Inpatient Clinical Pathway for Children who Require Continuous Administration of IV Fluids

Child Who Requires IV Fluids
For patients > 28 days and < 18 years of age
  • Out of Scope Locations
    • CCU
    • Day Medicine
  • Out of Scope Conditions
  • Parenteral Nutrition
  • Hypoglycemia
  • Suspected metabolic disease
  • Liver failure
  • Adrenal insufficiency
  • Abnormal renal function
  • Heart failure
  • Neurosurgical patients
  • DKA
  • Nephrotic syndrome
  • Severe anemia
  • Pre-chemotherapy hydration
  • Diabetes insipidus
Euvolemia Restored
Consider strategy for maintenance IVF
Initial Sodium Category IVF Recommendations

Low Sodium
125-134 mmol/L

If patients remain hyponatremic consider risk of SIADH

  • Preferred
    • Dextrose 5% and 0.9% NaCl
      Maintenance rate with potassium*
  • Alternative
    • Dextrose 5% and 0.9% NaCl
      Two-thirds Maintenance rate with potassium*

If sodium remains persistently high (> 155 mmol/L) or low (< 130 mmol/L) while following these guidelines:
Consider nephrology consult for assistance with acute management.

If patient is at risk for SIADH or hyponatremic, consider reducing infusion rate to two-thirds maintenance rate with potassium [see alternative].

Patients on prolonged IV fluids should be monitored for
electrolyte changes, especially if > 48 hours therapy, or if patient weight is < 10kg.

Dextrose 5% and lactated Ringer’s solution is an appropriate alternative to D5 normal saline.

Normal Sodium
135-145 mmol/L

(Or Sodium Value Unknown)

High Sodium
146-155 mmol/L

Dextrose 5% and 0.45% NaCl
Maintenance rate with potassium*

Ongoing Losses Replacement
Adjust fluid composition and rate to make up for ongoing losses, if applicable (Electrolyte Composition of Various Body Fluids)
Sodium bicarbonate: Consider addition only if severe ongoing losses of bicarbonate-containing body fluid
Frequent Reassessment
Reassess hydration status, oral intake, and ongoing losses every
6-12 hours and adjust fluids accordingly
Maintenance IV Fluid Rate: 4-2-1 Rule
Use patient's weight in Kgs:
  • 4 ml/kg/hr for the first 10 kg PLUS
  • 2 ml/kg/hr for the second 10 kg PLUS
  • 1 ml/kg/hr for each kg over 20 kg
  • Maximum rate of 120 ml/hr

Add potassium to all maintenance fluids if:

  • Renal function is normal based on urine output and creatinine (if checked)
  • And potassium level is normal (if checked)
  • Lactated ringers contains 4 mEq/l potassium

Patients < 10 kg
Add 10 mEq/L potassium chloride

Patients ≥ 10 kg
Add 20 mEq/L potassium chloride

Posted: October 2014
Revised: May 2022
Authors: L. Copelovitch, MD; L. Zaoutis, MD; L. Utidjian, MD; J. Edelson, MD; L. Simon, MD; J. Hart, MD;
M. Bruno, MD; B. Weinerman, MD; D. Whitney, MD, E. Salmon, MD; T. Nelin, MD