
via IV push without repeatedly disconnecting and reconnecting the syringe to the
patient’s IV. In larger patients >50 kg, a pressure bag or rapid infuser may be used
to rapidly administer large volumes of fluid through a large gauge peripheral IV
over the goal of 5 minutes.
The optimal fluid choice for resuscitation remains a matter of debate. While

Maitland et al. showed reduction in mortality in shock related to malaria with
albumin versus crystalloid resuscitation and the adult SAFE study showed a trend
toward improved survival in subgroup analysis of patients with septic shock
receiving albumin versus crystalloid, many other studies have shown no
differences in outcome with a colloid versus crystalloid resuscitation strategy.
Furthermore, the SAFE study showed worse outcomes in the subgroup analysis of
patients with traumatic brain injury who received colloid resuscitation. Therefore,