Normal Saline Order for Dehydrated Patients
Initial Assessment and Fluid Selection
For dehydrated patients, administer isotonic crystalloid solutions—either normal saline (0.9% NaCl) or balanced crystalloids like Ringer's lactate—with normal saline being the most widely used and cost-effective option for initial resuscitation. 1, 2
Specific Orders by Severity and Age
Severe Dehydration (Resuscitation Phase)
Administer 20 mL/kg boluses of normal saline (0.9% NaCl) intravenously, repeated until circulation normalizes. 2 This typically requires 60-100 mL/kg over the first 2-4 hours. 3
- For adults and older children: Rapid boluses of 20 mL/kg can be given 2
- For infants and young children: Same 20 mL/kg boluses, repeated as needed 2
- Reassess after each bolus for signs of improved perfusion (capillary refill, mental status, urine output) 3
Moderate Dehydration
Oral rehydration solution (ORS) is first-line therapy for moderate dehydration, not intravenous normal saline. 4 However, if IV therapy is required due to ORS failure:
- Administer normal saline at 100 mL/kg over 2-4 hours 4
- For infants unable to drink but not in shock: Consider nasogastric ORS at 15 mL/kg/hour before resorting to IV 1, 4
Maintenance Fluids After Resuscitation
Once circulation is restored, transition to isotonic maintenance fluids with dextrose and potassium. 2, 3
For pediatric patients:
- Use D5 0.9% NaCl (or D5 Ringer's lactate) with 20 mEq/L KCl added 2, 3
- Never use hypotonic solutions (sodium <130 mEq/L) as they significantly increase hyponatremia risk 2
For adults:
- Continue 0.9% saline or switch to balanced crystalloids at maintenance rates 1
- Standard rate: 1-1.5 mL/kg/hour 1
Ongoing Loss Replacement
Replace ongoing stool and emesis losses with additional normal saline or ORS: 4
- Children <2 years: 50-100 mL after each stool 1, 4
- Older children: 100-200 mL after each stool 1, 4
- Adults: As much as desired, though persistent dehydration warrants reassessment 1, 4
Critical Pitfalls to Avoid
Do not use hypotonic saline (0.45% or 0.2% NaCl) for initial resuscitation or in hospitalized children for maintenance—this significantly increases hyponatremia risk. 2 The number needed to harm is only 7.5 patients. 2
Monitor for hyperchloremic acidosis when administering large volumes of normal saline. 1, 5 Balanced crystalloids like Ringer's lactate may reduce this risk and slightly decrease hospital length of stay (by approximately 0.35 days), though normal saline remains acceptable. 5
In anaphylaxis, use normal saline exclusively—avoid lactated Ringer's as it may contribute to metabolic acidosis. 2
For burn victims, Ringer's lactate is preferred over normal saline as it has composition closer to plasma and may reduce acute kidney injury risk. 2
Monitoring Parameters
Reassess hydration status every 3-4 hours during active rehydration: 1
- Skin turgor and mucous membrane moisture 4
- Mental status and perfusion (capillary refill, extremity warmth) 4
- Urine output (target >1 mL/kg/hour) 1
- Weight changes throughout therapy 4
If vomiting occurs during fluid administration, wait 10 minutes then continue more slowly—most fluid is retained despite apparent vomiting. 6 Do not use antiemetics as they cause drowsiness and interfere with continued therapy. 6