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IV crystalloids are generally considered first-line fluids except for children with
hemorrhagic shock and dissociative shock. In terms of crystalloid solution choice,
several interventional trials in adults show decreased mortality and decreased
kidney injury with preferential use of balanced fluids for resuscitation rather than
0.9% saline, though additional confirmatory trials are ongoing. In children with
septic shock, several studies demonstrate an association of increased mortality
with hyperchloremia, which can be seen in the setting of large-volume saline
resuscitation. However, retrospective pediatric studies comparing balanced fluids
to 0.9% saline have reported conflicting results and 0.9% saline has the relative
benefits of low cost and universal compatibility compared to Plasma-Lyte and
lactated Ringer’s (LR), respectively. Until further data become available, use of
crystalloids (either 0.9% saline or balanced fluids such as LR or Plasma-Lyte) is
generally more common than colloids for initial fluid resuscitation due to their
availability, ease of administration, and low cost. There is evidence supporting a
risk of kidney injury with the use of synthetic colloids, such as hydroxyethyl
starch, and its use is currently not recommended by the Surviving Sepsis
Campaign.
The use of blood products for volume expansion is another important
consideration, especially in hemorrhagic shock. The Advanced Trauma Life
Support guidelines recommend resuscitation with crystalloid and blood products
for classes III and IV hemorrhagic shock (see Chapter 7 A General Approach to
the Ill or Injured Child for more details on trauma). Based on early studies of
adult septic shock and subsequent pediatric studies red blood cell (RBC)
transfusion has typically been recommended to maintain a goal hemoglobin >10
g/dL and an ScvO2 >70% for children with fluid-refractory septic shock during
the early stages of resuscitation. However, while RBC transfusion can increase
blood oxygen content, adverse effects can occur (e.g., transfusion-related acute
lung injury, immune suppression, or circulatory overload). RBCs also tend to
aggregate and obstruct the microcirculation in states of systemic inflammation
and endothelial activation (as with sepsis), and transfused RBCs may be less
efficient at delivering oxygen to vital organs due to a reduction in 2,3diphosphoglycerate content and other changes during storage. Data from two

adult randomized trials recently demonstrated that a hemoglobin threshold of 7 to
7.5 g/dL before transfusion provided similar outcomes as a higher hemoglobin
threshold. Consequently, recent consensus guidelines for RBC transfusion in
children were unable to reach consensus regarding the optimal transfusion
threshold for critically ill children with unstable nonhemorrhagic shock.