What is the protocol for Intravenous (IV) fluid maintenance?

From the Guidelines

Intravenous fluid maintenance should be guided by the Holliday-Segar formula, with a strong emphasis on using isotonic fluids to reduce the risk of hyponatremia, and balanced solutions to slightly reduce length of stay, as recommended by the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) guidelines 1.

Key Considerations

• The use of isotonic fluids is strongly recommended to reduce the risk of hyponatremia in acutely and critically ill children 1.
• Balanced solutions should be favored when prescribing intravenous maintenance fluid therapy to slightly reduce length of stay in critically ill children 1.
• The Holliday-Segar formula should be used to calculate daily fluid requirements, with adjustments made based on the patient's clinical condition, underlying diseases, and ongoing losses 1.
• Patients with heart failure, kidney disease, or electrolyte abnormalities require special consideration and may need modified maintenance rates 1.

Monitoring and Adjustments

• Regular monitoring of the patient's fluid status, vital signs, urine output, and electrolyte levels is essential to ensure adequate hydration and prevent complications 1.
• Adjustments to the maintenance fluid rate should be made based on the patient's clinical condition, underlying diseases, and ongoing losses 1.

Special Considerations

• In children at risk of increased endogenous secretion of ADH, restriction of total intravenous maintenance fluid therapy volume to between 65-80% of the volume calculated by the Holliday and Segar formula should be considered to avoid fluid overload 1.
• In children with heart failure, renal failure, or hepatic failure, restricting maintenance fluid therapy volume to between 50-60% of the volume calculated with the Holiday and Segar formula should be considered to avoid fluid overload 1.

From the Research

IV Fluid Maintenance

IV fluid maintenance is crucial in various medical settings, including surgery, sepsis, and acute pancreatitis. The choice of IV fluid can significantly impact patient outcomes.

Types of IV Fluids

• Normal Saline (NS): a commonly used IV fluid, but it may cause hyperchloremic metabolic acidosis and has a higher risk of acidosis and hyperkalemia 2, 3
• Lactated Ringer's (LR) solution: a balanced crystalloid solution that has a sodium, potassium, and chloride content closer to that of extracellular fluid, and may be associated with improved survival in patients with sepsis-induced hypotension 4
• Ringer's Lactate (RL) solution: similar to LR, it may be a preferred crystalloid over NS in certain situations, such as pediatric craniofacial surgery, due to its lower risk of metabolic acidosis 2

Clinical Outcomes

• In pediatric craniofacial surgery, the use of RL solution was associated with less frequent acidosis and no increased incidence of hyponatremia compared to NS 2
• In acute pancreatitis, there was no significant difference in clinical outcomes between patients receiving RL and those receiving NS 5
• In sepsis-induced hypotension, initial fluid resuscitation with LR solution was associated with improved survival and more hospital-free days compared to NS 4
• In renal transplantation, LR infusion may lead to a lower serum potassium level and a lower risk of acidosis, but there is a concern of hypercoagulable state in these patients 3

Recommendations

• The choice of IV fluid should be based on the individual patient's needs and the specific medical condition being treated 6
• Balanced crystalloid solutions, such as LR and RL, may be preferred over NS in certain situations due to their lower risk of acidosis and hyperkalemia 2, 4, 6, 3