Fluid and Electrolyte Management PDF

Fluid and Electrolyte Disturbances
Title of Guideline (must include Guideline for the management of Fluids and
the word Guideline (not Electrolytes in Children
protocol, policy, procedure etc)
Contact Name and Job Title
(author) Dr Lucy Cliffe Consultant Paediatrician
Directorate & Speciality Directorate: Family Health Children

Speciality: Emergency
Date of submission November 2015
Date on which guideline must be November 2018
reviewed (one to five years)
Explicit definition of patient group All patients under 19 years who require
to which it applies (e.g. inclusion management of their fluids or electrolyte
and exclusion criteria, diagnosis) disturbance
Abstract This guideline describes the management of Fluids

and Electrolytes in Children
Key Words Fluids; electrolytes
Statement of the evidence base of the guideline has the guideline been peer reviewed
by colleagues?
1a meta analysis of randomised controlled
trials
2a at least one well-designed controlled study

without randomisation
2b at least one other type of well-designed
quasi-experimental study
3 well designed non-experimental Yes
descriptive studies (ie comparative /
correlation and case studies)
4 expert committee reports or opinions and /
or clinical experiences of respected
authorities
5 recommended best practise based on the
clinical experience of the guideline
developer
Consultation Process Paediatric Guidleine Group
Target audience All staff at Nottingham Childrens Hospita
This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will
remain the responsibility of the individual clinician. If in doubt contact a senior
colleague or expert. Caution is advised when using guidelines after the review
date.
Dr Lucy Cliffe 1 November 2015

Document Control
Document Amendment Record
Version Issue Date Author Description

V1 June 2008 Dr Lucy Cliffe
Dr Damian Wood
V2 November 2013 Dr Lucy Cliffe
V3 April 2015 Dr Martin Christian Changes made in response to high
level incident
V4 October 2015 Dr Patric k Davies Information about administration of
Andrew Wignell high strength potassium infusions
Consultation with Rachel added and clarified- Pages 18 and
Bower (PCCU Nurse 19.
Educator) and Katie
Manning (E39 Ward
Manager)
General Notes:
Summary of changes for new version
Information about administration of high strength potassium infusions added and clarified-
Pages 18 and 19.

Important
Whenever possible the enteral route should be used for giving fluids and
well children feeding orally do not require any specific fluid management.
The use of intravenous fluids requires careful prescribing and close monitoring.
This guideline is intended to be a general guideline for paediatric fluid

management and correction of salt and water imbalance for infants and children
aged 1 month post term to 18 years, looked after on a paediatric ward, who do
not have evidence of acute or chronic renal disease, diabetes mellitus or
diabetes insipidus or hypoglycaemia.
Oncology patients receiving specific fluids pre-prescribed alongside

chemotherapy should be discussed with the Oncology team if fluid or electrolyte
issues arise.
This guideline does not replace any existing guidelines in paediatric and
neonatal intensive care units or specialist areas such as the renal unit where
there may be specific indications for fluid selection.
Please see specific fluid guidelines for:
Renal patients
Diabetes Mellitus
Diabetes Insipidus
Hypoglycaemia
Burns.

Contents
Assessment of Hydration ............................................................................................. 5
Resuscitation.................................................................................................................. 6
Risk of Acute Kidney Injury (AKI) ................................................................................... 6
Fluid Requirements ....................................................................................................... 7
Hyponatraemia ............................................................................................................ 11
Hypernatraemia ........................................................................................................... 15
Hyperkalaemia ............................................................................................................. 16
Hypokalaemia .............................................................................................................. 17
References .................................................................................................................. 20
Appendix 1: Paediatric fluid summary for routine surgical patients .......................... 21
Appendix 2: IV Fluid Bags Containing Potassium ...................................................... 23

Assessment of Hydration
The clinical assessment of hydration is difficult and often inaccurate. In

children who are dehydrated the accepted gold standard of assessment is acute
weight loss but this is often not possible due to lack of accurate pre-illness
weight.
A weight should be recorded at presentation and compared to

any recent weight measurements
The following table can be used to help make an assessment of hydration status:-
Clinical Sign No Mile to Severe > Notes

dehydration Moderate 3- 10%
(<3% weight 10%
loss
Reduced urine No Yes Yes Take care to differentiate

output urine from watery stool
Dry mouth No Yes Yes Mouth breathers may have
dry mouth
Sunken eyes No Yes Yes
Reduced skin No (recoils Yes (1-2 secs) Yes (> 2 Less in hypernatraemic
turgor instantly) secs) dehydration
Prolonged capillary No Might be Yes CRT < 2 seconds may be

refill time slightly Cool / seen as normal
prolonged mottled /
pale
peripheries
Drowsiness/ No Yes Severe
Irritability
Prolonged capillary refill time, abnormal skin turgor and absent tears have been
shown to be the best individual examination measures. Dry mucous
membranes can also be useful. If two out of four of these parameters are
present the child has a high chance of being >5% dehydrated.

Resuscitation
If signs of circulatory collapse are present i.e. prolonged capillary refill time,
tachycardia and/or hypotension then immediate resuscitation of intravascular
volume must occur. This should be via intravenous or intraosseous access.
Boluses of 20 ml/kg 0.9% sodium chloride (isotonic solution) should be used.
Reassessment and repeat boluses given as necessary with consideration of
the cause of circulatory collapse i.e. blood loss, sepsis so that alternative
resuscitation fluids can be considered if appropriate.
Risk of Acute Kidney Injury (AKI)

Certain children and young people are particularly at risk of developing AKI.
Measurement of serum creatinine and comparison with baseline should be undertaken
in children and young people with acute illness and any degree of dehydration if any of
the following are likely or present:
young age, neurological or cognitive impairment or disability, which may mean
limited access to fluids because of reliance on a parent or carer with
hypovolaemia
chronic kidney disease / transplant
heart failure
liver disease
past history of acute kidney injury
oliguria (urine output less than 0.5 ml/kg/hour)
use of drugs with nephrotoxic potential (such as NSAIDs, aminoglycosides,
ACE inhibitors, ARBs and diuretics) within the past week
symptoms or history of urological obstruction, or conditions that may lead to
obstruction
sepsis
a deteriorating paediatric early warning score
haematological malignancy
hypotension.
Serum creatinine must be checked against usual baseline if available children with
limited muscle mass will have particularly low normal creatinines and even small
changes within the usual reference range may be significant for them.
In 2015-2016, an algorithm will be introduced into laboratory reports to flag potentional

cases of AKI but until this is available, care must be taken to interpret creatinine results
according to previous baseline, not usual reference range.
If serum creatinine is 1.5x or more above baseline, consult Acute Kidney Injury
guideline (renal section) for further management.
Children who are dehydrated should not be given non-steroidal anti-inflammatory drugs
like ibuprofen. If dehydration is very mild, they may be given with caution, but consider
checking U&E after 24 hours.

Fluid Requirements
Well children with normal hydration
Very few well children require intravenous fluids. However an amount

calculated as "maintenance" is used as a starting point for the estimation of fluid
requirements.
Maintenance fluid is that volume of daily fluid intake, which replaces the
insensible losses (from breathing, perspiration, and in the stool), and at the same
time allows excretion of the daily production of excess solute load (urea,
creatinine, electrolytes etc) in a volume of urine that is of an osmolarity similar to
plasma.
The following calculations approximate the maintenance fluid requirement of

well children according to weight in kg.

Calculation of maintenance fluid requirements
The daily fluid requirement may be estimated from the child's weight
using the following formula:
Example:
A 23 kg child will require
100mls/kg for the first 10kg = 1000mls

50mls/kg for the second 10kg = 500mls
20mls/kg for all additional Kg = 60 mls
Total= 1560mls
Rate= 1560/24 = 65mls/hr
While most children will tolerate standard fluid requirements, some

acutely ill children with inappropriately increased anti-diuretic hormone
secretion (SIADH) may benefit from their maintenance fluid requirement
being restricted to two-thirds of the normal recommended volume (see
list below for at risk children).
Dehydration
In some situations a fluid deficit (allowance) for dehydration needs to be

taken into account and calculated.
Fluid deficit in ml = % dehydration x weight (Kg) x 10
This estimate is calculated from the child's weight and the degree of
dehydration, which is estimated clinically.
Example:
A 23kg child who has been assessed as being moderately dehydrated

can be estimated to be 5% dehydrated.
23kg is equivalent to 23 litres. If he is 5% dehydrated his deficit is 5% of
23 litres:
5/100 X 23 x 1000 = 1150mls
The deficit is usually replaced over 24 hours and so should be added to

the total daily maintenance volume before dividing by 24 to determine
the hourly rate.
In our example
Maintenance 1560ml + 5% Deficit 1150ml = 2710ml over 24hrs =

112mls/hr
If you wish to replace the fluid deficit over a longer period (e.g. in
hypernatraemic dehydration) then add the deficit to twice the daily
maintenance and divide by 48hrs.

Which Fluid?
If intravenous fluids are necessary isotonic solutions (appendix 1) should be used

in almost all circumstances to avoid iatrogenic hyponatraemia. There is currently
little evidence to recommend a particular strength of glucose.
Our standard solution for maintenance fluids is 0.9% sodium chloride with 5%
dextrose, with or without 10 mmol KCl or 20 mmol KCl per 500ml depending on
the serum potassium.
The use of 0.9% sodium chloride solutions will provide more than the required sodium
maintenance for some children. In well children with normal renal function, this additional sodium
will be excreted. DO NOT USE THIS GUIDELINE IN CHILDREN WITH RENAL DISORDERS.
Do not use 0.18% sodium chloride with 4% glucose in any situation outside of
specialist units. The low sodium content increases the risk of the patient
developing hyponatraemia.
Some children are at high risk of hyponatraemia and the use of isotonic
solutions (i.e. 0.9% sodium chloride) along with careful monitoring is
required to avoid iatrogenic hyponatraemia in hospital
These include children who have or are:
peri- or post-operative;
require replacement of ongoing losses;
a plasma sodium at the lower normal reference range and definitely if less
than
135mmol/L;
intravascular volume depletion;
hypotension;
central nervous system (CNS) infection;
head injury;
bronchiolitis;
sepsis;
excessive gastric or diarrhoeal losses;
salt-wasting syndromes;
chronic conditions such as diabetes, cystic fibrosis and pituitary deficits.
Replace any deficit as sodium chloride 0.9% with glucose 5% (isotonic

solution) or sodium chloride 0.9% over a minimum of 24 hours.
Use solutions containing potassium once patient has passed urine and U&E
results known. Maximum 40mmol/litre concentration via peripheral iv access
see Hypokalaemia section.
If there is not a suitable solution discuss with ward pharmacist or on-call
pharmacist if outside normal working hours.
Ongoing Losses
Ongoing losses should be assessed every four hours.

Fluids used to replace ongoing losses should reflect the electrolyte
composition of the fluid being lost.

In most circumstances this will be sodium chloride 0.9% with or without the
addition of potassium.
Monitoring
Hyponatraemia can develop within a short timescale and a robust monitoring

regime is essential.
Weight should be measured, if possible, prior to commencing fluid therapy
and daily thereafter.
Fluid balance including oral intake should be recorded using a fluid balance
chart.
Plasma sodium, potassium, urea and creatinine should be measured at
baseline and at least once a day in any child receiving 50% or more of their
maintenance fluids intravenously.
Consider measuring U&Es every four to six hours if an abnormal reading is
found. This should definitely be done if the plasma sodium is below 130
mmol/L.
Check plasma electrolytes immediately if clinical features suggest
hyponatraemia is developing. Symptoms include increased headaches,
vomiting, nausea, irritability, altered levels of consciousness, seizures
and apnoea.
Ideally, use the same sampling technique, either capillary or venous blood
sampling, on each occasion. This can avoid potentially misleading changes in
serial sodium measurements.
Urine chemistry may be useful in a small number of high-risk cases or when
the cause behind an abnormal sodium result is unclear.

Hyponatraemia
Hyponatraemia is a common electrolyte abnormality in hospitalized children. It
exists when the ratio of water to sodium is increased. This can occur with low,
normal or high levels of body water and similarly low or normal levels of body
sodium. Most commonly hyponatraemia indicates an expanded extracellular fluid
volume and is less often caused by sodium (or salt) depletion. Assessment of the
childs volume status is essential in order to understand the cause of
hyponatraemia and will affect the management required.
Hyponatraemia is defined as a plasma sodium of less than 135mmol/L.

Severe hyponatraemia is defined as a plasma sodium of less than
130mmol/L.
The serum osmolality (paired with urinary osmolality) is diagnostically helpful
Causes of Hyponatraemia
Iatrogenic - Intravenous fluid administration (hypotonic solutions)

- Diuretics
- Diluted formula feeds (including Factitious illness)
- Desmopressin use
- Psychogenic polydipsia
SIADH - CNS infections
- Head injury
- Bronchiolitis, pneumonia
- Surgery
Extra-renal losses - Gastroenteritis
- Skin (sweating, burns)
- Third space losses
Renal Losses - Polyuric phase ATN
- Tubulointerstitial nephritis
- Obstructive uropathy
- Cerebral salt wasting
- Absence of aldosterone or lack of effect (e.g 21-hydroxylase
deficiency)
Other - Glucocorticoid deficiency
- Hypothyroidism
- Congestive heart failure
- Cirrhosis
- Nephrotic Syndrome
- Diabetic ketoacidosis (Hyperosmolality 2 hyperglycaemia)
The development of fluid-induced hyponatraemia in the previously well child

may not be well recognised by clinicians. Since 2000, there have been four child
deaths (and one near miss) following neurological injury from hospital-acquired
hyponatraemia reported in the UK.1-3
International literature cites more than 50 cases of serious injury or child death
from the same cause, and associated with the administration of hypotonic
infusions.4 The infusion of hypotonic fluids together with the non-osmotic
secretion of ADH may result in hyponatraemia.
A major consequence of hyponatraemia is an influx of water into the

intracellular space resulting in cellular swelling, which can cause cerebral

oedema, seizures and brain stem herniation. The clinical manifestations of
hyponatraemia are due to the low plasma osmolality. Hyponatraemic
encephalopathy is a serious complication and children are a group of patients
particularly susceptible to developing neurological complications. This is due to
the reduced space for brain swelling in the skull and impaired ability of the
paediatric brain to adapt to hyponatraemia compared to adults. Acute
symptomatic hyponatraemic encephalopathy is considered a medical emergency.
Prevent hyponatraemia by using isotonic intravenous solutions, identifying
those patients
at risk and monitoring patients as above.
Most children with mild to moderate hyponatraemia are asymptomatic
The symptoms and signs of severe hyponatraemia are predominately
neurological:
o Headache
o Nausea, vomiting
o Lethargy or irritability
o Hyporeflexia
o Decreased conscious state
o Seizures
Should clinical symptoms of hyponatraemia develop, check U & Es,

glucose and serum osmolality immediately.
Acute hyponatraemic encephalopathy is a medical emergency
The ideal rate of serum sodium correction depends on the presence and severity
of symptoms. Correction that is too rapid (>8 mmol/L Na+/24h) can result in
cerebral demyelination, especially of the pons, with risk of severe and lasting
brain injury. This is especially a risk if hyponatraemia has been present for more
than 5 days and is rapidly corrected.
The hyponatraemic child with seizures or CNS depression
Notify senior help urgently and refer to PICU.

Resuscitation (ABC) and intravenous anticonvulsants as clinically indicated.
Hyponatraemic seizures often respond poorly to conventional
anticonvulsants, and sodium correction should not be delayed. The sodium
should be raised until it reaches 125mmol/L or until seizures stop, whichever
occurs first.
Use intravenous 2.7% sodium chloride solution 4ml/kg over 15-30
minutes. It is stored on PICU. This will generally raise the serum sodium by
3 mmol/L and will usually stop the seizures. 2.7% sodium chloride is
hypertonic but can be given peripherally in an emergency and then switched
to a central venous line if there is an ongoing requirement.
Measure the serum sodium after the first bolus. Ongoing seizures and
persistent hyponatraemia will require more 2.7% sodium chloride.
Many children with hyponatraemia and seizures will have other reasons for
seizures (fever, meningitis, hypoglycaemia), and these should also be
addressed.
After the seizures have resolved the total sodium correction (including the
bolus) should not exceed 8 mmol/L per day (e.g. from 122-130mmol/L).
Measure electrolytes every hourly until stable, then every 4-6 hours until the
serum sodium is normal and the child is off intravenous fluids.

Management of Hyponatraemia
Serum Na < 135

AND Seizures or CNS
Depression
(Child in DKA see DKA
guideline)
No Yes
Notify senior help

What is the childs and refer to PICU
volume status?
Resuscitate
ABC as
necessary
Normal or Moderate Severe
increased dehydration dehydration or
and Na 130 - dehydration with
135 Na <130
Give anticonvulsants if
required
Lorazepam 0.1ml.kg IV
(max 4mgs)
Restrict to Oral/NG Maintenance Or
50% rehydration and deficit Diazepam PR or
maintenance calculate fluid Midazolam Buccal
Give 0.9% maintenance and requirements 0.5mg/kg / (max 10mgs)
sodium chloride with deficit fluid replaced with
dextrose if oral requirements 0.9% saline
route not with dextrose
possible
Give 4ml/kg of 2.7%

saline (1.8 mmol Na/kg)
IV over 15-30 mins
(peripheral ok)
Monitor
- Fluid balance, including daily weights
- Repeat U&Es 4 6 hourly if Na <130 and at least
daily if Na 130 135 Measure Na after bolus
- Assess for signs of symptomatic hyponatraemia and repeat bolus until
and recheck U&Es urgently if suspected seizures stop or NA>125
- Neuro obs 2 hourly until Na in normal range
Transfer to PICU

The child with no symptoms of hyponatraemia
Management of children without specific symptoms of hyponatraemia depends

on volume status.
Active correction of hyponatraemia (e.g. with 2.7% Sodium chloride) is not

necessary.
Allow the plasma sodium concentration to rise at no more than 8 mmol/L per day
using the guidelines below, based on hydration state. Continue correction to 135
mmol/L.
1. The child with normal or increased volume status
Restrict maintenance fluids to 50% of requirements to slowly remove the increased body water
Do not use hypotonic solutions (see above) give 0.9% sodium chloride with added dextrose if
IV fluids necessary
2 The child with moderate dehydration and serum sodium 130-135mmol/L
Try oral or nasogastric rehydration calculate maintenance and deficit requirements as above
If NG rehydration is not possible or results in a too rapid fall in sodium give intravenous 0.9%
Sodium chloride with 5% dextrose.
3 The child with severe dehydration or dehydration with serum sodium <130mmol/L
Give intravenous 0.9% Sodium chloride with 5% dextrose until the child can take enteral feeds
calculating maintenance and deficit as above
Measure electrolytes every 4 hours until stable
4 Hyponatraemia in patients with Diabetic Ketoacidosis follow separate guideline
All children should have neuro obs 2 hourly until sodium normal

Hypernatraemia
Hypernatraemia is defined as a serum sodium > 145 mmol/l however is it usually acted on
once sodium > 150 mmol/l. There are a number of causes of hypernatraemia as listed :-
Water and sodium loss - Gastroenteritis

- Burns
- Diabetes mellitus
Water deficit Diabetes insipidus (nephrogenic or central)
- Increased insensible losses e.g. preterm,
phototherapy
- Inadequate intake e.g. failure to establish
breastfeeding
Excessive sodium intake - Inappropriately prepared infant formula
- Salt poisoning
- Hypertonic intravenous fluids
- Hyperaldosteronism
Most children with hypernatraemia are clinically dehydrated. However, as there

is a shift of water from the intracellular to extracellular space, initially infants
and children can be less symptomatic. Clinical features of hypernatraemia
include:-
A doughy feel to the skin.

Irritability
Weakness, lethargy
Alongside these there are likely to be the clinical features of dehydration.

The degree of dehydration should be assessed and a fluid deficit calculated.
If there is no sign of dehydration in the setting of hypernatraemia consider

causes related to excessive salt intake.
Management
This will depend on the cause of hypernatraemia.
For hypernatraemic dehydration with Na > 150 mmol/l:-
Avoid rapid correction as this may cause cerebral oedema, convulsion and
death.
Aim for correction of deficit over 48 hours and a fall of serum Na
concentration <0.5mmol/L per hour
If Na > 170 mmol/l consider slower correction of deficit e.g. over 72 hours.
NG fluid replacement (e.g. using oral rehydration solution) or IV fluids can
be used
If IV fluids used give 0.9% sodium chloride (+/- 5% dextrose) to ensure the
drop in sodium is not too rapid.
Remember to also give maintenance and replace ongoing losses
as per recommendations above
Repeat U&E every 4 hours until stable.
In hypernatraemic dehydration associated with excessive weight loss in breast fed babies please refer to
the management flowchart in Guideline to support women with newborn feeding
and the management of weight loss in babies. (short title Weight loss in Babies)

Hyperkalaemia
See Separate hyperkalaemia guideline (in renal section)

Hypokalaemia
Definition
Potassium level < 3.4 mmol/L (Treat if < 3.0 mmol/L or symptomatic < 3.4
mmol/L)
Causes
The common causes of hypokalaemia are:

- Sepsis
- GIT losses - diarrhoea, vomiting
- Iatrogenic - diuretic therapy, salbutamol, amphoterecin,
catecholamines eg
dopamine
- Diabetic ketoacidosis and the treatment thereof
- Renal tubular defects
The rare causes include Cushings syndrome, primary or secondary

hyperaldosteronism and Bartter syndrome.
Hypokalaemia is frequently associated with chloride depletion and with

metabolic alkalosis.
Refractory hypokalaemia may occur with hypomagnasaemia.
ECG Changes Of Hypokalaemia
Hypokalaemia produces one of the least specific ECG changes.

These normally occur when K+ < 2.5mmol/l therefore patients w ith K + <2.5mmol/l should
have continuous cardiac monitoring.
Cardiac monitoring should be considered in patients with a K+ < 3 mmol/l
1. Prominent U wave.
2. ST segment depression.
3. Flat, low or diphasic T waves.
Normal T wave amplitude in V5: <1year 11mm
>1year 14mm
V6: <1year 7mm
>1year 9mm
4. With further lowering of K+ the PR interval may become prolonged and sinoatrial block may occur

Treatment
Identify and treat the underlying condition. Unless symptomatic a
potassium level between 3.0 and 3.4 mmols is generally not supplemented
but rather monitored in the first instance.
The treatment of hypokalaemia does not lend itself to be incorporated into

a protocol and as a result each patient will need to be treated individually.
1) Oral Supplementation
Supplementation, in the form of Potassium Chloride (KCL), to a maximum

of 2 mmol/kg/day in divided doses is common but more may be required in
practice.
Available preparations:
Kay-Cee-L: Syrup 1mmol/ml each of K+ and Cl-
Sando K: Effervescent tablets (12 mmol of K+ and 8 mmol of Cl- per tablet)
Slow-K: ( To be avoided if possible because of increased
nausea and vomiting compared to above preparations)
Slow release tablet (8 mmol each of K+ and Cl- per tablet)
2) Intravenous Supplementation via Maintenace Fluids

(NB. 1gram KCl = 13.3 mmol KCl)
Potassium can ONLY be added to intravenous fluid bags on PICU, HDU,

NICU and E39 (Oncology) Wards. In all other areas, only pre-prepared bags
of potassium can be used.
(Pharmacy can add Potassium to bags for other wards during normal
working hours but this must be a registrar or consultant prescription).
Outside of these times, it may be possible to produce the required fluid
through addition of glucose (rather than potassium- see Appendix 2).
If the required fluid cannot be produced other than through the addition
of potassium, the patient will need to be transferred to PICU, PHDU or
E39
Administration
Potassium chloride is always given by IV infusion, NEVER by bolus
injection.
Maximum concentration via a peripheral vein is usually 40mmol per
litre (concentrations of up to 60mmol/litre can be used after discussion
with senior medical staff).
Maximum rate on a general (non-Critical Care) ward is
0.2mmol/kg/hour (with an absolute maximum of 20mmol/hour).
Rates of up to 0.5mmol/kg/hour (from all sources combined, e.g. PN
and fluids) can be infused in a critical care setting, and on ward E39
(Paediatric Oncology) where the following conditions are met:
The patient is on continuous ECG Monitoring.
Administration is via a central line

The serum potassium is low (definition as above), despite
maximal amounts in pre-made fluids and/or PN.
The potassium output is thought to be consistent and stable,.
The potassium is measured, in the first instance, every 2.5

hours (capillary blood gas acceptable). Once serum potassium
stability is proven, then as long as the output is consistent,
monitoring can be relaxed. Note: extreme caution required in
patients who are not actively losing potassium through urine,
stool, or gastric losses. Those who are replenishing whole body
potassium will be able to cope with high potassium intakes until
they are replete, whereupon they will suddenly become
hyperkalaemic. These patients need continuous very close
monitoring at these infusion rates.
3) Intravenous Correction (Critical Care Only)
K+ < 2.5 mmol/L may be associated with significant cardiovascular

compromise. In the emergency situation, potassium chloride can be
administered in the form of a low-volume infusion. See Paediatric Critical
Care for details.
Recommendations
All clinical incidents involving the use of intravenous fluids should be

reported via our local clinical incident reporting policy.
Clinical audit should be used to monitor local practice and staff education
regarding the use of intravenous fluids in children.
Summary
Whenever possible the enteral route should be used for fluids
The use of intravenous fluids requires careful prescribing and close monitoring
Iatrogenic hyponatraemia is a serious potential complication with the use of iv fluids
Use 0.9% sodium chloride with dextrose unless special circumstances on PICU, NICU or specialist
unit (renal, oncology)

References
References for hydration, fluid requirements, hyponatraemia and hypernatraemia
National Patient Safety Agency Reducing the risk of hyponatraemia when administering
intravenous infusions to children. March 2007. www.npsa.nhs.uk/health/alerts
Royal Childrens Hospital Melbourne. Hyponatraemia Guideline. www.rch.org.au/clinicalguide
Nottingham Paediatric Guidelines 11.5 Gastroenteritis (Jan 2007)
1 Playfor SD. Hypotonic intravenous solutions in children. Expert Opinion on Drug Safety.
2004; 3: 67-73
2 Jenkins J and Taylor B. Prevention of hyponatraemia. Arch Dis Child. 2004; 89-93
3 Cosgrove M and Wardhaugh A. Iatrogenic hyponatraemia. Arch Dis Child. Online [e-letter]
(27 June 2003)
4 Moritz ML and Ayus JC. Review. Preventing neurological complications from dysnatraemias
in children. Paediatr Nephrol.2005; 147: 273-274
References for Hyperkalaemia/Hypokalaemia:
1. McClure RJ et al. Treatment of hyperkalaemia using intravenous and nebulised

salbutamol. Arch Dis Child 1994;70:126-128.
2. Murdoch IA et al. Treatment of hyperkalaemia with intravenous salbutamol. Arch
Dis Child 1991;66:527-528.
3. Kemper MJ et al. Effective treatment of acute hyperkalaemia in childhood by
short term infusion of salbutamol. European J Ped 1996;155(6):495-497.
4. Allon M et al. Effect of bicarbonate administration on plasma potassium in dialysis
patients: interactions with insulin and albuterol. Am J Kidney Dis 1996; 28(4):508-
514.
5. Howes LG. W hich drugs affect potassium? [Review]. Drug Safety 1995
12(4):240-244 .
6. Liou HH et al. Intravenous hypokalaemiac effects of intravenous infusion or
nebulization of salbutamol in patients with chronic renal failure; a comparative
study. Am J Kidney Dis 1994;23(2):266-271.
7. Anonymous. Hyperkalaemia - silent and deadly [Editorial] 1989 1(8649):1240.
8. Helfrich E et al. Salbutamol for hyperkalaemia in children. [Review] Acta
Paediatrica. 2001;90(11):1213-6
9. Halperin ML et al. Potassium. The Lancet. 1998; 352(7):135-140.

Appendix 1: Paediatric fluid summary for routine
surgical patients
(Dr S Wake, Consultant Paediatric Anaesthetist)
This page summarises the fluid management protocols in NUH for well children
aged 1 month post term to 18 years undergoing routine surgery. It should be used
in conjunction with the main guideline. Children with relevant pre-existing medical
conditions (eg renal, burns, oncology, diabetes patients) should have fluids
managed as appropriate to their condition.
IF IN DOUBT ABOUT FLUID PRESCRIPTION CONSULT FULL

GUIDELINE, CONTACT PATIENTS OWN MEDICAL TEAM OR SEEK
MORE SENIOR ADVICE.
Where possible the enteral route for giving fluids should be used.
The need for IV fluids should be reviewed twice daily.
Children on IV fluids are at risk of developing electrolyte abnormalities,
especially in the post operative period, in particular hyponatraemia.
Maintain oral fluid intake of clear fluids until 2 hours pre -operatively.
If IV fluids are necessary isotonic fluids should be prescribed as per general
guidelines
ie 0.9% sodium chloride with 5% glucose.
Maintenance requirements are estimated from the child's weight using the
following formula:
1st 10kg 100ml/kg/day 4ml/kg/hr
2nd 10kg 50ml/kg/day 2ml/kg/hr
All additional kg of 20ml/kg/day 1ml/kg/hr

weight
Surgical deficits and losses should usually be replaced with isotonic fluids that do
not contain glucose over a specified time period in addition to maintenance fluids.
Ongoing losses should be assessed every 4 hours and replacement should

reflect the electrolyte content of the fluid being lost. Clinical assessment, including
weight where appropriate, is vital.
Dehydration deficit can be estimated using the following formula:

FLUID DEFICIT in ml = % dehydration x weight (kg) x10
All children receiving post operative IV fluids should have their U&E checked
within 24 hours of returning from theatre and every 24 hours while IV fluid therapy
continues. Potassium replacement is guided by U&E results.

Appendix 2: IV Fluid Bags Containing Potassium
If not stocked, all bags are available from the pharmacy department.
Potassium Concentration Available solutions

No potassium in 500mL Sodium chloride 0.9%
Sodium chloride 0.9%/dextrose 5%
Dextrose 5%
Dextrose 10%
Dextrose 5%/sodium chloride 0.45%
No potassium in 1000mL Sodium chloride 0.9%
Dextrose 5%
Sodium chloride 0.9%
10mmol/500ml Sodium chloride 0.9%/dextrose 5%
Dextrose 5%
Dextrose 10%
20mmol/500ml Sodium chloride 0.9%
Sodium chloride 0.9%/dextrose 5%
Dextrose 5%
Dextrose 10%
Dextrose 5%
Dextrose 5%
Dextrose 2.5%/sodium chloride 0.45%
Dextrose 5%
To make a bag with differing concentrations of dextrose you can add dextrose 50%,
but you MUST NEVER ADD POTASSIUM (unless in the Emergency Department
and it is going down a central line for a patient awaiting a bed on PICU).
To get a bag containing: Add:
Dextrose 10%/sodium chloride 0.45% 500ml 50ml of 50% dextrose to a 500ml bag of dextrose
5%/sodium chloride 0.45%
Dextrose 10%/sodium chloride 0.9% 500ml 50ml of 50% dextrose to a 500ml bag of dextrose
5%/sodium chloride 0.9%
Dextrose 10% /sodium chloride 0.18% 60ml of 50% dextrose to a 500ml bag of dextrose 4%/
500ml sodium chloride 0.18%
Handy hints for paediatric patients

Potassium chloride is always given by IV infusion, never by bolus injection
Maximum concentration via a peripheral is usually 40mmol/l. (concentrations of up to
80mmol/l have been used after discussion with senior medical staff)
Maximum rate is 0.2mmol/kg/hour
Higher concentrations may be administered via a central line
Higher rates may be justified on INTENSIVE CARE ONLY
Gail Foreshew Emergency Department Pharmacist, Updated by Beverly Harwood October 2008

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Fluid and Electrolyte Disturbances

Directorate & Speciality Directorate: Family Health Children

Abstract This guideline describes the management of Fluids

Key Words Fluids; electrolytes

2a at least one well-designed controlled study

Dr Lucy Cliffe 1 November 2015

Document Amendment Record

Version Issue Date Author Description

Summary of changes for new version

Dr Lucy Cliffe 2 November 2015

This guideline is intended to be a general guideline for paediatric fluid

Oncology patients receiving specific fluids pre-prescribed alongside

Please see specific fluid guidelines for:

Dr Lucy Cliffe 3 November 2015

Dr Lucy Cliffe 4 November 2015

The clinical assessment of hydration is difficult and often inaccurate. In

A weight should be recorded at presentation and compared to

Clinical Sign No Mile to Severe > Notes

Reduced urine No Yes Yes Take care to differentiate

Sunken eyes No Yes Yes

Prolonged capillary No Might be Yes CRT < 2 seconds may be

Dr Lucy Cliffe 5 November 2015

Risk of Acute Kidney Injury (AKI)

In 2015-2016, an algorithm will be introduced into laboratory reports to flag potentional

Dr Lucy Cliffe 6 November 2015

Very few well children require intravenous fluids. However an amount

The following calculations approximate the maintenance fluid requirement of

Dr Lucy Cliffe 7 November 2015

A 23 kg child will require

100mls/kg for the first 10kg = 1000mls

While most children will tolerate standard fluid requirements, some

In some situations a fluid deficit (allowance) for dehydration needs to be

Fluid deficit in ml = % dehydration x weight (Kg) x 10

A 23kg child who has been assessed as being moderately dehydrated

5/100 X 23 x 1000 = 1150mls

The deficit is usually replaced over 24 hours and so should be added to

Maintenance 1560ml + 5% Deficit 1150ml = 2710ml over 24hrs =

Dr Lucy Cliffe 8 November 2015

If intravenous fluids are necessary isotonic solutions (appendix 1) should be used

These include children who have or are:

Replace any deficit as sodium chloride 0.9% with glucose 5% (isotonic

Ongoing losses should be assessed every four hours.

Dr Lucy Cliffe 9 November 2015

Hyponatraemia can develop within a short timescale and a robust monitoring

Dr Lucy Cliffe 10 November 2015

Hyponatraemia is defined as a plasma sodium of less than 135mmol/L.

Iatrogenic - Intravenous fluid administration (hypotonic solutions)

The development of fluid-induced hyponatraemia in the previously well child

A major consequence of hyponatraemia is an influx of water into the

Dr Lucy Cliffe 11 November 2015

Should clinical symptoms of hyponatraemia develop, check U & Es,

Acute hyponatraemic encephalopathy is a medical emergency

The hyponatraemic child with seizures or CNS depression

Notify senior help urgently and refer to PICU.

Dr Lucy Cliffe 12 November 2015

Serum Na < 135

Notify senior help

Give 4ml/kg of 2.7%

Dr Lucy Cliffe 13 November 2015

Management of children without specific symptoms of hyponatraemia depends

Active correction of hyponatraemia (e.g. with 2.7% Sodium chloride) is not

1. The child with normal or increased volume status

2 The child with moderate dehydration and serum sodium 130-135mmol/L