What types of intravenous (IV) fluids are recommended for pediatric patients with head trauma?

Intravenous Fluid Therapy in Pediatric Head Trauma

For pediatric patients with head trauma, isotonic balanced crystalloid solutions should be used as the first-line IV fluid therapy to reduce the risk of hyponatremia and maintain adequate cerebral perfusion. 1

Initial Fluid Selection

• Isotonic fluids are strongly recommended for pediatric patients with head trauma to prevent hyponatremia, which can worsen cerebral edema 1
• Balanced crystalloid solutions (such as Plasmalyte) should be favored over 0.9% sodium chloride (normal saline) to reduce length of stay and avoid hyperchloremic metabolic acidosis 1, 2
• In severe head trauma specifically, normal saline may be preferred over lactated Ringer's solution due to concerns about the lactate buffer in patients with potential liver dysfunction 1, 3
• Hypotonic solutions should be strictly avoided as they can worsen cerebral edema and increase intracranial pressure 4

Fluid Volume Considerations

• Fluid restriction should be considered in head trauma patients due to the risk of increased antidiuretic hormone (ADH) secretion, which can lead to fluid retention and cerebral edema 1
• For patients at risk of increased ADH secretion (including head trauma), restrict maintenance fluid volume to 65-80% of the volume calculated by the Holliday-Segar formula 1
• Aggressive crystalloid resuscitation should be avoided as higher volumes (>20 cc/kg) in the first hour have been associated with increased mortality in pediatric trauma patients 5
• For initial resuscitation in shock, an initial fluid bolus of 20 mL/kg is suggested, with subsequent patient reassessment before additional fluid administration 1

Specific Fluid Components

• Glucose provision should be included in maintenance IV fluids to prevent hypoglycemia, with regular blood glucose monitoring (at least daily) 1
• Potassium should be added to maintenance fluids based on the child's clinical status and regular potassium level monitoring 1
• There is insufficient evidence to recommend routine supplementation of magnesium, calcium, and phosphate in maintenance IV fluids 1

Special Considerations for Head Trauma

• Mannitol may be used for reduction of intracranial pressure and brain mass at a dose of 1-2 g/kg body weight or 30-60 g/m² body surface area over 30-60 minutes 6
• Small or debilitated patients should receive a reduced mannitol dose of 500 mg/kg 6
• Avoid fluid overload and cumulative positive fluid balance to prevent prolonged mechanical ventilation and increased length of stay 1
• Regular reassessment of fluid balance, clinical status, and electrolytes (especially sodium levels) should be performed at least daily 1

Monitoring Parameters

• Regular monitoring of serum sodium is crucial to detect early hyponatremia 1
• Blood glucose should be monitored at least daily to guide glucose provision in IV fluids 1
• Fluid balance should be assessed daily, accounting for all sources of fluid input including IV medications, blood products, and line flush solutions 1
• Neurological status should be continuously monitored for signs of increased intracranial pressure 1

Common Pitfalls to Avoid

• Using hypotonic fluids, which can worsen cerebral edema and increase intracranial pressure 4
• Excessive fluid administration, which can lead to cerebral edema and worse outcomes 5
• Failing to monitor electrolytes, especially sodium levels, which can affect neurological status 1
• Using lactate-containing solutions in patients with severe liver dysfunction 1
• Administering fluid boluses without reassessment, which can lead to fluid overload 1