Can D10 (10% dextrose) one third normal saline (0.9% sodium chloride solution) IV fluid be used as a maintenance IV fluid?

D10 One-Third Normal Saline as a Maintenance IV Fluid

D10 one-third normal saline can be used as a maintenance IV fluid, but isotonic solutions (like normal saline with appropriate dextrose) are now recommended as first-line maintenance IV fluids for most pediatric patients due to significantly lower risk of hyponatremia.

Current Recommendations for Maintenance IV Fluids

• The American Academy of Pediatrics (AAP) recommends that patients 28 days to 18 years of age requiring maintenance IV fluids should receive isotonic solutions with appropriate KCl and dextrose because they significantly decrease the risk of developing hyponatremia 1
• Isotonic solutions (such as 0.9% saline) are preferred over hypotonic solutions (such as one-third normal saline or 0.3% saline) for maintenance IV therapy 1
• The use of hypotonic fluids has been associated with an increased risk of hospital-acquired hyponatremia 1

Composition Considerations

• D10 refers to 10% dextrose solution, containing 10 grams of dextrose per 100 mL 2
• One-third normal saline contains approximately 0.3% sodium chloride (about 51 mEq/L of sodium) 1
• D10 one-third normal saline is considered a hypotonic solution 1

Safety Concerns with Hypotonic Solutions

• Multiple clinical trials have demonstrated that hypotonic maintenance fluids increase the risk of hyponatremia compared to isotonic fluids 1
• This association has been found with both 0.2% saline (34 mEq/L sodium) and 0.45% saline (77 mEq/L sodium) 1
• The risk for hyponatremia with hypotonic fluids persisted even in patients who received fluids at a restricted rate 1
• Hyponatremia can lead to hyponatremic encephalopathy, which is a medical emergency that can be fatal or lead to irreversible brain injury if inadequately treated 1

Specific Clinical Scenarios Where D10 One-Third Normal Saline May Be Used

• In patients with tyrosinemia type I presenting with acute liver disease, intravenous 10% dextrose/normal saline solutions at 1.5-2.0 times the normal IV fluid maintenance rate for age may be used to maintain normoglycemia 1
• In patients with hypoglycemia, D10 has been shown to be effective and safe 3

Monitoring Recommendations

• If using hypotonic fluids like D10 one-third normal saline, frequent laboratory monitoring of serum electrolytes is necessary 1
• Patients at high risk for developing electrolyte abnormalities (those who have undergone major surgery, ICU patients, those with large gastrointestinal losses, or those receiving diuretics) require more frequent monitoring 1
• If neurologic symptoms that could be consistent with hyponatremic encephalopathy are present (unexplained nausea, vomiting, headache, confusion, or lethargy), electrolytes should be measured immediately 1

Special Populations and Considerations

• Certain patient populations are at particularly high risk for hyponatremia, including those with congenital or acquired heart disease, liver disease, renal failure or dysfunction, or adrenal insufficiency 1
• Patients receiving certain medications (desmopressin, antiepileptic medications like carbamazepine, and chemotherapeutic agents) are also at higher risk for developing hyponatremia 1
• Patients with edematous states (CHF, cirrhosis, nephrotic syndrome) have impaired ability to excrete both free water and sodium and require careful fluid management with close monitoring 1

Conclusion

While D10 one-third normal saline can technically be used as a maintenance IV fluid in certain specific situations, current evidence and guidelines strongly favor isotonic solutions for most pediatric patients requiring maintenance IV fluids to prevent iatrogenic hyponatremia. If hypotonic fluids must be used, close monitoring of electrolytes is essential.