Inpatient Clinical Pathway for Children who Require Continuous Administration of IV Fluids

Out-of-scope Locations
  • PICU, N/IICU, CICU, CCU, Day Medicine
Out-of-scope Conditions
  • Abnormal renal function
  • Nephrotic syndrome
  • Severe anemia
  • Neurosurgical patients
  • Pre- and post-
    chemotherapy hydration
  • Tumor Lysis Syndrome
  • Burns
Assess for Dehydration
Mucous membranes, skin turgor, etc.
or compare to baseline weight
Isotonic fluid boluses until euvolemia restored
Initial Sodium Level IVF Recommendations KCl Considerations Calculating Maintenance Rate
4-2-1 Rule

Low
125-134 mmol/L

  • Preferred
    • Dextrose 5% and 0.9% NaCl with KCl at maintenance rate
    • SIADH risk factors present, consider
      2/3 maintenance rate
  • Alternative
  • Add KCl to maintenance IVF when:
    • Renal function (based on urine output and serum creatinine) and serum potassium are both normal
  • < 10 kg
    Add 10 mEq/L KCl
  • ≥ 10 kg
    Add 20 mEq/L KCl
  • Lactated ringer’s contains
    4 mEq/L potassium
  • Weight in kgs:
    • 4 ml/kg/hr for the first 10 kg
    • plus
    • 2 ml/kg/hr for the second 10 kg
    • plus
    • 1 ml/kg/hr for each kg over 20 kg
    • Max rate of 120 ml/hr
  • Normal
    • 135-145 mmol/L
    • or
    • Value unknown

High
146-155 mmol/L

Dextrose 5% and 0.45% NaCl with KCl at maintenance rate
Frequent Reassessment
  • Reassess hydration status, oral intake, and ongoing losses q6-12hr, adjust IVF accordingly
  • Monitor for electrolyte changes
  • Sodium persistently high (> 155 mmol/L) or low (< 130 mmol/L) consider Nephrology Consult
  • Adjust fluid composition and rate to make up for ongoing losses
    Review Electrolyte Composition of Various Body Fluids
Posted: October 2014
Last Revised: March 2024
Editors: Clinical Pathways Team