Paediatric IV Fluid Guidelines

Aaron Carr #11 06/2014

1
PAEDIATRIC IV FLUID GUIDELINES

Resuscitation Fluids

Acceptable Fluids:
o 0.9% Sodium Chloride
o Hartmanns Solution (Ringer-Lactate Solution, Compound Sodium Lactate)
o 5% Human Albumin Solution (HAS, PPS)

Dose:
o 20ml/kg, repeat as required
o 10ml/kg in Trauma, repeat as required
o 10ml/kg over 30-60mins in DKA, Can be repeated to a maximum of
30ml/kg

Cautions:
o Refer to Sepsis 6 pathway if septic shock is suspected
o Any child receiving 40ml/kg or more of fluid resus should automatically be
referred for an anaesthetic opinion.
o Trauma patients should receive 10ml/kg of blood following 40ml/kg fluid
resus.

(Sutherland & Sedgeworth, 2006),
http://guidelines.nhshighland.scot.nhs.uk/Paediatric/Ketoacidosis/home.htm
(Farmer, 2011)
(Advanced Life Support Group, 2011)


Fluid in Hypoglycaemia

Acceptable Fluid:
o 10% Glucose

Dose:
o 2ml/kg Bolus

(Resus Council, 2010)

Paediatric IV Fluid Guidelines
Aaron Carr #11 06/2014
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IV Maintenance Fluids

Acceptable Fluids:
o 0.45% Sodium Chloride / 5% Glucose
o 0.9% Sodium Chloride / 5% Glucose
o 0.18% Sodium Chloride / 10% Glucose
For Infants of up to 1 Week Old only

Give isotonic 0.9% Saline based solutions to children who are at high risk of
hyponatraemia or require neuroprotective measures
(NPSA, 2007)

If K
+
is indicated, use the pre-prepared potassium containing bags up to a
maximum concentration of 20mmol/500ml via the peripheral route. Higher
concentrations can be given enterally or via a Central Venous Catheter. In
exceptional circumstances where these routes are inappropriate, potassium can
be infused peripherally with maintenance fluid at 40mmol/500ml by following
the guidelines for administration of strong K
+
solutions detailed below.
(DHSSPSNI, 2007)

Monitoring:
Check blood glucose frequently. Infants may require additional glucose, which
may need to be added to the bag (refer to Non-standard Glucose Solutions
sheet).
(Sutherland & Sedgeworth, 2006)

Minimum of daily U&Es while on IV maintenance fluids.
4-6 hourly if Na
+
is less than 130 mmol/litre).

If plasma Na
+
is less than 130 mmol/litre, or greater than
160 mmol/litre, or plasma Na
+
changes more than 5 mmol/litre in 24 hours, child
requires consultant led review.
(DHSSPSNI, 2007)








Paediatric IV Fluid Guidelines
Aaron Carr #11 06/2014
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IV Maintenance Fluid Calculation for Infants:

Age
0 Days 1 Days 2 Days 3 Days 1
Month
1 Month 10kg
ml/kg/Day 60 90 120 150 100

Infants are sometimes given more than 150ml/kg/Day via the enteral route, but
should never receive more than this IV.

Total daily volume should be divided by 24 to give an hourly rate in ml/hr.

IV Maintenance Fluid Calculation for Children:

For Children greater than 10kg, IV Maintenance fluids volumes are calculated by
the following formula:

o For the first 10kg - 100ml/kg/day
o For the second 10kg - 50ml/kg/day
o For each additional kg - 20ml/kg/day
o Total Daily Requirement = Sum of Above
o Hourly Requirement = Sum 24

TO A MAXIMUM OF 80ml/hr for Girls & 100ml/hr for Boys
(DHSSPSNI, 2007)

Worked Example:

Maintenance fluids for a 35kg child:

0 10kg = 10 x 100 = 1000ml
11 20kg = 10 x 50 = 500ml
>20kg = 15 x 20 = 300ml
TOTAL = 1800ml / day

Hourly fluid requirement = 1800 = 75ml/hr
24hrs

Paediatric IV Fluid Guidelines
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Volumes of continuous infusions and enteral intake should be deducted
from maintenance fluids to ensure children keep within daily limits for
total fluid intake.

Worked Example:

35kg child hourly fluid requirement = 75ml/hr
Enteral intake = 20ml/hr
Continuous drug infusion(s) = 10ml/hr

Therefore IV Maintenance should run at 45ml/hr

Similarly, if a patient is receiving large bolus volumes of IV drugs over the course
of the day, this total will need to be deducted from their daily fluid requirement,
and their hourly maintenance rate calculated accordingly.


Fluids for IV Drug Infusions

Acceptable Fluids:

o 0.9% Sodium Chloride
o 5% Glucose

Continuous drug infusions should be made up in 0.9% Saline or 5% Glucose
unless otherwise specified.

o 0.9% Sodium Chloride / 5% Glucose

Aminophiline and Salbutamol often represent a significant proportion of a
childs fluid allowance and should be made up in 0.9% Saline / 5% Glucose. This
should maintain blood sugars while providing isotonic hydration.

Exceptions to these guidelines may have to be made in children who are
hypernatraemic or hypoglycaemic.







Paediatric IV Fluid Guidelines
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Replacement of Pre-Existing Losses

In the case of significant dehydration, replacement fluid can be given hourly in
addition to normal maintenance.

Acceptable Fluids:
o 0.9% Sodium Chloride

Dose:
Weight:

kg
Clinically Assessed Percentage Dehydration:

%
Total replacement required:
Weight (kg) x Percentage Dehydration x 10
ml
Enter the volume of resuscitation fluid given:

ml
Subtract the volume of resuscitation fluid given
from the total replacement required:
ml
Divide by 48 to give the hourly replacement
requirement:
ml/hr
For 48 hrs
(Adapted from Farmer, 2011)


Replacement of Ongoing Losses

Acceptable Fluids:
o 0.9% Sodium Chloride +/- 10-20mmol KCl/500ml using a pre-prepared
bag.
o 5% Human Albumin Solution (HAS, PPS) may be considered for Drain losses

Dose:
o Calculate fluid losses 1-4 hourly and replace ml/ml
o Surgical or renal losses may be Replaced dependant on specialist advise

(DHSSPSNI, 2007)




Paediatric IV Fluid Guidelines
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Non-Standard Glucose Infusions

Sodium Chloride 0.45% / Glucose 10%
o Withdraw 55ml from a 500ml bag of
0.45% Sodium Chloride / 5% Glucose
o Add 55ml Glucose 50%
o MIX WELL

Sodium Chloride 0.45% / Glucose 12.5%
o Withdraw 82.5ml from a 500ml bag of
0.45% Sodium Chloride / 5% Glucose
o Add 82.5ml Glucose 50%
o MIX WELL

Sodium Chloride 0.45% / Glucose 15%
o Withdraw 110ml from a bag of
0.45% Sodium Chloride / 5% Glucose
o Add 110ml Glucose 50%
o MIX WELL

Sodium Chloride 0.9% / Glucose 10%
o Withdraw 55ml from a 500ml bag of
0.9% Sodium Chloride / 5% Glucose
o Add 55ml Glucose 50%
o MIX WELL

Sodium Chloride 0.9% / Glucose 12.5%
o Withdraw 82.5 ml from a 500ml bag of
0.9% Sodium Chloride / 5% Glucose
o Add 82.5ml Glucose 50%
o MIX WELL

Sodium Chloride 0.9% / Glucose 15%
o Withdraw 110ml from a 500ml bag of
0.9% Sodium Chloride / 5% Glucose
o Add 110ml Glucose 50%
o MIX WELL

(Adapted from Sutherland & Sedgeworth, 2006)


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Non standard solutions can be made up using dextrose saline with 10mmol or
20mmol of Potassium Chloride added as a pre-prepared bag. A small amount of
Potassium Chloride will be lost in the discarded volume, but this is considered
acceptable.

Label bag with amount of additive and resultant total concentration of fluid
components. Label to be affixed on front of bag in-between fluid type and expiry
date information.

Fluid Inventory

All NHS Highland facilities which receive sick children should hold stock of the
following:

0.9% Saline
10% Glucose
0.45% Saline 5% Glucose
0.9% Saline 5% Glucose

Rural General Hospitals and equivalent may ideally stock the following if space
allows (listed in descending order of importance):

0.45% Saline 5% Glucose + 10mmol KCl / 500ml Bag
0.45% Saline 5% Glucose + 20mmol KCl / 500ml Bag
0.9% Saline 5% Glucose + 10mmol KCl / 500ml Bag
0.9% Saline 5% Glucose + 20mmol KCl / 500ml Bag
















Paediatric IV Fluid Guidelines
Aaron Carr #11 06/2014
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Guidelines for the Administration of
Strong K
+
Solutions
Maintenance Fluids
In rare circumstances, it may be clinically expedient to administer K
+
solutions of
greater than 20mmol/500ml via the peripheral IV route where the use of enteral
potassium supplementation or the placement of a central line is considered
inappropriate.

This must be a consultant led decision and be prescribed by an ST3
Paediatrician or above to a maximum of
40mmol K
+
/ 500ml Maintenance fluid. The same doctor must then
make up and check the fluid bag along with the bedside nurse.

Acceptable Fluids:
o 0.45% Sodium Chloride / 5% Glucose
o 0.9% Sodium Chloride / 5% Glucose

Do not add potassium to a ready-to-use solution which already contains
potassium; instead add the entire K
+
requirement to a plain bag of maintenance
fluid using concentrated Potassium Chloride 20mmol in 10ml. This minimises
opportunities for error.

Shake the bag vigorously following addition of concentrated Potassium
for at least 1 minute.
Fatalities have been reported following insufficient mixing of Potassium
containing solutions.

Affix Drugs Added To This Infusion label to the front of the fluid bag in-
between fluid type and expiry date information.

Administration:
o Admit child to the HDU.
o Nurse on an ECG monitor and record observations hourly on an HDU Chart
o Peripheral IV Catheter must be the largest that can realistically be sited and
be in good condition. If in doubt, re-site IV Cannula.
o Child to be nursed with IV insertion site visible at all times and not covered
by a bandage.
o Infusion site to be checked hourly.
o U&E to be checked 4-6 Hourly.





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References

Advanced Life Support Group (2011) Advanced Paediatric Life Support: The Practical Approach
(APLS) 5
TH
Edition, Wiley-Blackwell

Department of Health, Social Services and Public Safety (2007) Paediatric Parenteral Fluid
Therapy (1 month 16 yrs). Available at: http://www.dhsspsni.gov.uk/hsc__sqsd__20-
07_wallchart.pdf

Farmer,G (2011) Management of Ketoacidosis in Children. Available at:
http://guidelines.nhshighland.scot.nhs.uk/Paediatric/Ketoacidosis/home.htm

National Patient Safety Agency (2007) Reducing the risk of hyponatraemia when administering
intravenous infusions to children. Available at:
http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60073&type=full&servicet
ype=Attachment

Resuscitation Council (UK) (2010) Paediatric Emergency Treatment Chart. Available at:
http://www.resus.org.uk/pages/PETchart.pdf

Sutherland, A. Sedgeworth, C. (2006) Scottish Paediatric Retrieval Service Intravenous Medicine
Information. Available at:
http://www.snprs.scot.nhs.uk/SPRS%20Monograph%2014%2008%2006.pdf