Paeds · acute-care-resuscitation-and-toxicology
Fluid bolus therapy and vasoactive support
Also known as Paediatric fluid resuscitation · Fluid bolus in children · Vasoactive infusions in paediatric shock · Inotrope and vasopressor therapy in children · Fluid-refractory shock management
A fellowship approach to fluid bolus therapy and vasoactive support in the shocked child. Give 10 to 20 mL per kilogram of isotonic crystalloid in aliquots with reassessment after each, stop for overload or no benefit, escalate to adrenaline or noradrenaline for fluid-refractory shock, and keep the first-hour fluid total as a ceiling rather than a target. The FEAST trial anchors why fluid strategy must stay population-specific.
Checked against its sources on 3 Sept 2026
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Target exams
Red flags
- No improvement or worsening after two or three fluid boluses: stop fluids, start a vasoactive infusion, call PICU or retrieval
- Signs of fluid overload at any point: new basal crackles, hepatomegaly, gallop rhythm, rising respiratory distress or oxygen requirement
- Hypotension in a child: decompensated shock, escalate immediately rather than giving further unmonitored boluses
- Cold peripheries with weak central pulses and prolonged capillary refill: cold shock, adrenaline is the first-line vasoactive agent
- Warm peripheries with flash capillary refill and wide pulse pressure: warm vasodilatory shock, noradrenaline is the first-line vasoactive agent
- Duct-dependent congenital heart disease or suspected cardiogenic shock: smaller aliquots of 5 to 10 mL per kilogram, early vasoactive support, avoid driving toward a fixed fluid volume
- Resource-limited setting without access to intensive care or vasoactive agents: apply FEAST caution, give fluids cautiously and seek retrieval early
Life stages
Care settings
Clinical exam formats
Board mappings
- Acute Care
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
- Current 2026 PREP curriculum — Learning Objective 2.2.3: Perform acute resuscitation and advanced life support
- Current 2026 PREP curriculum — Learning Objective 2.4.4: Assess and manage infants, children and young people with potential cardiac, respiratory or neurological emergencies or acute sepsis
- Renewed curriculum for first-year trainees from 2027 — Learning goal 11: Acute care and procedures
- Renewed curriculum for first-year trainees from 2027 — Learning goal 17: Acute care
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- 3. Professional skills and knowledge: Clinical procedures
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing
- General Paediatrics: Resuscitates, stabilises and treats extremely unwell babies, children and young people, liaising with specialist teams, as necessary
- General Paediatrics: Assumes the role of Acute Paediatric Team Leader
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- General Pediatrics Content Outline — Domain 7: Emergency and Critical Care
- General Pediatrics Content Outline — Universal Task 1: Physiology and Pathophysiology
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- General Pediatrics EPA 7: Recognizing a Severely Ill Patient, Providing Initial Management, and Mobilizing Resources Needed for Continued Care
- Patient Care 3: Organize and Prioritize Patient Care
- Patient Care 5: Patient Management
- Systems-Based Practice 1: Patient Safety
- Interpersonal and Communication Skills 2: Interprofessional and Team Communication
- Medical Expert
- Pediatrics: Core EPA #2 — Resuscitating and stabilizing critically ill patients
Overview & Definition
Fluid bolus therapy and vasoactive support are the two circulatory tools that resuscitate the shocked child. A fluid bolus is a measured aliquot of isotonic crystalloid, given rapidly with the intention of restoring effective circulating volume, improving perfusion, and buying time while the cause is treated. Vasoactive support is the infusion of an catecholamine or vasopressor that restores vascular tone, cardiac contractility, or both, when fluid alone has not reversed shock. Neither is a protocol you drive toward a fixed endpoint; each is a treatment you give, measure, and either continue or stop based on whether the child improved. [4] [2]
The disciplined sequence is assess, give an aliquot, reassess, repeat or stop, and escalate to vasoactive support when shock is fluid-refractory. This is a closed loop, not a checklist. Before every bolus you state the improvement you expect in heart rate, perfusion, interaction, urine output or lactate. After every bolus you check whether that improvement happened. If it did not, you do not blindly repeat the same treatment — you reconsider the shock type, the fluid volume already given, and whether it is time to start a vasoactive infusion. [4] [9]
The fluid-and-vasoactive loop
- 1
Confirm shock and set a goal
Diagnose shock from the whole circulation assessment, decide what improvement you expect from fluid, and state it before you give it.
- 2
Give 10 to 20 mL per kilogram
Administer isotonic crystalloid over 5 to 20 minutes, not as a slow drip, and not as a blind push without reassessment.
- 3
Reassess the whole child
After each aliquot, check heart rate, pulses, skin colour and temperature, capillary refill, mental state, urine output, lactate and respiratory status.
- 4
Repeat or stop
If shock persists and there is no overload, repeat up to the ceiling. Stop immediately for no benefit, worsening, or any sign of fluid overload.
- 5
Escalate to vasoactive
When shock is fluid-refractory or overload is developing, start adrenaline or noradrenaline and call PICU or retrieval.
This topic focuses on the fluid and vasoactive tools themselves. It complements the shock classification, septic shock and ABCDE assessment pages, which cover recognition, pathophysiology and cause-specific pathways. Here the clinical question is narrower and more dangerous: once you have decided to give fluid or start an infusion, exactly what do you give, how much, how fast, when do you stop, and when do you switch to vasoactive support? [4]
References11ShowHide
- [1]Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection The New England journal of medicine, 2011.PMID 21615299
- [2]Weiss, Scott L Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026 Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2026.PMID 41869844
- [3]Weiss, Scott L Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2020.PMID 32032273
- [4]Bjorklund A, Resch J, Slusher T Pediatric Shock Review Pediatrics in review, 2023.PMID 37777656
- [5]Topjian AA, Raymond TT, Atkins D, et al. Part 4: Pediatric Basic and Advanced Life Support 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Pediatrics, 2021.PMID 33087552
- [6]Schlapbach LJ, Watson RS, Sorce LR, et al. International Consensus Criteria for Pediatric Sepsis and Septic Shock JAMA, 2024.PMID 38245889
- [7]Sankar J, Das RR, Banothu KK Fluid resuscitation in children with severe infection and septic shock: a systematic review and meta-analysis European journal of pediatrics, 2024.PMID 38916738
- [8]Burgunder L, Heyrend C, Olson J, et al. Medication and Fluid Management of Pediatric Sepsis and Septic Shock Paediatric drugs, 2022.PMID 35307800
- [9]Gupta S, Sankar J Advances in Shock Management and Fluid Resuscitation in Children Indian journal of pediatrics, 2023.PMID 36715864
- [10]Alobaidi R, Morgan C, Basu RK, et al. Association Between Fluid Balance and Outcomes in Critically Ill Children: A Systematic Review and Meta-analysis JAMA pediatrics, 2018.PMID 29356810
- [11]Young KD, Korotzer NC Weight Estimation Methods in Children: A Systematic Review Annals of emergency medicine, 2016.PMID 27105839