Continuous IV Fluid Administration Clinical Pathway — Inpatient

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Out-of-scope Locations

PICU, N/IICU, CICU, CCU, Day Medicine

Out-of-scope Conditions

Heart failure
Parenteral Nutrition
Hypoglycemia
Suspected Metabolic
Disease
Confirmed SIADH
DKA
Diabetes Insipidus
Adrenal insufficiency

Abnormal renal function
Nephrotic syndrome
Severe anemia
Neurosurgical patients
Pre- and post-
chemotherapy hydration
Tumor Lysis Syndrome
Burns

Child > 28 Days Who Requires
Continuous IV Fluids (IVF) for Illness

Healthy Euvolemic Child NPO for Procedure/Sedation/Anesthesia
- NPO Guidance
- IV Fluid Recommendations

Assess for Dehydration
Mucous membranes, skin turgor, etc.
or compare to baseline weight

Isotonic fluid boluses until euvolemia restored

Initial Sodium Level	IVF Recommendations	KCl Considerations	Calculating Maintenance Rate 4-2-1 Rule
Low 125-134 mmol/L Review SIADH Risk Factors	Preferred Dextrose 5% and 0.9% NaCl with KCl at maintenance rate SIADH risk factors present, consider 2/3 maintenance rate Alternative Dextrose 5% and lactated ringer’s Consider compatibility issues based on fluid’s electrolyte composition	Add KCl to maintenance IVF when: Renal function (based on urine output and serum creatinine) and serum potassium are both normal < 10 kg Add 10 mEq/L KCl ≥ 10 kg Add 20 mEq/L KCl Lactated ringer’s contains 4 mEq/L potassium	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 Max rate of 120 ml/hr
Normal 135-145 mmol/L or Value unknown
High 146-155 mmol/L	Dextrose 5% and 0.45% NaCl with KCl at maintenance rate

Frequent Reassessment

Reassess hydration status, oral intake, and ongoing losses q6-12hr, adjust IVF accordingly
Monitor for electrolyte changes
Sodium persistently high (> 155 mmol/L) or low (< 130 mmol/L) consider Nephrology Consult
Adjust fluid composition and rate to make up for ongoing losses
Review Electrolyte Composition of Various Body Fluids

Posted: October 2014
Last Revised: March 2024

Authors:
- L. Copelovitch, MD;
- L. Utidjian, MD;
- L. Simon, MD;
- J. Hart, MD;
- D. Whitney, MD;
- T. Nelin, MD;
- M. Dunn, MD;
- E. Kane, MD;
- S. Goka, MD;
- D. Richards, MD;
- M. McShane, MD;
- E. Vaimberg, MD;
- A. Johnson, MD;
- A. Moore PharmD

Editors: Clinical Pathways Team

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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

Evidence