148 Maintenance Fluids

PURPOSE OF INTRAVENOUS (IV) FLUID THERAPY: WHY uMAINTENANCE"?

Parenteral fluids are typically administered to patients whose spontaneous and/or enteral
intake is insufficient to meet physiologic needs. Delivering a particular quantity of water,
dextrose, and electrolytes every hour at a weight-based "maintenance rate" is intended to
meet the cellular requirements for basic functionality. The widely used formula for calcu-
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lating this rate (the "4-2-1 rule") was developed in 1957 and was popularized as much for
simplicity as for accuracy. Its original proponents utilized a rough estimate of patient energy
requirements to extrapolate fluid needs, escalating stepwise with increases in weight, to
arrive at the "4-2-1" progression. This approximation results in a "maintenance" hourly value
providing the necessary intake to meet a minimum of one's basal metabolic needs, but likely
not those accompanying routine physical activities. It is worth noting that this formula was
developed based on data from hospitalized, bedridden patients.1

CALCULATION OF THE MAINTENANCE FLUID RATE

Based on the estimations of the rising energy requirement with each kilogram of body
weight, a patient's maintenance IV rate is calculated as shown in Table 48-1.
AB stated earlier, calculations are done according to the "4-2-1" rule. This rate can be used
solely for parental fluid administration or as a goal for the total hourly fluid intake {also tak-
ing into account continuous infusions and/or high-volume medications). Patients with nor-
mal end-organ function (e.g., those children simply nil per os [NPO] prior to surgery) may
tolerate delivery of a full "maintenance" IV fluid volume in addition to other medications,
infusions, and flushes without complication. Contrast this with a fluid-overloaded child with
multiorgan dysfunction, who may not tolerate much "surplus" IV volume without cardiopul-
monary consequences. In this instance, it may be beneficial to limit total hourly intake to the
calculated maintenance rate, delivering only a portion of the total via continuous IV fluids.
Fluid restriction, even to intake rates below maintenance, can be appropriate in patients with
impaired renal function, pulmonary pathology, or fluid overload

CHOOSING IV FLUID COMPOSITION

Choice of intravenous fluids should be made with an understanding of both the clinical situ-
ation and the respective risk-benefit profile.
The three major components of IV fluids are as follows:
• Base sodium content: One of the primary determinants of serum osmolality. All intra-
venous fluids use sodium and chloride as the primary contributors to solution tonicity
in order to allow for safe intravenous administration. IV fluids can be isotonic (similar

M iJ ,j! J!' § M Esllrnatlon of Peclatrlc MaintenMce Fluid Requll'l!lllents1

Weight {kg) Maintenance Rllte
0-10 4 mUkg/hr
11-20 40 mUhr + 2 mUkg/hr
>20 60 mUhr + 1 mUkglhr

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 Part 2: Organ Systems. Section 4: Renal/Fluids and Electrolytes

tonicity to plasma), hypotonic, or hypertonic, depending primarily on their respective

sodium and dextrose content
Serum osmolality= (2 X serum sodium)+ (blood urea nitrogen+ 2.8)

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+ (serumglucose+18)
Hypotonic fluid administration, using relatively low sodium concentrations, has been
implicated in the development of iatrogenic hyponatremia and a similarly hypotonic serum}
• Dextrose: Provides some nutritional value, typically expressed as a percentage (% = grams
of solute /100 mL of fluid volume)
o Glucose Infusion Rate (GIR): Key to avoiding a catabolic state and maintaining
euglycemia when IV fluids are the only source of calories. GIR calculation requires the
following formula:

. . [% dextrose x intravenous fluid rate (:)]

Glucose infuston
[6xWt(kg)]

o Recommendations for a minimum GIR are based on age:

5 mglkg/min for <6 years of age; 2.5 mglkglmin for years old
o aDS" (5 g/100mL volume) given at maintenance rate does not deliver an adequate GIR in
children under 6 years of age
• Additives: Provide essential electrolytes for cellular function and compensate for ongoing
losses
o Potassium: Most effectively delivered as potassium chloride. Daily potassium require-
ment related to 24-hour fluid needs; amounts to approximately 1 to 2 mEq/100 mL water.
This is typically provided using IV fluids with a potassium concentration of 20 to 40
mEq/L. Potassium acetate and potassium phosphate are also used. most often in diabetic
ketoacidosis.
o Sodium bicarbonate: Indicated in normal anion gap metabolic acidosis caused by renal or
gastrointestinal losses ofbicarbonate and in certain drug exposures or toxidromes.
The content of the most commonly used IV fluid preparations is illustrated in Table 48-2.

M i,! :I ! J !:fM Bectrolyte Camposition and Osmolalty of Commonly Used IV Fluids

%Sodium Chloride, Sodium Chloride Osmolality
Fluid Dextrose• (mEq/L) (mEq/L) (mOsm/L)
Normal saline 0.9% NaCI 154 154 308
D5 normal saline D 5%, 0.9% NaCI 154 154 560
Hypertonic saline 3%NaCI 513 513 1026
D5 half-normal saline D 5%, 0.45% NaCI 77 77 406
D5 quarter-normal saline D 5%, 0.225% NaCI 34 34 321
DSW DS%,0% NaCI 272
Lactated Ringer's 0.6% NaCit 130 109 273
Plasma 135-145 95-105 285-295
NS = normal saline, D = dextrose, W = water
"%=grams of solute /100 ml of fluid volume
tAl so contains 0.3196 sodium lactate, 0.0396 potassium chloride, and 0.0296 calcium chloride for total of 4 mEq
potassium, 3 mEq calcium, and 2 BmEq lactate per liter of lactated Ringer's

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 Chapter 48: Maintenance Fluids

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Note the osmolality of 0.9% (normal) saline and lactated Ringer's (LR), two formulations
considered isotonic to serum despite having higher and lower osmolality than blood. In
general, isotonic crystalloids (without dextrose) are appropriate for rapid administration to
provide urgent intravascular volume expansion during states of hypovolemia and/or shock.
Bolus infusion of fluids containing dextrose is avoided as it may cause a transient hypergly-
cemia, encouraging an osmotic diuresis and contributing to further volume depletion.
Examples of clinical scenarios with specific fluid recommendations:
• Metabolic acidosis: 0.9% normal saline will provide an excess chloride load while running
at a maintenance rate, potentially resulting in hyperchloremia and a worsening non-anion
gap acidosis
• Renal insufficiency, oliguria: Avoid potassium additives
• Traumatic brain injury. central nervous system (CNS) pathology: Avoid sodium chloride
concentrations less than 0.9%, hypotonic fluids and hyponatremia; avoid 5% albumin

ROUTE OF DELIVERY: IS A PERIPHERAL IV SUFFICIENT?

Most preparations are safe to administer through peripheral access, especially at rates
approximating maintenance. However, special consideration should be paid to hypertonic
formulations, such as 3% saline, which may not be safe to deliver through a peripheral vein.
Smaller-diameter vessels can be the setting for local hemolytic reactions when the hyper-
tonic solution contacts the epithelium. Central venous access allows for access oflarger-bore
vasculature, containing relatively more blood around the entry site of the catheter and its
solution. This "excess" local blood serves to "dilute" the infusing fluid before it can contact
the vessel wall and promote a reaction. As such, central venous access should be obtained
when anticipating a prolonged infusion of hypertonic fluid. A similar access plan is prudent
when giving fluids that are significantly hypotonic, such as "half-" or "quarter-normal" saline
without dextrose.
An understanding of tonicity again becomes important with higher dextrose concentra-
tions. Preparations containing more than 12.5% dextrose are usually not safe or appropriate
to deliver via peripheral access, and a central venous catheter may be required to meet nutri-
tional goals via the parenteral route if higher calories are desired.
• Central venous access: All fluids are safe, including hypotonic or hypertonic fluids,
dextrose content > 12.5%
• Peripheral access only: Isotonic fluids (0.9% NaCl or LR without dextrose or dextrose with
¥.1 normal saline [NS] or dextrose with lA NS) or any fluid with less than 12.5% dextrose
is safe

THE ADVERSE EFFECTS OF INTRAVENOUS FLUIDS

Intravenous fluids are a therapy with an appropriate dose and duration like any other
drug. Some side effects of maintenance IV fluids can carry significant morbidity and even
mortality.
Side effects of intravenous fluids include:
• Metabolic acidosis
• Tissue edema
• Organ damage to the brain, kidney, and lungs
• Sodium derangements
• Coagulation abnormalities
• Dilutional anemia leading to unnecessary blood transfusions
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 Part 2: Organ Systems. Section 4: Renal/Fluids and Electrolytes

• Fluid overload: Increasing evidence has shown that excessive fluid administration and
subsequent overload can have detrimental effects on the outcomes of all manner of pedi-
atric patients, such as those with septic shock. acute kidney injury, and acute respiratory

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distress syndrome (ARDS). In such patients, as alluded to earlier, sometimes a set goal of
"maintenance fluid delivery" must be adjusted to incorporate all sources of intravenous
intake. Additionally, patient fluid status is best viewed as another "vital sign," with cumula-
tive balance reported alongside heart rate and blood pressure. When appropriate, it may be
useful to calculate the percentage of overload in a given patient, using the following formula:

Fluid overload= [[lntake{mL) -Output{mL)]+ Wt {kg)]x100%

Percentage of fluid overload can be useful to determine management strategy, such as

initiation of diuresis or renal replacement therapy for fluid removal.

FOUR PHASES OF INTRAVENOUS FLUID THERAPY

During critical illness, dynamic physiologic changes make fluid needs time-dependent as
well. Data suggest up to 20% of critically ill patients receive "inappropriate" intravenous
fluids. A recent framework describes the changing role of IV fluids during the course of
critical illness by stratifying fluid needs by stage: rescue, optimization, stabilization and
de-escalation.
• Rescue: Active {decompensated) shock state, requires rapid isotonic fluid boluses for
volume expansion and resuscitation.
• Optimization: Compensated shock states, arrest less likely; fluid given more judiciously,
continue to optimize cardiac function, improve perfusion, and avoid {further) organ
dysfunction.
o Use gradual fluid challenges instead of rapid boluses.
• Stabilization: Steady state, absence of shock; fluid to replace ongoing losses, support basic
metabolism.
• De-escalation: Early recovery, consider cessation of extraneous fluids, work toward fluid
removal and a negative fluid balance.
Stabilization and de-escalation seek to avoid the known adverse effects of aggressive fluid
management, accumulation, and overload. Not all patients will enter critical illness in the
rescue phase, and those without signs of shock may not require any rapid fluid administra-
tion at all Of course, patients may regress at any point, which should prompt a reassessment
of fluid needs.3

REFERENCES
1. Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy.
Pediatrics. 1957;19{5):823-832.
2. Moritz ML, Ayus ]C. Intravenous fluid management for the acutely ill child. Curr Opin
Pediatr. 2011;23:186-193.
3. Hoste EA, Maitland K, Budney CS, et al. Four phases of intravenous fluid therapy:
A conceptual model. BJA. 2014;113{5):740-747.

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