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Consensus Guidelines for IV Fluid Management

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Northern California Pediatric Hospital Medicine Consortium

This work is licensed under a Creative Commons Attribution-Noncommercial 4.0 International License

Table of Contents

 

Executive summary

Objectives

  • Standardize care of pediatric patients who require maintenance IV fluids in the hospital
  • Reduce utilization of maintenance IV fluids
  • Use best available evidence to guide selection and monitoring of appropriate maintenance IV fluids with consideration for patient-specific factors

Recommendations

  • Indication: Maintenance IV fluids are appropriate for euvolemic patients who cannot take adequate hydration orally or via other enteral source (e.g. nasogastric tube)
  • Rate Calculation: Calculate hourly maintenance fluid rates using standard weight-based formula (4-2-1 rule)
  • Do not administer maintenance IV fluids at rates above calculated maintenance. Replace ongoing losses separately from maintenance fluids
  • Fluid Composition: In patients older than 28 days who do not meet exclusion criteria, use isotonic fluids
  • Do not use ¼ NS for maintenance fluids outside the neonatal period
  • Add 5% dextrose to maintenance fluids for patients with limited or no oral nutritional intake
  • Add potassium to maintenance fluids unless contraindicated
  • Use caution and select fluids on a case-by-case basis for patients with the following conditions: Renal disease/renal dysfunction, endocrine disorders causing electrolyte abnormalities, neurosurgery or brain injury, severe cardiac disease, ICU Level of Care (PICU or NICU), severe malnutrition, known metabolic disease, sickle cell patients, liver failure/hepatic dysfunction, high extrarenal water loss
  • Laboratory monitoring: Check serum electrolytes (with attention to sodium, chloride, bicarbonate) as clinically indicated for patients receiving >75% of maintenance needs via IV. Reassess more frequently based on clinical status or abnormal results
  • Clinical monitoring: Monitor strict intake and output, weight, blood pressure, and signs of fluid overload daily in patients receiving maintenance IV fluids
  • Discontinuation: Discontinue maintenance IV fluids as soon as patients can take adequate enteral fluids

Methods

This guideline was developed through local consensus based on published evidence and expert opinion as part of the UCSF Northern California Pediatric Hospital Medicine Consortium.

 

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Consensus Clinical Guidelines

Inclusion criteria

  • Euvolemic general pediatric (surgical and non-surgical) patients in inpatient setting requiring IV fluids
  • Otherwise healthy euvolemic pediatric patients in ED setting awaiting admission

Exclusion criteria (note: guidelines may apply but fluids must be carefully selected and individualized)

  • Renal disease/renal dysfunction
  • Endocrine disorders causing electrolyte abnormalities
  • Neurosurgery or brain injury
  • Severe cardiac disease
  • ICU Level of Care (PICU or NICU)
  • Severe malnutrition
  • Known metabolic disease
  • Sickle cell patients
  • Liver failure/hepatic dysfunction
  • High extrarenal water loss

 

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PART I: Background / rationale

  • IV fluid administration is a common but not completely benign intervention. Appropriate selection of maintenance IV fluid rate and composition can reduce the risk of fluid-related adverse effects including iatrogenic hyponatremia
    • Infants have less urine concentrating ability than adults and maximum concentrating ability is not reached until approximately 18 months. In addition, larger body surface area per volume with increased insensible losses in infants & small children -> more hypotonic fluids (replace more free water).
  • A substantial body of pediatric literature demonstrates an increased risk of hospital-acquired hyponatremia in children receiving hypotonic maintenance IV fluids compared with isotonic fluids in both surgical and medical populations. This is likely due to a combination of hypotonic fluid administration and fluid retention related to elevated ADH secretion:
    • Risk of hyponatremia is most well documented in post-surgical patients but has also been described in general pediatric medical patients
    • There is a small risk of seizures associated with hyponatremia
  • Randomized trials and meta analyses do not demonstrate increased risk of hypernatremia in patient's receiving isotonic maintenance fluids. Concerns regarding hypertension, fluid overload, or hyperchloremic metabolic acidosis have also not been consistently demonstrated, though clinical monitoring remains important.
  • IV fluid composition & rate
    • Definitions:
      • Isotonic = normal saline (0.9% NS), lactated ringers (LR), Plasmalyte
      • Hypotonic = 0.45% NS (½ NS) < 0.2% NS (¼ NS)
      • See APPENDIX 1 - IV fluid composition

     

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    PART II: Selection of IV Fluids for Pediatric Inpatients

    • Hospitalized children commonly have elevated antidiuretic hormone (ADH) due to physiologic stress.

      • Patients with the following conditions are at increased risk for hyponatremia if given hypotonic fluids: 

        • Pulmonary disease (particularly pneumonia)
        • Pain
        • CNS disease
        • Gastroenteritis and nausea/vomiting in general
        • Recent surgery
      • Clinical signs of excessive ADH secretion include:
        • Hyponatremia and low serum osmolality
        • Inappropriately elevated urine sodium and urine osmolality
        • Absence of clinical signs of hypovolemia
        • Weight may be normal or increased
    • Choice of IV Fluids
    • Sodium (Na) Content
        • Age greater than or equal to 28 days: Isotonic fluid @ full maintenance rate (most common choice 0.9% NS however Plasmalyte and Lactated Ringers are reasonable alternatives)
        • Age less than 28 days: ½ (0.45%) NS @ full maintenance rate
          • **¼ NS should not generally be used outside the neonatal period
    • Dextrose Content
      • Add 5% dextrose to maintenance IV fluids for all pediatric patients who are NPO or are unable to take adequate oral intake
        • Particularly important in patients at risk of hypoglycemia (patients < 1 yr of age, patients with diabetes mellitus, recent use of dextrose-containing fluids > D10, history of hypoglycemia), or NPO > 24 hours
        • Use caution in patients with: hyperglycemia (e.g. neurotrauma), monitor serum glucose and adjust as needed
      • Potassium Content
        • Add potassium to maintenance IV fluids for most pediatric patients
          • Contraindications include
            • Hyperkalemia
            • Renal insufficiency or acute kidney injury
            • Oliguria/anuria
            • Systemic acidosis
            • Use of potassium-sparing diuretics
            • Adrenal insufficiency
            • Severe tissue damage such as burns, rhabdomyolysis
          • Ensure adequate UOP prior to adding potassium to fluids
          • Appropriate potassium content:
            • < 12 months => 10 meq/L KCI
            • Greater than or equal to 12 months => 20 meq/L KCI
          • NOTES:
            1. Potassium should never be added to bolus IV fluids.
            2. The potassium added to maintenance fluids is indicated to maintain normal serum potassium levels, not as repletion for hypokalemia
      • Deficit Replacement:
          • Use isotonic fluid for fluid deficit replacement / boluses
          • In patients requiring large volumes of replacement fluids (e.g. AGE) consider:
            • More frequent laboratory monitoring (at least every 24 hours)
            • Use of a balanced isotonic solution (LR or Plasma-Lyte) to reduce risk of hyperchloremic metabolic acidosis when large volumes are administered
      • Calculating IV Fluid Rate/Volume
        • Do not exceed calculated maintenance rates unless clinically indicated. Replace ongoing losses separately.
        • 4-2-1 rule (100-50-20 rule)
          • 4 mL/kg/hr (100 mL/kg/day) for the first 10kg PLUS
          • 2 mL/kg/hr (50 mL/kg/day) for the second 10kg PLUS
          • 1 mL/kg/hr (20 mL/kg/day) for each kg over 20kg
          • Maximum rate of 120 mL/hr
          • NOTE: use dose-calculation weight or ideal body weight

       

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      Part IlI: When and How to Use IV Fluids

      "Maintenance" IV fluids

        • Indications:
          • Euvolemic medical and surgical patients who cannot take adequate enteral hydration
          • Do not initiate maintenance IV fluids in dehydrated patients until appropriate rehydration has been performed
        • Before initiated IV fluids, asses:
          • Current volume status
          • Need for fluid restriction
          • Need for fluid resuscitation
        • Monitoring:
          • Clinical monitoring
            • Strict intake & output (particular attention to ongoing losses)
            • Daily weight
            • Signs/symptoms of fluid retention:
              • Peripheral or pulmonary edema
              • Dependent edema
              • Elevated blood pressure
              • Unexplained weight gain
          • Electrolyte monitoring:
            • Consider checking electrolytes ~24-36 hrs after initiation for patients receiving >75% of maintenance fluid needs via IV; re-check if clinical concern for dysnatremia (seizure, headache, lethargy, renal dysfunction), or if requiring IV fluids > 96 hours
              • Follow serum sodium, chloride, and bicarbonate for possible hypernatremia, hyperchloremic metabolic acidosis, hyponatremia
          • Assess for readiness to wean IV fluid:
            • At or approaching baseline mental status
            • Clinically stable or improving clinical status
            • Demonstrated ability to take enteral fluids with adequate urine output
            • Return of bowel function in post-surgical patients
            • Well-controlled pain and nausea
          • When to Consider PN (Parenteral Nutrition): dependent on expected clinical trajectory
            • Hospitals without ability to obtain central access and/or who do not stock parenteral nutrition (PN) fluids:
              • Consider patient's trajectory after 3 days on IVF taking <50% of nutrition enterally
                • If not improving or worsening, consider transfer to tertiary center or consult with Pharmacy /Nutrition for capabilities
            • Hospitals with ability to obtain central access and parenteral nutrition
              • Consider consulting nutrition and starting PN after 5-7 days on IVF taking less than 50% of nutrition enterally
          • Weaning & discontinuation of IV fluids:
            • Discontinue IV fluids and saline-lock IV as soon as clinically appropriate
            • NOTE: use caution with discontinuing IV fluids in patients with ongoing fluid losses

        Frequently Asked Questions

        1. When should I use normal saline vs a balanced isotonic fluid (lactated ringers or plasmalyte)? Are there compatibility concerns with specific medications or conditions?

        For most patients admitted to the pediatric wards, any isotonic fluid selection whether normal saline, lactated ringers, or plasmalyte are all acceptable options.

        When to prefer normal saline:

        • Neurosurgical or traumatic brain injury patients where sodium control is critical
        • Medication compatibility concerns (see below)

        When to prefer LR or plasmalyte:

        • When giving large volumes of fluids during deficit replacement to reduce risk of hyperchloremic metabolic acidosis
        • While there is evidence of improved outcomes with balanced fluids in resuscitation of adults, literature is limited currently in pediatrics. The PRoMPT BOLUS trial is a multisite RCT currently ongoing evaluating the use of NS vs LR in acute resuscitation of pediatric patients

        When to avoid LR:

        • Consider utilizing plasmalyte or NS in patients with severe hepatic failure or metabolic crises. Lactated ringers contains 28 mEq/L of lactate. In the majority of patients including those with stable liver disease or metabolic conditions, this is quickly metabolized by the liver and there is no significant evidence that this can cause a lactic acidosis. However given reasonable alternatives exist in patients with severe liver disease or metabolic crises it is reasonable to avoid LR
        • Some medications are incompatible with R due to the calcium content. The most common examples are blood products or ceftriaxone in neonates. Check with pharmacy or institutional compatibility charts before co-infusing medications with LR

        2. Should I avoid LR or plasmalyte in hyperkalemia?

        In general LR or plasmalyte do not need to be avoided in hyperkalemia. While LR contains 4 mEq/L of potassium and plasmalyte contains 5 mEq/L of potassium, these are generally not clinically significant given the relatively low volumes of fluids patients are receiving. It should also be noted that the if normal saline causes a non-gap metabolic acidosis shunting of intracellular potassium into the extracellular space could cause a larger increase in serum potassium than LR or plasmalyte would cause. However, in any patient with hyperkalemia receiving IV fluids that contain potassium consider more frequent monitoring of electrolytes.

        3. When is 0.45% normal saline (1/2 NS) an appropriate maintenance fluid?

        Routine use of hypotonic maintenance fluids including ½ NS is generally not recommended in children older than 28 days to avoid hospital-acquired hyponatremia. These fluids should be reserved for:

        • infants less than 28 days old
        • patients with documented hypernatremia where controlled sodium reduction is indicated specific subspecialty-directed care plans (such as patients with diabetes insipidus with guidance from endocrinology or nephrology)

        4. What recommended strategies exist for maintenance IV fluids during an IV fluid shortage

        In general during IV fluid shortages every attempt should be made to minimize unnecessary IV fluid use while still prioritizing patient safety. It is usually safer to reduce unnecessary IVF exposure rather than substituting for less appropriate fluid types. This can be done in a stepwise manner:

        • Avoid unnecessary maintenance fluids by encouraging enteral hydration and promptly discontinuing maintenance fluids once adequate enteral intake is achieved.
          • Bear in mind that oral rehydration therapy is safe and effective for most children with mild-moderate dehydration
          • Consider NG placement for rehydration
        • Consider whether full maintenance rate is required for patients or if they can maintain hydration with a lower rate that replaces ongoing losses
        • If isotonic fluids are unavailable and IV fluids are necessary, work with pharmacy for safe substitutions. If giving hypotonic fluids consider more frequent lab monitoring to assess for hyponatremia

        5. Are there clinical situations in which I should regularly not give full (1x) maintenance IV fluids?

        In situations with elevated risk of SIADH (see full guidelines above), it is reasonable to give 2/3 maintenance IV fluids to reduce risk of fluid retention. Similarly, consider giving less than full maintenance fluids in patients with cardiac disease, renal dysfunction, or significant fluid overload. In late preterm/term infants who are not feeding well, standard maintenance fluid rates may overestimate physiologic need. In these patients consider individualized volume, monitoring clinical status and electrolytes closely. Finally, in patients who are tolerating some PO intake adjust IV fluids to account for this rather than giving full maintenance IV fluids in addition to PO intake.

         

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        APPENDIX 1:IV Fluid Composition

         

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        APPENDIX 2: Maintenance IV Fluid Selection Clinical Pathway

         

         

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        REFERENCES

        Choong K, et al. Hypotonic versus Isotonic Maintenance Fluids After Surgery for Children: A Randomized Controlled Trial. Pediatrics. 2011; 128(5): 857-866.

        Edelson JB, et al. Intravenous Fluid Management in the Pediatric Hospital Setting: Is Isotonic Fluid the Right Approach for all Patients? Current Treatment Options in Pediatrics. 2015
        http://link.springer.com/article/10.1007/s40746-014-0006-0/fulltext.html

        Feld, LG et al. Clinical Practice Guideline: Maintenance IV Fluids in Children. Pediatrics. 2018; 142(6).

        Foster BA, et al. Hypotonic versus Isotonic Fluids in Hospitalized Children: A Systematic Review and Meta-Analysis. Journal of Pediatrics. 2014; 165: 163-169.

        Friedman JN, et al. Comparison of Isotonic and Hypotonic Intravenous Maintenance Fluids. JAMA. 2015; 169(5): 445-451.

        McNab S. Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children (Cochrane Review). 2014.  
        https://www.researchgate.net/publication/269770875_Isotonic_versus_hypotonic_solutions_for_maintenance_intravenous_fluid_administration_in_children

        McNab S, et al. 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomized controlled double-blind trial. Lancet 2015; 385: 1190-97.

        Wang J, et al. Isotonic versus Hypotonic Maintenance IV Fluids in Hospitalized Children: A Meta Analysis. Pediatrics. 2014; 133: 105-113.

        Shukla S, et al.  Use of Hypotonic Maintenance Intravenous Fluids and Hospital-Acquired Hyponatremia Remain Common in Children Admitted to a General Pediatric Ward. Front. Pediatr. 2016; 4:90. doi: 10.3389/fped.2016.0009

        MAJOR U.S. CHILDREN'S HOSPITAL CLINICAL PATHWAYS:

        IV Fluid Clinical Pathways

        Children's Hospital of Philadelphia (CHoP):

        http://www.chop.edu/clinical-pathway/fluid-administration-continuous-iv-clinical-pathway-inpatient

        Seattle Children's Hospital:

        http://www.seattlechildrens.org/healthcare-professionals/gateway/pathways

         

        Disclaimer

        These clinical practice guidelines are based upon the evidence-based consensus opinions of consortium members affiliated with UCSF Benioff Children's Hospitals. They are intended to guide pediatric/neonatal providers, but do not substitute for individual clinical judgment. Evaluation and treatment of specific patients should be adapted based upon the unique conditions of each patient, family and clinical environment.

         

        Northern California Pediatric Hospital Medicine Consortium. Originated 6/2015. Last edited 4/2019.

        UCSF QIEC Approval: ______

        UCSF BCH Medication Subcommittee approval 9/2018, revised and re-approved 8/13/19 P&T Approval: ______ 

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