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Is PALS Wrong? Rapid Bolus Did Worse

September 28, 2017

Spoon Feed
PALS recommends giving a fluid bolus to children in shock over 5-10 minutes.  This study showed that giving it more slowly, over 15-20 minutes, decreased the need for mechanical ventilation.

Why does this matter?
PALS is the bible for pediatric resuscitation, but the bible may be wrong on how fast to administer IV fluid boluses.  Simply giving the bolus over 15-20 minutes vs. 5-10 minutes reduced the need for intubation in these critically ill children.

Slow it Down
In this single center RCT, 96 children with septic shock were randomized to receive 40-60 mL/kg in 20 mL/kg doses each over either 15-20 minutes or the standard 5-10 minute timeframe.  For the composite outcome of need for mechanical ventilation or rise in oxygenation index (if intubated) at 6 and 24 hours by an assessor blinded to treatment group, the slower bolus rate was markedly better and greatly decreased the risk.  The majority of the effect on the composite outcome was reduction in need for mechanical ventilation, not rise in oxygenation index.  As a result, the trial was stopped after the interim analysis due to increased harm in the rapid fluid bolus group. Nonetheless, mortality and length of stay were unchanged.  Keep in mind this was a small RCT at one center, which may limit the generalizability of the study. 

Fluid Bolus Over 15-20 Versus 5-10 Minutes Each in the First Hour of Resuscitation in Children With Septic Shock: A Randomized Controlled Trial.  Pediatr Crit Care Med. 2017 Aug 2. doi: 10.1097/PCC.0000000000001269. [Epub ahead of print]

Peer reviewed by Thomas Davis, MD.

What are your thoughts?