A 6-year-old is in septic shock not responding to two fluid boluses of 10 mL/kg each of normal saline. He remains hypotensive with cool extremities. The most appropriate next step is:
- A Give a third fluid bolus of 20 mL/kg
- B Start dopamine infusion
- C Reassess with clinical parameters and start vasoactive agent if fluid-refractory shock is confirmed ✓
- D Start epinephrine infusion
Correct answer: C. Reassess with clinical parameters and start vasoactive agent if fluid-refractory shock is confirmed
Explanation
Current PALS/Surviving Sepsis guidelines advise against aggressive fluid resuscitation beyond 40–60 mL/kg without reassessment; fluid-refractory shock requires initiation of vasoactive therapy. Dopamine or epinephrine is added if hemodynamic instability persists after initial resuscitation. Blindly giving more fluid risks fluid overload and pulmonary edema. The choice between dopamine and epinephrine depends on clinical phenotype (cold vs. warm shock), but the key step is confirming fluid-refractoriness before escalating.
Reference: Ghai Essential Pediatrics, 10th ed.
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Written and medically reviewed by the StethoPrep medical team.