Maintenance IV Fluid Rate for D5 0.3% NaCl
D5 0.3% NaCl (dextrose 5% in 0.3% sodium chloride) should NOT be used as maintenance IV fluid in hospitalized patients—isotonic solutions (D5 0.9% NaCl or D5 Lactated Ringer's) should be used instead at standard maintenance rates calculated by the Holliday-Segar formula or weight-based dosing.
Why D5 0.3% NaCl is Not Recommended
The question asks about maintenance rates for D5 0.3% NaCl, but this hypotonic solution is explicitly contraindicated by current evidence-based guidelines:
The American Academy of Pediatrics strongly recommends isotonic solutions (D5 0.9% NS or D5 Lactated Ringer's) for maintenance IV fluids in children aged 28 days to 18 years to significantly decrease the risk of developing hyponatremia 1, 2.
The European Society of Pediatric and Neonatal Intensive Care recommends isotonic balanced solutions with glucose for most hospitalized children in acute and critical care settings 1, 2.
Hypotonic maintenance fluids (including 0.3% NaCl, which contains approximately 51 mEq/L sodium) increase the risk of hospital-acquired hyponatremia by more than 2-fold for mild hyponatremia and more than 5-fold for moderate hyponatremia 1.
The Danger of Hypotonic Solutions
Hospital-acquired hyponatremia from hypotonic fluids can cause hyponatremic encephalopathy, a medical emergency that can be fatal or lead to irreversible brain injury 1, 2.
Approximately 15-30% of hospitalized patients develop hyponatremia, and hypotonic maintenance fluids significantly contribute to this risk 1, 2.
Acutely ill patients frequently have elevated arginine vasopressin (AVP) from pain, nausea, stress, postoperative states, or pulmonary/CNS disorders, which impairs free-water excretion and places them at high risk for hyponatremia when hypotonic fluids are administered 1, 2.
Correct Maintenance Fluid Composition and Rates
Use isotonic solutions at standard maintenance rates:
For children: Calculate maintenance rate using the Holliday-Segar formula (100 mL/kg/day for first 10 kg, 50 mL/kg/day for next 10 kg, 20 mL/kg/day for each kg above 20 kg) or 1500 mL/m²/day 1.
Isotonic solutions include D5 0.9% NaCl (sodium 154 mEq/L) or D5 Lactated Ringer's (sodium 130 mEq/L), both with appropriate potassium chloride added 1.
Multiple clinical trials have demonstrated that isotonic maintenance fluids significantly decrease the risk of hyponatremia without increasing the risk of hypernatremia 1, 3.
Extremely Limited Exceptions (Rarely Applicable)
D5 0.3% NaCl or other hypotonic solutions may only be considered in these highly specific scenarios:
Cerebral malaria with volume depletion where the goal is to provide dextrose while minimizing salt that could leak into pulmonary and cerebral tissues 2.
Patients requiring active correction of documented hypernatremia, though this should be done with careful monitoring and specific correction protocols 2.
Patients with documented syndrome of inappropriate antidiuresis (SIAD) who are euvolemic and require free water replacement, but this requires close monitoring and is a specialized scenario 2.
Critical Monitoring Requirements
If isotonic maintenance fluids are used (as recommended):
Check serum sodium within 24 hours of starting maintenance IV fluids, especially in high-risk patients 2.
Monitor electrolytes at least daily in all patients receiving maintenance IV fluids 2.
If neurologic symptoms develop (unexplained nausea, vomiting, headache, confusion, lethargy), measure electrolytes immediately as these may indicate hyponatremic encephalopathy 2.
Patients at high risk (post-surgical, ICU patients, those with large GI losses or on diuretics) require more frequent laboratory monitoring 2.
Implementation Success
Quality improvement studies have demonstrated that isotonic IVF use can be increased from baseline rates of 9-20% to >80-95% through education, electronic medical record changes, and clinical decision support, without increasing adverse events 4, 5, 6, 7.
No increase in hypernatremia or other adverse outcomes has been documented with the transition from hypotonic to isotonic maintenance fluids 4, 5, 7.