Pediatric Intravenous Fluid Therapy

- Executive Summary

Intravenous fluid therapy is an essential component of care for most hospitalized children. It is very common everyday practice in pediatric inpatient, emergency, critical care as well as day care settings. Providing appropriate fluid therapy is integral to patient care. Monitoring, prevention and correction of electrolyte disturbances is also a critical aspect in acutely ill and hospitalized children.

In addition to the general practice of fluid therapy, there are a variety of special situations

requiring specific goals and practices regarding fluid therapy. Trauma, burns, perioperative

patients and those with metabolic disturbances such as diabetic ketoacidosis, salt-losing adrenal

crisis and AKI may require specific fluid protocols.

This guideline focuses on the composition of IVF needed to preserve a child’s extracellular volume while simultaneously minimizing the risk of developing volume depletion, fluid overload, or electrolyte disturbances, such as hyponatremia or hypernatremia. The goal is to promote safe and effective fluid therapy for pediatric patients in various settings of care

➡️Guideline development process and methods

After reviewing all the inclusion and exclusion criteria and quality appraisal results, the GDG/ GAG recommended using the following source original clinical practice guidelines (CPGs):

1- AAP: Clinical Practice Guideline: Maintenance Intravenous Fluids in Children (2018)

2- ESPGHAN/ESPEN: ESPGHAN/ESPEN Guidelines on Pediatric Parenteral Nutrition: Fluids and Electrolytes (2018)

3- ACCM: American College of Critical Care Medicine guidelines (2017)

4- SSC: Surviving Sepsis Campaign Guidelines (2020)

5- NSW: Standards for Pediatric Intravenous Fluids: NSW health (2015)

6- Starship: Intravenous Fluids and Electrolytes in PICU. Starship child health (2019)

7- Rch: Intravenous Fluids. The Royal Children’s Hospital Melbourne (2020)

We conducted Adolopment for these guidelines: (Adoption, Adaptation, and Development)

         -   Adoption for most of the guideline recommendations.

         -  Development of Good Practice Statements

➡️Recommendations and Good Practice Statements (GPS)

This version of the CPG includes recommendations and good practice statements on the following four sub-sections:

A. Providing appropriate fluid therapy to promote safe and effective therapy for pediatric patients in various settings of care

B. Monitoring, prevention and correction of electrolyte disturbance.

We can summarize the guidelines’ recommendations for Pediatric Intravenous Fluid Therapy in the following:

·  We recommend that normal maintenance fluid requirements in children and infants beyond the neonatal period : (Holliday and Segar formula)

A. the first 10 kg; 100 /kg/day (4ml/kg/hour)

B. weight between 10 and 20 kg +50 ml/extra kg/d (+2 ml/extra kg/h)

C. weight above 20 kg +20 ml/extra kg/d (+1 ml/extra kg/h)

Sum total requirements A +B+ C. (strong recommendation).

·  We suggest that 2/3 of normal maintenance rate should be used in most unwell children unless they are dehydrated. (Weak (conditional) recommendation).

·  We suggest that 20-50% increase in maintenance fluids may be required in patients on radiant heaters. (Weak (conditional) recommendation).

·  We suggest that bnormal losses should be replaced as well. The losses of the preceding 4 hours should be replaced over the following 4 hours. (Weak (conditional) recommendation).

·  We suggest that negative balance (intake below maintenance requirements) is suggested in patients with fluid overload. (Good practice statement).

·   We recommend that Isotonic solutions with appropriate potassium and dextrose are preferred in sick pediatric patients requiring maintenance IV fluids especially during the first 24h. (Strong recommendation).

·  We suggest that fluids with 0.45% sodium chloride content or balanced electrolyte solutions may be considered alternatives (Weak (conditional) recommendation).

·  We recommend that maintenance potassium chloride at 20 mmol/L may be added unless arterial or venous K is greater than 5mmol/L. (Strong recommendation).

·  We recommend that final mixture glucose concentration of 5% is recommended when no other source of carbohydrate is provided. (Strong recommendation).

·  We suggest that different concentrations of glucose may be used:
In children older than 6 months with any brain problem, glucose should only be added if required. (Weak (conditional) recommendation).

·  We suggest that glucose concentration of 10% is suggested in infants below six months of age. (Weak (conditional) recommendation).

·  We suggest that glucose concentration of 10% is required in critically ill patients with acute hepatic failure or suspected in-born errors of metabolism. (Good practice statement)

·  We recommend that patients with hypovolemic shock or distributive shock (including septic & anaphylactic shock) should receive fluid resuscitation:             

Amount: 20 mL/Kg per bolus, Type: isotonic crystalloid (eg normal saline) (30)

Duration: push or rapid infusion over 5-10 min. (Strong recommendation).

· We suggest that patients with cardiogenic shock should only receive fluid resuscitation if they are judged to have preload insufficiency.

Cardiac ultrasonography evaluation is recommended during such assessment. (Good practice statement).

·  We suggest that patients with poor cardiac function may also be volume depleted. Smaller boluses (5-10 mL/kg) should be given more slowly (over 10-20 min) for these patients. (Good practice statement).

·  We recommend that fluid resuscitation should be avoided or discontinued when there is evidence of intravascular volume overload.

During fluid resuscitation, monitor for the development of increased work of breathing, rales, hypoxemia, cardiac gallop rhythm, hepatomegaly or a diminishing MAP-CVP.

Initial volume resuscitation should be omitted if rales or hepatomegaly are present. (Strong recommendation).

·   We recommend that fluid boluses may be repeated with the goal of normal perfusion, cardiac output and blood pressure provided there are no signs of fluid overload.

A total of up to 60 mL/Kg may be needed during the first hour.

(Strong recommendation).

· We suggest that patients should be assessed for the presence & severity of dehydration and deficits should be replaced according to the degree of dehydration. (Good practice statement).

·  We suggest that replacement should generally be over 24 hours; however:

- Longer duration is required in cases of diabetic ketoacidosis (48h) or hypernatremia (48-72h)

- Rapid rehydration over 3-6hrs (min. 6hrs in infants) may be used in cases with gastroenteritis except when rapid fluid administration needs to be avoided (eg heart failure, sodium disturbances). (Good practice statement).

· We suggest that 0.9% saline or a balanced electrolyte solution, with 5% glucose and appropriate potassium, is recommended for replacement of ongoing losses or dehydration. (Weak (conditional) recommendation).

·  We suggest that commercially available rehydration solutions with appropriate (20-30mmol/L) potassium may be an alternative. (Good practice statement).

· We suggest that treatment of hyponatremia must be based on the underlying cause. Corrections of severe hyponatremia should be slow, over at least 48-72h. (Weak (conditional) recommendation).

· We suggest that correction of hypernatremia should be addressed using free water replacement. In dehydrated patients, a hypotonic fluid (such as 0.45 saline), with appropriate glucose & potassium, should be given at 1.25-1.5 times normal maintenance. (Good practice statement).

·   We recommend that plasma glucose & electrolytes should be checked at the onset of IV fluid therapy and at least daily. (Strong recommendation).

We recommend that patients receiving IV fluids should be monitored for signs of dehydration, oedema/ overload, daily weight and fluid intake/ output. (Strong recommendation).

➡️Guideline Registration

PREPARE (Practice guideline REgistration for transPAREncy), WHO Collaborating Center for Guideline Implementation and Knowledge Translation, EBM Center, University of Lanzhou, Lanzhou, China. Registration Number: ((submitted and in process)). Link: http://www.guidelines-registry.org/