Clinical Practice Guidelines

Intravenous Fluids

  • This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

    IV FLUIDS - for children beyond the newborn period

    See also:

    Guideline on Neonatal Fluid Requirements
    Checklist of commonly used fluids
    Dehydration
    Hyponatraemia Guideline
    Hypernatraemia Guideline

    Sections:

    Background
    Unwell children (+/- abnormal hydration)
    Monitoring
    Special fluids
    Notify Paediatric Team when:
    Consider transfer when:
    Information specific to RCH patients
    Calculating Maintenance FluidsNotes

    For RCH patients please see current research study: PIMS Paediatric Intravenous Maintenance Solution study 

    Background:

    • Whenever possible the enteral route should be used for fluids. These guidelines only apply to children who cannot receive enteral fluids.
    • The safe use of IV fluid therapy in children requires accurate prescribing of fluid and careful monitoring
    • Always check orders that you have written, and ensure that you double check on orders written by other staff when you take over the child's care
    • Incorrectly prescribed or administered fluids are potentially very dangerous. More adverse events are described from fluid administration than for any other individual drug. If you have any doubt about a child's fluid orders - ask a senior doctor.

    Assessment of fluid requirements: Unwell children (+/- abnormal hydration) 

    How much Fluid?

    If required, administer an initial bolus(es) of fluid to correct intravascular depletion then:

     Hypovolaemia

    Give boluses of 10-20ml/kg of normal (0.9%) saline, which may be repeated.

    Do not include this fluid volume in any subsequent calculations

    Maintenance plus
    Deficit
     (dehydration guidelines), plus
    Ongoing losses (dehydration guidelines)

    Maintenance

    Remember that the maintenance fluid volume will need to be adjusted in ALL unwell children.

    In non-dehydrated children, consider using 2/3 maintenance in unwell children, especially those with pneumonia or meningitis. For fluid options in the dehydrated child see dehydration guidelines.

    WEIGHT (kg) Maintenance - eg fasting for theatre (mL/hour)  2/3 maintenance - pneumonia, meningitis (mL/hour)
     20  13
    10  40  27
    15  50  33
    20   60  40
    25  65  43
    30  70  47
    35  75  50
    40  80  53
    45  85  57
    50  90  60
    55  95  63
    60  100  67


    REMEMBER to consider deficit and ongoing losses - especially in severe gastroenteritis, if there are drain losses, ileostomies etc.

    Which Fluid?

    DO NOT use 0.18% NaCl with 4% glucose with KCl 20mmol/L (or 4% and 1/5 NS, or 5% and ¼ NS) in unwell children. 

    Three good fluid solutions for sick children include:

    Fluid  Alternative names  Uses
     0.9% NaCl  Normal saline Initial boluses
    Replacement of deficit
    Replacement of losses
     0.9% NaCl with 5% Glucose*  OR  Normal saline with glucose  Maintenance
     0.45% NaCl with 5% Glucose*  1/2 Normal saline with glucose  Maintenance

    Premade solutions with potassium chloride 20mmol/L are available and should be used unless the serum potassium is elevated, there is anuria or renal failure.

    *The most appropriate NaCl concentration is currently subject to research at RCH in the PIMS study.

    Monitoring

    • All children on IV fluids should be weighed prior to the commencement of therapy, and daily afterwards. Ensure you request this on the treatment orders.
    • Children with ongoing dehydration/ongoing losses may need 6 hourly weights to assess hydration status
    • All children on IV fluids should have serum electrolytes and glucose checked before commencing the infusion (typically when the IV is placed) and again within 24 hours if IV therapy is to continue.
    • For more unwell children, check the electrolytes and glucose 4-6 hours after commencing, and then according to results and the clinical situation but at least daily.
    • Pay particular attention to the serum sodium on measures of electrolytes. If <135mmol/L (or falling significantly on repeat measures) see Hyponatraemia Guideline. If >145mmol/L (or rising significantly on repeat measures) see Hypernatraemia Guideline
    • Children on iv fluids should have a fluid balance chart documenting input, ongoing losses and urine output.

    Special Fluids

    Outside the newborn period, do not use these fluids apart from exceptional circumstances and check the serum sodium regularly

    10% Dextrose
    Used in neonates (sometimes with additional NaCl). Used in ICU for patients under 12 months (with 0.45% saline). Sometimes used by infusion in neonates and children with metabolic disorders. Check blood glucose regularly.

    15-20% Dextrose
    Very occasionally used by infusion in children with metabolic disorders. Check blood glucose regularly.

    25% and 50% Dextrose
    Rarely required in children, misuse can cause severe adverse events. Only used in discussion with senior staff as bolus or low volume infusions (1-2 ml/hr) to correct refractory hypoglycaemia.

    Consider consultation with local paediatric team when:

    - Unsure of which fluid/how much fluid to use
    - Electrolyte abnormalities
    - Using a non-standard 'special' fluid

    Consider transfer when:

    - Children requiring care above the level of comfort of the local hospital.
    - Severe electrolyte or glucose abnormalities

    For advice and inter-hospital (including ICU level) transfers ring the Sick Child Hotline: (03) 9345 7007

    Information Specific to RCH

    Children on intravenous fluids need daily electrolyte monitoring.

    20-50% dextrose should not be given outside the ICU of NNU setting without discussion with a consultant.

    Calculating Maintenance fluid:

    MOST UNWELL CHILDREN SHOULD NOT BE GIVEN UNADJUSTED MAINTENANCE - BUT IT IS THE BASIS FROM WHICH OUR CALCULATIONS ARE MADE.

    • daily fluid intake which replaces the insensible losses (from breathing, through the skin, and in the stool)
    • allows excretion of the daily production of excess solute load (urea, creatinine, electrolytes etc) in a volume of urine that is of an osmolarity similar to plasma.
    • volume calculated per kilo.
     Patients weight mls/day   mls/hour
     3 to 10kg  100 x wt  4 x wt
     10 - 20kg  1000 plus  50 x (wt-10)  40 plus  2 x (wt-10)
     >20kg  1500 plus  20 x (wt-20)  60 plus  1 x (wt-20)

    100mls/hour (2400mls/day) is the normal maximum amount.

    CLICK HERE FOR CALCULATOR

    Weight (kg)   6  8  10  12  14  16 20   30  40  50 60   70
     Ml/hr  16  24  32  40  44  48  52  60  70  80 90   100  100


    Additional Notes

    There is often confusion about the difference between oral and IV fluid requirements for young infants. The water requirement is identical for both routes of administration. The relatively low energy density of milk means that infants need 150-200mls/kg/day to obtain adequate nutrition. That is why they pass more dilute urine than older children.