In a child with poor perfusion, the bolus is a test as much as a treatment. Give it, then reassess heart rate, capillary refill, conscious level and liver edge before deciding on the next one. A child who improves and stays improved needs no more; a child who improves and relapses needs escalation, not repetition; and a child who develops hepatomegaly or new crackles is telling you the problem is not hypovolaemia.
Write the response down, not just the volume given. The commonest failure is not giving too much fluid — it is giving the fourth bolus because nobody recorded what the first three did, so each clinician in turn starts the sequence again. A single line after each bolus stating heart rate before and after, and whether the liver edge moved, is what stops that.
- Reassess perfusion, conscious level and liver edge after every bolus, before ordering the next
- Record the response, not only the volume — heart rate before and after is enough
- New hepatomegaly or crackles means stop and reconsider the diagnosis
- Improvement that does not last is an indication to escalate, not to repeat
- Agree in advance who decides when to start inotropes, so the decision is not made by default
Why it matters
Fluid is given in a sequence by different people, and without a recorded response each one restarts the sequence from the beginning.
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