Intravenous fluid therapy

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Read the full CAHS clinical disclaimer

Aim

To guide staff in the use of intravenous fluid therapy in children. Refer to Intravenous Fluid Management – Medication Management Manual (internal WA Health only).

Resuscitation Fluid^1,2,3

Reason	Fluid	Volume / rate
To restore circulatory volume, if shocked: - Tachycardia - Capillary refill >2 seconds (centrally) - Hypotension	Crystalloid (1st line): 0.9% sodium chloride Balanced solutions (e.g. Plasma-Lyte 148) are an alternative to sodium chloride 0.9% if available4 Packed red blood cells (RBC)	10-20mL/kg boluses repeat if required Reassess and repeat until no longer shocked In blood loss aim to start with boluses of RBC if shocked, otherwise boluses of sodium chloride 0.9% until RBC available To be administered as fast as possible

Reason

Fluid

Volume / rate

To restore circulatory volume, if shocked:

- Tachycardia
- Capillary refill >2 seconds (centrally)
- Hypotension

Crystalloid (1st line): 0.9% sodium chloride

Balanced solutions (e.g. Plasma-Lyte 148) are an alternative to sodium chloride 0.9% if available4

Packed red blood cells (RBC)

10-20mL/kg boluses repeat if required

Reassess and repeat until no longer shocked

In blood loss aim to start with boluses of RBC if shocked, otherwise boluses of sodium chloride 0.9% until RBC available

To be administered as fast as possible

Maintenance fluids^3,5

Reason	Fluid	Volume/rate
Maintain hydration by replacing:	Choice according to age:	The volume is weight related
Normal losses (renal, gastrointestinal tract) insensible losses (lungs, skin)	Neonate (< 4 weeks): Glucose 10% Child (≥ 4 weeks to 18 years): Sodium chloride 0.9% + glucose 5%. Only change to intravenous fluids containing potassium chloride when patient is passing urine. Prescribe available standard (premixed) infusion solutions whenever possible. Refer to Appendix 1 Table 2. Potassium chloride^3,5: Dose: 2 - 6mmol/kg/24 hours Max Rate: Give no more than 0.2mmol/kg/hour (max 10mmol/hour) without prior discussion with a PCC Consultant. Refer to the PCH Potassium Chloride Monograph - Medication Manual (internal WA Health only) for further information on administration and monitoring. Never bolus fluids containing potassium chloride. Potassium chloride should be delivered from the maintenance fluid bag. Extra potassium must not be added to standard (premixed) bags containing potassium.	<10kg = 100mL/kg/24 hours 10-20kg =1000mL +(50mL for each kg over 10kg)/ 24 hours >20kg=1500mL+(20mL for each kg over 20kg)/ 24 hours

Reason

Fluid

Volume/rate

Maintain hydration by replacing:

Choice according to age:

The volume is weight related

Normal losses (renal, gastrointestinal tract) insensible losses (lungs, skin)

Neonate (< 4 weeks): Glucose 10%

Child (≥ 4 weeks to 18 years): Sodium chloride 0.9% + glucose 5%.

Only change to intravenous fluids containing potassium chloride when patient is passing urine. Prescribe available standard (premixed) infusion solutions whenever possible. Refer to Appendix 1 Table 2.

Potassium chloride^3,5:
Dose: 2 - 6mmol/kg/24 hours
Max Rate: Give no more than 0.2mmol/kg/hour (max 10mmol/hour) without prior discussion with a PCC Consultant.

Refer to the PCH Potassium Chloride Monograph - Medication Manual (internal WA Health only) for further information on administration and monitoring.

Never bolus fluids containing potassium chloride. Potassium chloride should be delivered from the maintenance fluid bag.

Extra potassium must not be added to standard (premixed) bags containing potassium.

<10kg = 100mL/kg/24 hours

10-20kg =1000mL +(50mL for each kg over 10kg)/ 24 hours

>20kg=1500mL+(20mL for each kg over 20kg)/ 24 hours

Deficit replacement fluids

Reason	Fluid	Volume / rate
Restore hydration by replacing fluids already lost:	Depends on clinical condition:	Deficit = weight x % dehydrated x 10
e.g. gastroenteritis, burns	Vomiting / diarrhoea – sodium chloride 0.9% + glucose 5% Refer to Burns – Intravenous (IV) Fluids - ED Guidelines Refer to Pyloric Stenosis – ED Guidelines	Fluid calculator If normonatraemic rehydrate over 24 hours If hypernatraemic or hyperosmolar rehydrate over 48 hours

Calculate the total fluid amount for 24 hours = maintenance fluid + deficit fluid.

Hourly rate (mL/hour) = total fluid amount/24 hours.

You can enter the child’s weight and estimated percentage dehydration into the Fluid Calculator and print out all the appropriate calculations.

For fluids in diabetic ketoacidosis: Refer to the Diabetic ketoacidosis Emergency Department Guideline.

Special Considerations

Any decision to stop IV therapy, (e.g. when transferring a patient to a ward area or undergoing a procedure such as X-ray etc) must be authorised by a Senior Nurse or Doctor.

If a patient is receiving IV hydration for a period greater than 24 hours, monitoring of electrolytes is recommended.

Standard Fluids

Standard intravenous fluids are those that are commercially pre-made and available at Perth Children’s Hospital. Standard (pre-mixed) intravenous fluids supplied by an external manufacturer are always preferred wherever possible.

Standard intravenous fluids kept at PCH that are supplied from Baxter via Health Support Services (HSS) are described below in Table 1.

High risk fluids, i.e. those containing potassium or those that are significantly hyper or hypo-osmolar are to be stocked within automated dispensing machines (ADMs) and not left in clinical areas. High risk fluids that are supplied from Baxter via pharmacy are described in Table 2.

Non-Standard Fluids

Only where it is clinically appropriate should patients receive a non-standard intravenous fluid.

As the preparation of non-standard intravenous fluids requires specialised medication compounding knowledge, the following must be observed:

During normal hours – Where possible, they will be prepared within Pharmacy. If this is not possible, Pharmacy will give advice on its preparation.
After hours – Contact the on-call pharmacist for advice.

Some non-standard intravenous fluids, because of their significant hyperosmolarity (i.e. fluids greater than 900 mOsm/L), are not suitable for administration via a peripheral intravenous line. Contact Pharmacy for advice.

Table 1: Standard bulk intravenous fluids supplied via HSS

Fluid	Sizes available
Sodium chloride 0.9%	50mL, 100mL, 250mL, 500mL, 1000mL
Sodium chloride 0.45%	500mL
Water for injection	1000mL
Compound Sodium Lactate (Hartmanns)	1000mL
Compound Sodium Chloride (Ringers)	1000mL
Electrolyte Replacement Solution (Plasma-Lyte 148 pH 7.4)	500mL
Sodium Chloride 0.9% with Glucose 5%	1000mL
Sodium Chloride 0.45% with Glucose 2.5%	500mL
Sodium Chloride 0.22% with Glucose 10%	500mL
Sodium Chloride 0.18% with Glucose 4%	500mL
Glucose 5%	50mL, 100mL, 250mL, 500mL, 1000mL
Glucose 10%	500mL
Mannitol 10%	1000mL
Mannitol 20%	500mL

Table 2: Standard bulk intravenous fluids supplied via Pharmacy

Fluids	Sizes available
Potassium chloride 20mmol/L in sodium chloride 0.45% with glucose 5%	1000mL
Potassium chloride 20mmol/L in sodium chloride 0.9%	1000mL
Potassium chloride 20mmol/L in sodium chloride 0.9% with glucose 5%	1000mL
Potassium chloride 20mmol/L with magnesium chloride 5mmol/L in sodium chloride 0.45% and glucose 5%	1000mL
Potassium Chloride 30mmol/L in Compound Sodium Lactate (Hartmanns)	1000mL
Potassium chloride 40mmol/L in sodium chloride 0.9%	1000mL
Potassium chloride 40mmol/L in sodium chloride 0.9% with glucose 5%	1000mL
Sodium chloride 3%	1000mL

References

Advanced Paediatric Life Support: The Practical Approach. 6th ed Australia and New Zealand Version. Wiley-Blackwell, 2016
Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine Eighth Edition. Journal of Pediatric Critical Care 8.2 (2021): 116. Web. Kundan Mittal..
Textbook of Paediatric Emergency Medicine 3rd Edition Cameron P, Browne GJ, Mitra B, et al (2018) Publisher: Elsevier Edition updated
Vandana A et al. Plasmalyte versus normal saline as a resuscitation fluid in children: A randomized controlled trial. Journal of Pediatric Critical Care, 2021; 3(8): 134-138
Nelson Textbook of Pediatrics: 21st Edition Robert M. Kliegman, St Geme JW, Blum MJ et al. 2020 Publisher: Elsevier
AMH Children’s Dosing Companion (2022) Australian Medicines Handbook Pty Ltd, [Internet] Browse by drug - AMH Children's Dosing Companion (health.wa.gov.au)

Endorsed by:	CAHS Drug & Therapeutics Committee	Date:	Jun 2022
		Review date:	Apr 2025

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