• fluid
• sepsis
• guideline
• pediatric
• critical care

In their 1832 letter to The Lancet, Thomas Latta and colleagues1 noted that, with intravenous delivery of a salt solution to a patient with hypovolaemic shock from cholera, ‘improvement in the pulse and countenance is almost simultaneous, the cadaverous expression gradually gives place to appearances of returning animation, the livid hue disappears, the warmth of the body returns’. Since then, administration of intravenous fluids to restore circulating blood volume became the cornerstone of resuscitation for severe hypovolaemia and shock. Numerous observational and some interventional studies have demonstrated an association of resuscitation protocols which include early fluid administration with improved patient outcomes in shock syndromes. However, missing from this pool of evidence were high-quality randomised trials that directly compared early bolus fluid resuscitation with an alternative strategy.

In 2011, the Fluid Expansion as Supportive Therapy (FEAST) study was published (table 1). This study was designed to investigate early resuscitation with a saline or albumin bolus compared with no bolus in children with a severe febrile illness (57% positive for malaria and 32% with haemoglobin <50 g/L) and impaired perfusion treated in sub-Saharan Africa. Children with severe hypotension, however, were treated with 40–60 mL/kg boluses without an option for no bolus. Mortality at 48 hours in the saline and albumin groups was 10.6% and 10.5%, respectively, but was significantly lower in the no bolus control group at 7.3%. These data—the first randomised high-quality evidence—demonstrated harm from early fluid bolus resuscitation in children. This study ignited an important debate over …