Pediatric Maintenance Fluid Recommendations for the Emergency Unit
For pediatric patients in the emergency unit requiring intravenous maintenance fluids, use isotonic balanced crystalloid solutions (such as Ringer's Lactate) at a restricted volume of 65-80% of the Holliday-Segar calculation, with glucose supplementation and daily electrolyte monitoring to prevent hyponatremia and fluid overload. 1
Fluid Type and Composition
Tonicity
- Isotonic fluids must be used to reduce the risk of hyponatremia in acutely ill children 1
- This represents Level A evidence with strong consensus from the ESPNIC 2022 guidelines 1
- Hypotonic solutions (0.18% saline) should be avoided, as they significantly increase hyponatremia risk (14.3% incidence vs 1.72% with isotonic fluids) 2
Balanced vs Unbalanced Solutions
- Balanced crystalloid solutions (Ringer's Lactate) should be preferred over normal saline to reduce length of stay 1
- This carries Level A evidence for acutely ill children and Level B evidence for critically ill children 1
- Avoid lactate-buffered solutions in severe liver dysfunction to prevent lactic acidosis 1
Glucose Content
- Sufficient glucose must be included in maintenance fluids, guided by at least daily blood glucose monitoring to prevent hypoglycemia 1
- Avoid excessive glucose to prevent hyperglycemia, which requires daily monitoring 1
Electrolyte Supplementation
- Potassium should be added based on clinical status and regular monitoring to avoid hypokalemia 1
- Routine supplementation of magnesium, calcium, and phosphate is not recommended without signs of deficiency 1
- Vitamins and trace elements should not be routinely supplemented 1
Volume Calculation and Restriction
Standard Approach
- Calculate baseline requirements using the Holliday-Segar formula, then restrict to 65-80% of this calculated volume 1
- This restriction is recommended for acutely and critically ill children at risk of increased ADH secretion 1
Special Populations Requiring Greater Restriction
- For children with edematous states (heart failure, renal failure, hepatic failure): restrict to 50-60% of Holliday-Segar calculation 1
Total Fluid Accounting
- Include ALL fluid sources in daily calculations: IV fluids, blood products, IV medications (infusions and boluses), line flushes, and enteral intake 1
- This does not include replacement fluids or massive transfusion 1
Monitoring and Reassessment
Frequency
- Reassess at least daily for fluid balance and clinical status 1
- Monitor electrolytes regularly, especially sodium levels 1
- Monitor blood glucose at least daily 1
Goals
- Avoid fluid overload and cumulative positive fluid balance to prevent prolonged mechanical ventilation and increased length of stay 1
- This represents Level D evidence but strong consensus 1
Route Considerations
- Consider enteral or oral route if tolerated to reduce length of stay and costs 1
- This carries Level C evidence for acutely ill children 1
- IV maintenance should be reserved for children who cannot tolerate enteral intake 1
Important Clinical Caveats
Distinction from Resuscitation
- These recommendations apply to maintenance fluids only, not resuscitation for shock 1, 3
- For septic shock requiring resuscitation, different protocols apply (20 mL/kg boluses with reassessment) 1
Common Pitfall: Traditional Holliday-Segar at Full Volume
- The traditional approach of using hypotonic fluids at full Holliday-Segar rates is outdated and dangerous 1, 2
- This practice significantly increases hyponatremia risk, which can cause neurological damage or mortality 4, 2
Fluid Creep Prevention
- Be vigilant about "fluid creep" from multiple sources (medications, flushes, blood products) 1
- Many centers underestimate total fluid intake when not accounting for all sources 5