What is the preferred IV fluid for a 20kg child with fever?

Preferred IV Fluids for a 20kg Child with Fever

For a 20kg child with fever, the preferred IV fluid is an isotonic crystalloid solution (such as 0.9% saline or Ringer's lactate) given as a 20 mL/kg bolus if signs of shock are present, followed by maintenance fluids calculated at 60 mL/hour. 1

Initial Assessment and Fluid Resuscitation

• Evaluate for signs of shock (tachycardia, prolonged capillary refill >2 seconds, altered mental status, decreased urine output) to determine if bolus fluids are needed 1
• If signs of shock are present, administer an initial fluid bolus of 20 mL/kg of isotonic crystalloid solution 1
• Reassess the patient after each fluid bolus for clinical response and signs of fluid overload (increased work of breathing, rales, hepatomegaly) 1
• Additional boluses may be given up to 40-60 mL/kg in the first hour if shock persists and no signs of fluid overload develop 1, 2

Maintenance Fluid Selection and Rate

• For a 20kg child, calculate maintenance fluid requirements using the Holliday-Segar formula: 3

  • First 10kg: 4 mL/kg/hour = 40 mL/hour
  • Second 10kg: 2 mL/kg/hour = 20 mL/hour
  • Total maintenance rate = 60 mL/hour

• Use isotonic solutions (0.9% saline or Ringer's lactate) rather than hypotonic solutions for maintenance fluids to reduce the risk of iatrogenic hyponatremia 2, 4, 5

• Consider balanced crystalloids (e.g., Ringer's lactate) over 0.9% saline to reduce the risk of hyperchloremic metabolic acidosis, especially if large volumes are needed 2, 6

Special Considerations

• If the child has fever but no signs of shock, avoid bolus fluids and start with maintenance fluids only 1, 2
• For a febrile child who needs glucose supplementation, add dextrose to the isotonic solution (D5 0.9% NS or D5 LR) 1, 7
• Monitor for signs of fluid overload, especially in children with underlying cardiac or renal disease 1, 2
• Avoid hypotonic solutions (such as 0.45% saline or 0.18% saline) as they increase the risk of hospital-acquired hyponatremia 8, 4, 5

Monitoring During Fluid Administration

• Regularly assess vital signs, capillary refill time, mental status, and urine output 1, 2
• Monitor for signs of fluid overload: increased respiratory rate/effort, rales, hepatomegaly 1
• In a child with fever, account for increased insensible losses and monitor for dehydration 9

Common Pitfalls to Avoid

• Administering hypotonic fluids, which can lead to iatrogenic hyponatremia 8, 4, 5
• Failing to reassess the patient after each fluid bolus 1
• Not accounting for "fluid creep" from medication administration and IV flushes, which can contribute significantly to total fluid intake 6
• Continuing with aggressive fluid resuscitation despite signs of fluid overload 1, 2