Among children with septic or severe infection shock, those in whom resuscitation is attempted via fluid bolus may have a higher mortality rate at 48 hours compared with children who do not receive a fluid bolus, suggested findings of a systematic review recently published in Shock.

Previous research has shown conflicting results as to whether fluid bolus administration in children with septic or severe infection shock as an early intervention was helpful or harmful, with mortality rates in such children after fluid bolus ranging from 8% to 41%.

In the current study, investigators in China conducted a systematic review and meta-analysis to assess the mortality rates after fluid bolus in children with septic or severe infection shock. The primary outcome was overall mortality associated with shock. Secondary outcomes included the incidence of mortality at 48 hours and 4 weeks.

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A total of 19 studies involving 9321 pediatric patients with septic shock or severe infection shock between 1999 and 2020 were assessed. The majority of the studies were conducted in India (n=6), Kenya (n=5), and Vietnam (n=3). Nearly all (18) studies reported mortality at 48 hours, with only 1 reporting mortality in the fluid bolus group. Most studies included patients with septic shock as well as those with general shock, malaria shock, dengue shock, or malnutrition shock.

The investigators evaluated 17 studies with reports of mortality at 48 hours. Compared with patients with fluid bolus, there was a decreased rate of mortality among patients who did not have fluid bolus (risk ratio [RR], 0.74; P <.01) and no heterogeneity was reported. The subgroup of patients with general shock did not have statistically significantly different values (RR, 0.79; P =.07).

For patients with malaria shock, there was a significant difference in mortality rates among patients with and without fluid bolus, with better outcomes for patients without bolus (RR, 0.65; P =.01).

In the 2 studies that reported mortality at 4 weeks, pooled results suggested that patients with no bolus were more protected against 4-week mortality than patients with bolus (RR, 0.71; P <.01).

Overall, the analysis “showed no difference on mortality after using fluid bolus in pediatric patients,” the investigators stated. For the secondary outcome of mortality at 48 hours, the group with no bolus showed decreased mortality compared with the bolus group, especially in children with malaria, they added.

Study limitations included the variations in sample sizes across the studies reviewed, variations in the definitions of shock across the 19 studies, and the fact that only 2 investigations reported mortality at week 4. The investigators concluded that “meta-analysis with more long-term follow-up and larger sample size studies are warranted to address the conclusion in the future.”


Yue J, Zheng R, Wei H, et al. Childhood mortality after fluid bolus with septic or severe infection shock: a systematic review and meta-analysis. Shock. 2021;56(2):158-166. doi:10.1097/SHK.0000000000001657