Clinical Practice Guidelines

Intravenous fluids


  • Statewide logo

    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

    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.
    • Remember to check compatibility of intravenous fluid with any intravenous drugs that are being co-administered.

    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 0.9% sodium chloride (normal 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

    This guideline should be used as a starting point and will need to be adjusted in ALL unwell children.

    Generally 2/3 of maintenance rate should be used in unwell children unless they are dehydrated.  This is because they are likely to be secreting anti-diuretic hormone (ADH), so will need less fluid.  Children with meningitis or other acute CNS conditions will likely require additional fluid restriction – seek senior advice.

    For fluid options in the dehydrated child see dehydration guidelines.

    Weight (kg) Full Maintenance (mL/hour)
    Well child eg fasting for theatre 
     2/3 maintenance (mL/hour)
    Most unwell children eg pneumonia, meningitis
     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?

    Some good fluid solutions for sick children include: 

    Fluid  Alternative names  Uses
     0.9% sodium chloride   Normal saline Initial boluses
    Replacement of deficit
    Replacement of losses

     Plasma-Lyte148 and 5% Glucose

    (contains 5mmol/L of potassium)

     

     Maintenance hydration

    (this should be the standard maintenance fluid prescribed at RCH)

    Replacement of deficit

    Replacement of losses

     Plasma-Lyte148 and 5% Glucose with 20mmol/L potassium

    (15mmol/L of KCl will need to be added to a standard bag to bring the concentration to 20mmol/L)

     

     Maintenance hydration - should only be used for children with hypokalaemia

    Replacement of deficit

    Replacement of losses

     0.9% sodium chloride and 5% Glucose +/- 20mmol/L KCl  Normal saline with glucose

    Maintenance

    Replacement of deficit

    Replacement of losses

    Consider whether potassium is required in the fluid.  This should be avoided, if possible, unless premade fluid bags containing potassium are available.  Adding potassium to bags of fluid on the ward is a safety risk.

    Hypotonic fluid (containing a sodium concentration less than plasma) is no longer recommended in children.  These fluids have been associated with morbidity/mortality secondary to hyponatraemia.  Fluids that should NOT be given include:

    0.18% NaCl with 4% glucose +/- KCl 20mmol/L (or 4% and 1/5 NS) should NOT be given


    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 emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Information Specific to RCH

    From February 2016, Plasma-Lyte148 and 5% Glucose will be the standard maintenance fluid prescribed.

    0.45% sodium chloride and 5% glucose +/- KCl (or 5% and ½ NS) should NOT be given.

    Children on intravenous fluids need daily electrolyte monitoring.

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

    Calculating maintenance fluid:

    Calculating Maintenance fluid rate:
    Most unwell children should have a restriced (2/3) maintenance rate prescribed.  The basis from which calculations are made are detailed below
    • 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 Full Maintenance 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) [S1] 

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

    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.