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Fluid and Electrolyte Administration in Children 1

Hospital-wide Patient CareClinicalPracticeGuideline

Validonlyondateprinted:2008-12-0921:46.Discardimmediatelyafteruse!

Fluid and Electrolyte Administration in

ChildrenIssuingDepartment:

EducationandQuality Category: PatientAssessment&Monitoring

Issuing Authority: RonaldLaxer Sub-Category: Management

Section Name: PatientManagement Publication Status:  Approved

Content Reviewer: DesmondBohn Last Modified: 2007-12-0420:32

Additional Editors: DenisGeary Additional Readers: RonaldLaxer,LynnUrmson

Written By: DesmondBohn-DepartmentChief,CriticalCareMedicine AmandaHurdowar-QualityAnalyst

Review CommitteeName:

MedicalAdvisoryCommittee

1.0 Introduction 

Sodiumisthemajorcationoftheextracellularfluid(ECF)compartmentandtogetherwithchlorideanionconstitutesthemajoreffectiveosmolalityofthatspace.Potassiumandphosphatearethemajorintracellularionsandthetwocompartmentsareseparatedbyasemi-permeablemembranewhichallowsfreeflowofwaterbetweentheintracellularfluid(ICF)andtheECFwithnoosmolargradientbetweenthem.Serumosmolarityistightlyregulatedbyosmoreceptorsinthehypothalamus.Anyminorincreaseinosmolalityissensedbythesereceptorsandcausesthereleaseofantidiuretichormone(ADH)andtheexcretionofaconcentratedurine.LoweringofserumosmolalitynormallyinhibitsthereleaseofADHandtheexcretionofadiluteurine.Saltandwaterhomeostasisisfrequentlyabnormalinhospitalizedpatientsandhyponatraemia(PlasmaSodium(PNa)<135mmol/l)isthemostcommonlyoccurringelectrolyteabnormality,which,exceptinrarecircumstances(e.g.hyperglycaemiaorhypertriglyceridemia),indicatesalowserumosmolalityandanexpandedICFcompartment.

Acute hyponatraemia,definedasafallinserumsodiumto<130mmol/Lwithin48hours,whichcanresultinacutecerebraloedemaandbrainstemherniation,hasfrequentlybeenassociatedwiththeadministrationofintravenous(IV)hypotonicfluidsinchildren,particularlyintheperioperativeperiod.Thesepatientsretainwaterduetothefailureofthenormalphysiologicalresponse,whichwouldbetheinhibitionofADHsecretionandexcretionofadiluteurine.Non-physiologicalstimuliforADHsecretionincludepain,vomiting,anxiety,narcotics,anestheticagentsandpositivepressureventilation.Isotonicfluids,whichcontainnoelectrolytefreewater,willreducethisriskbutnoteliminateit.Studieshaveshownthatintraoperativevolumeexpansionwithisotonicfluidsresultsintheexcretionofahypertonicurineandtheriskofhyponatraemia,aprocessreferredtoasdesalination.Theuseofhypotonicsalineinthepostoperativeperiodincreasestheriskofdevelopingacutehyponatraemia.

2.0 Definitions

Definition Serum [Na+] mmol/L

Normal/referencerange 135-145

Hyponatraemia <135

 AcuteHyponatraemia ReductioninPNato<130mmol/Lin48hrs

ModerateHypernatraemia 150-169

SevereHypernatraemia >169

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3.0 Clinical Practice Recommendations

Thepurposeofthisclinicalpracticeguidelineistofacilitateappropriatescreening,prescriptionandmonitoringofIVfluidsandelectrolyteadministrationinpatientsadmittedtoSickKidsortreatedintheEmergencyDepartment.Thetargetusersofthisguidelinearephysicians,nursesandparamedics.

ThisguidelineshouldbefollowedwhenprescribingIVmaintenancefluids,definedasthoseestimatedtoreplacenormalphysiologicurineoutputandinsensiblelosses,inchildrennotreceivingenteralfluidorthosewithreducedoralintake.Recommendationsonthetypeofsolutiontobeusedforfluidbolustherapyarealsoincluded.IVfluidsprescribedtoreplacelossesfromtheGItractandotherECFcompartmentsshouldbeofthesameelectrolytecompositionasthefluidthatisbeinglost.Thisguidelinedoes not apply topatientsintheneonatalintensivecareunit.

Indications: Intravenousfluidsareprescribedinpaediatricpatientsforthefollowingindications:(a)maintenancefluidtherapy toreplaceestimatednormalphysiologicurineoutputandinsensiblelossesinpatientswithreducedornooralintake;(b)bolusfluidtherapy toexpandthecirculatingvolumeinchildrenwithhypovolaemiaorshock;or(c)fluidtherapytoreplaceabnormallosses fromtheGItractandotherbodycavities.

3.1 General Principles3.1.1  AnyhospitalizedchildrequiringIVfluidsshouldbeconsideredatriskofnon-physiological

(inappropriate)ADHsecretion.Groupsparticularlyatriskidentifiedinpublishedcaseseriesincludechildrenundergoingsurgeryandthosewithacutemedicalillnessesincludingmeningitis,encephalitis,bronchiolitisandpneumonia.Intheabsenceofaneedtocorrectafluiddeficitinthesepatients,IVfluidsshouldbeadministeredattherateof60-70%oftheusualcalculationfornormalmaintenancerequirementsandintheformofisotonicsalineorRinger'sLactate.Thetypeoffluidchosenshouldbebasedontheguidelinesbelow.(GradeC)

3.1.2 Oralfluidintakemustbeincludedinestimationoffluidrequirements.Mostoralfluidsareveryhypotonic.(i.e.lowsodiumconcentration)BoththevolumeandtheconcentrationofsodiuminIVandoralfluidsareimportantcontributorstodevelopmentofhyponatraemia.(GradeC)

3.1.3 ProprietaryenteralfluidpreparationsandTPNsolutionsarelowinsodium(<40mmol/L)andmaybeasubstantialsourceofelectrolytefreewater.PatientsonlongtermTPNandwhoarenotacutelyillarenotatincreasedriskforthedevelopmentofacutehyponatraemia.(GradeC)

3.1.4 Infantsandyoungchildrenhavelimitedglycogenstoresandsalinesolutionswithaddeddextrosearerequiredtopreventhypoglycaemiaandketosis.(GradeC)

3.1.5 Childrenwithcardiacfailure,renalfailureandhepaticfailurewithasciteshavechronicallylowPNavaluesbecauseofwaterretentionand/orabnormalitiesoftherenin/angiotensinmechanism.Thesepatientshavechronichyponatraemiaandarenotatriskforthedevelopmentofcerebraloedema.(GradeC)

3.2 Assessment

3.2.1 BeforestartingIVfluids,baselineserumelectrolytes(Na,K,glucose,urea,creatinine)shouldbe

measured.2

PatientsundergoingdaysurgerywheretheIVisdiscontinuedattheendofthecasedonotneedtheirelectolytesmeasured.(GradeC)

3.3 Prescription of IV fluid therapy

3.3.1 2/3 & 1/3 (0.3 NaCl with 3.3% dextrose) is no longer available in the hospital .0.2%NaCl withdextroseand5or10%dextroseinwaterallcontainsubstantialamountsofelectrolytefreewater

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andmust not be used as maintenance IV fluids .1-3

Patientswithademonstratablefreewaterdeficitmayrequiretheadministrationofthesetypesofhypotonicsolutions.TheuseofthesefluidsisrestrictedtotheCCU,NICU,andNephrologyservices.ConsultationshouldbeobtainedfromNephrologyifthesesolutionsarebeingconsidered.(GradeB)

3.3.2 IVfluidbolusesshouldonlybeusedinchildrenwithsignificantECFcontractionorimpending

shockandonlyintheformofisotonicsaline(0.9%NaClorRingersLactate ).TheinjudicioususeofIVbolustherapywilltransientlyoverexpandtheECFcompartmentandresultinanincreaseintherenalsodiumexcretion.(GradeC)

3.3.3 IVfluidtherapytoreplacelossesfromtheGItractshouldonlybeintheformofisotonicsaline(

0.9%NaClorRingersLactate ).4

Solutionswithaddeddextrosemayberequiredbasedonpatientageandthebloodglucoselevel.(GradeB)

3.3.4 Untilserumelectrolytevaluesareknown,whenstartingIVmaintenancefluids,0.9%NaClor

RingersLactate arerecommended.1,3

Solutionswithaddeddextrosemayberequiredbasedonpatientageandthebloodglucoselevel.Thissolutionshouldbeadjustedwhenserumelectrolyteresultsbecomeavailable.(GradeC)

3.3.5 Ifserumsodiumislessthan138mmol/L,0.9%NaCl,

5 

orRingersLactate shouldbeprescribed.Solutionswithaddeddextrosemayberequiredbasedonpatientageandthebloodglucoselevel.(GradeC)

3.3.6 Ifserumsodiumisbetween138-144mmol/L,IVfluidsshouldcontainasodiumconcentrationof

77-154mmol/Lsuchas0.45%NaCl,2 

0.9%NaCl ,orRingersLactate .Solutionswithaddeddextrosemayberequiredbasedonpatientageandthebloodglucoselevel.(GradeC)

3.3.7 Ifserumsodiumisbetween145-154mmol/L,theIVfluidsodiumconcentrationshould

approximateonehalfnormalsaline(0.45%NaCl .5

Solutionswithaddeddextrosemayberequiredbasedonpatientageandthebloodglucoselevel.PatientswithraisedintracranialpressuremayrequiretheincreasesinPNatohypernatraemiclevelstotreatcerebraloedema.(GradeC)

3.3.8 Patientswithhypernatraemia(PNa>154mmol/L)haveeitherawaterloss(dehydration)orsaltgain(theuseofIVsolutionswithahighsodiumconcentration).Infantsandyoungchildrenwithseverehypernatraemiaduetodehydration(freewaterloss)areatriskforthedevelopmentofcerebraloedemawithrapidrehydrationwhenhypotonicsalineisused.Thedeficitshouldbereplacedslowly,initiallywithisotonicsaline.(ConsultNephrology)Patientswithhypernatraemiaduetosaltgainmayreceivehypotonicfluidssuchas0.2%NaCl(eg.0.2%NaClwithdextrose).(Refertorecommendation3.3.1).(GradeC)

3.3.9 Perioperativefluidsshouldonlybeintheformofisotonic(0.9%NaClorRingersLactate ).Solutionswithaddeddextrosemayberequiredbasedonpatientageandthebloodglucoselevel.IntheabsenceoftheneedtocontinuewithIVfluidsforthereplacementofongoinglossestheIV

shouldbediscontinuedorreducedtominimumandpatientsencouragetotakeenteralfluids.6

(GradeB) 

3.3.10  Althoughthedataonacutehyponatraemiacomefromcasereportsandcasesseriesthelimitednumberofpublishedprospectivestudiessuggestthattheuseofisotonicsalineislesslikelyto

resultinhyponatraemiaanddoesnotresultinhypernatraemia.4,6,7

(GradeB)

3.4 Monitoring

3.4.1 Patientsreceiving>50%ofmaintenancefluidsbytheIVrouteshouldhaveatleastdailymeasurementsofserumelectrolytesandglucose.(GradeC)

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3.4.2  AllchildrenreceivingIVfluidshaveanaccuratedailyintakeandoutputrecordkeptand,whenfeasible,dailyweightmeasurement.(GradeC)

3.5 Diagnosis and treatment of acute symptomatic hyponatraemia

3.5.1  Acutesymptomatichyponatraemiaisamedicalemergencyandrequiresrapidandaggressivetreatmenttopreventthedownwardspiralofseizures,apneoaandbrainstemconing.Thecommonfeaturesoftheonsetofcerebraloedemaduetohyponatraemiaarelethargy,diminishedlevelofconsciousness,headacheandvomiting.MostcaseshavebeenreportedinchildrenwherethePNalevelhasfallenfromnormallevelsto<125mmol/Lwithin48hoursbutcanoccurathigherlevels.Acutehyponatraemiashouldbesuspectedwherethereisthenewonsetof

seizuresinpatientsreceivinghypotonicIVfluids.8

(GradeC)

3.5.2 DiscontinuetheIVfluidbeingadministeredandgive2-3mL/kgof3%NaClor1g/kgmannitolrapidly.(GradeC)

3.5.3 Notifythecriticalcareunit.(GradeC)

3.5.4 MeasuretheserumelectrolytesandcorrectthePNatoabove130mmol/Lacutelyusingeither2-3mL/kgof3%saline(repeatifnecessary)or1g/kgmannitol,administeredrapidly.(GradeC)

3.5.5 ChangeIVmaintenancefluidtoisotonicatminimallevels.(GradeC)

3.6 Assessment & prescribing recommendations summary

Assessment: Lab Tests

Condition Lab Tests to be orderedPrior to IV fluidadministration

Serum electrolytes (Na, K, glucose, urea, creatinine)Timing: At the time of the decision to administer

ALL patients receivingmaintenance IV fluids at

50% calculatedmaintenance levels orreplacement IV fluids forongoing losses

Daily serum electrolytes (Na, K)Daily intake and output

Daily weight measurement

Prescription of IV Fluids

Condition Recommendations for IV Fluids prescription Na mmol/L0.9%NaClwithorwithoutdextrose*or 154V Bolus (use for

severe ECFContraction

/impending Shock)

RingersLactatewithorwithoutdextrose* 130

0.9%NaClwithorwithoutdextrose*or 154erioperative

RingersLactatewithorwithoutdextrose* 130

0.9%NaClwithorwithoutdextrose*or 154nknownserum [Na+]

RingersLactatewithorwithoutdextrose*

(contains4mmol/Lpotassium)130

0.9%NaClwithorwithoutdextrose*or 154erum [Na+] < 138mmol/L RingersLactatewithorwithoutdextrose* 130

IVfluidsshouldcontainasodiumconcentrationof77-154mmol/Lsuchas:

0.45%NaClwithorwithoutdextrose*or 77

0.9%NaClwithorwithoutdextrose*or 154

Serum [Na+] =138 – 144 mmol/L

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RingersLactatewithorwithoutdextrose* 130

FormaintenanceIVfluid,sodiumconcentration

shouldapproximateonehalfnormalsaline,suchas:

Serum [Na+] =145 – 154 mmol/L

0.45%NaClwithorwithoutdextrose 77

Serum [Na+]

>155 mmol/L**

0.2%NaClwithdextroseforsaltgainorisotonic

salineforfreewaterloss(Seebelowfordetails)

34

*Solutions with added dextrose may be required based on patient age and the blood glucose level .

KCl to be added to IV solutions depending on plasma level .

** Patients with severe hypernatraemia due to dehydration (free water loss) are at risk for cerebral

oedema with rapid rehydration using hypotonic saline . A nephrology consult is required . Patients

with hypernatraemia due to salt gain should receive hypotonic fluids .

For a summary of this guideline , click on the Fluid and Electrolyte Administration

in Children CPG Summary --> 

4.0 Implementation of CPG

¨ Factorsorprocessesthatwillassistwithimplementationo Reorganizethe2-bincartsinthehospital:Takeoffwhatwedonotwantused(i.e.0.2%

NSwithdextrose)butmaintainthisinCCU,NICUservicesandasrequiredbyareaformedicationadministration.

¨ Organizationalchangesthatmayberequiredtoapplytherecommendationso ReviewKidCareordersets,remove2/3-1/3andrestrict0.2%NaClwithdextrose,D5W,D10W

¨ Keyreviewcriteria/indicatorsformonitoringandauditpurposeso Audittoseethepercentageofpatientswhoarehavingtheirelectrolytesmeasuredo Audittoseehowmanytimessolutionswith0.2%NaClwithdextrose,D5W,D10Ware

prescribedand%validcases

5.0 Related Documents

National Patient Safety Agency (UK) Patient Safety Alert: Reducing the risk of Hyponatraemia whenadministering IV infusions to children . Issued March 28, 2007

6.0 Statement of Evidence  AliteraturesearchwascompletedusingMedline(1966-2007),Embase(1980-2006),theCochraneLibrary,personalfilesandreferencelists,usingkeywords:fluidtherapy,hypotonicsaline,andhyponatraemia.Asystematicreviewanddetailsoftheliteraturesearchhavebeen

publishedpreviously.1

TheCPGdevelopmentgroupmetonseveraloccasionstodiscusstheliteratureandtodraftrecommendations.

Table1servesasaguidelinetothehierarchyofevidenceavailable;withmeta-analysisconsideredtobethehighestlevelofevidenceandexpertopinionconsideredtobethelowestlevelofevidencethatcanbeusedtosupporteachrecommendationinthisCPG.

Table 1. Grades of Recommendation

A At least one randomized controlled trial , systematic review, or meta-analysis.

B At least one cohort comparison , case study or other experiment study .

C Expert opinion, experience of a consensus panel .

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7.0 References

1. ChoongK,KhoM,MenonK,BohnD.Hypotonicversusisotonicsalineinhospitalizedchildren:Asystematicreview.ArchDisChild2006.2. IntraveneousFluidsClinicalPracticeGuideline,RoyalChildren'sHospital.Melbourne,Australia;

200X.3. TaylorD,DurwardA.Pouringsaltontroubledwaters.ArchivesofDiseaseinChildhood2004;89(5):411-4.4. NevilleKA,VergeCF,RosenbergAR,O'MearaMW,WalkerJL.Isotonicisbetterthanhypotonicsalineforintravenousrehydrationofchildrenwith gastroenteritis:aprospectiverandomizedstudy. ArchDisChild2006;91(3):226-32.5. HoornEJ,GearyD,RobbM,HalperinML,BohnD.Acutehyponatremiarelatedtointravenousfluidadministrationinhospitalizedchildren:anobservationalstudy.Pediatrics2004;113(5):1279-84.6. BurrowsFA,ShutackJG,CroneRK.Inappropriatesecretionofantidiuretichormoneinapostsurgicalpediatricpopulation.CritCareMed1983;11(7):527-31.7. WilkinsonE,RieffJ,RekateHL,BealsS.Fluid,blood,andbloodproductmanagementinthecraniofacialpatient.PediatricNeurosurgery1992;18(1):48-52.8. SarnaikAP,MeertK,HackbarthR,FleischmannL.Managementofhyponatremicseizuresinchildrenwithhypertonicsaline:asafeandeffectivestrategy.CritCareMed1991;19:758-762.

8.0 Guideline Groupand Reviewers

Guideline Group Membership :DesmondBohn,DepartmentChief,CriticalCareMedicine1.RonaldLaxer,VPEducationandQuality2.BarbaraBruinse,ManagerforClinicalResponseTeam,VascularAccess3.BruceDodgson,StaffAnaesthetist,Anaesthesia4.DenisGeary,DivisionHead,Nephrology5.KusielPerlman,EndocrinologistEndocrinology;6.LynnUrmsonAssociateRiskManager,QualityManagement7.SanjayMahantStaffPhysician,PaediatricMedicine8.ValerieLanglois,StaffNephrologist,Nephrology9.

UnniNarayanan,OrthopaedicSurgeon,Surgery10.MarijaBojic,GeneralDutyRN,6AWard,11.CarolynBeck,StaffPaediatrician,PaediatricMedicine12.

Internal reviewers:Dr.JamesWright,ChiefofSurgery1.Dr.DenisDaneman,ChiefofPaediatrics2.Ms.PamelaHubley,AssociateChiefofNursing3.Dr.JohnathonMaguire,ChiefResident,Dept.OfPaediatrics4.

External reviewers:Dr.TrevorDuke,RoyalChildren’sHospital,Australia1.Dr.TerryKlassen,StolleryChildren’sHospital,Edmonton,AB2.

Dr.MajulaGowishanker,StolleryChildren’sHospital,Edmonton,AB3. Dr.TimFrewen,Children'sHospitalofWesternOntario,London,ON4.Dr.RamSingh,PaediatricCriticalCareChildren'sHospitalofWesternOntario,London,ON5.

Reviewerswereselectedtoreflectdifferentbackgroundsandperspectives.Theircommentsandsuggestionswereconsideredandthedocumentamendedaccordingly.

Keywords:IVFluids;HyponatraemiaChange Level

 ©The Hospital for Sick Children. All Rights Reserved. This document is specific to SickKids internal activities at the

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time of printing. SickKids does not accept responsibility for use of this material by any person or organization notassociated with SickKids. No part of the document should be used for publication without appropriateacknowledgement.