Electrolyte Abnormalities Electrolyte abnormalities such as hypoglycemia or hypocalcemia may precipitate or worsen existing shock Blood glucose and ionized calcium can both be measured rapidly via bedside point of care testing and should be measured during the initial resuscitation If present, hypoglycemia and hypocalcemia should be corrected during the initial resuscitation If an inborn error of metabolism is known or suspected, diagnostic evaluation should also include measurement of serum ammonia levels This includes neonates with shock of unknown etiology, as their initial presentation may be due to metabolic crisis With the exception of children with glucose-6-phosphate dehydrogenase deficiency, all children with inborn errors of metabolism in shock should receive dextrose-containing fluids (at least D10 ) to aid in the conversion from catabolic to anabolic state Any center treating a patient with known or suspected inborn error of metabolism should consult immediately with a specialty center while resuscitating with volume and dextrose as above As mentioned above, hyperchloremia may develop with large-volume fluid resuscitation using 0.9% saline Hyperchloremia can induce a metabolic acidosis and has been shown to reduce renal blood flow in animal studies Recently, hyperchloremia has been associated with a greater risk of organ dysfunction, in particular acute kidney injury, and increased risk of mortality in pediatric septic shock Transition from 0.9% saline to resuscitation using balanced fluids, such as LR or Plasma-Lyte, may help to limit the degree of hyperchloremia although whether this contributes to improved clinical outcomes is not clear