Intravenous Fluids in the
Hospitalized Child
Kathleen W. Bartlett, M.D.
July 11th ,2018
Special thanks to Kyle Rehder, MD, Associate
Professor of Pediatric Critical Care at Duke for
sharing some of his slides.
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History and Risks of Hypotonic Fluids in Intravenous Fluid Therapy, Study notes of Pediatrics
An historical overview of intravenous fluid therapy, focusing on the use and risks of hypotonic fluids. Topics include milestones in intravenous fluid therapy, the physiology of maintenance IVF therapy, and the risks of hypotonic fluids. The document also discusses the history of resuscitation fluids and maintenance fluids, as well as the importance of maintaining proper sodium levels in parenteral fluid therapy.
What you will learn
- What are the risks of hyponatremia in hospitalized children?
- What are the risks of using hypotonic fluids in maintenance IVF therapy?
- What are the historical milestones in intravenous fluid therapy?
- How do isotonic and hypotonic fluids differ in their effects on serum sodium levels?
- What are the recommended maintenance fluids for different populations?
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Intravenous Fluids in the
Hospitalized Child
Kathleen W. Bartlett, M.D.
July 11th^ ,
Special thanks to Kyle Rehder, MD, Associate Professor of Pediatric Critical Care at Duke for sharing some of his slides.
Objectives
• Review the history of current practice
in IVF management.
• Discuss the physiology of
maintenance IVF therapy.
• Detail the risks of maintenance IVF
therapy with hypotonic fluids.
• Describe the physiology and benefits
of oral rehydration therapy.
History of intravenous fluid therapy
- 1831 pandemic of cholera spread across
Europe
- O’Shaughnessy observed:
1. Cholera serum has “lost a large proportion
of its water”
2. “It has also lost a great proportion of its
neutral saline ingredients.”
3. High salt and water content of excrement
- Subsequently proposed “injecting into the
veins such substances as an examination
of the blood…would show to be most
capable of restoring it to the arterial
qualities.”
Dr. William Brooke O’Shaughnessy
O’Shaughnessy WB. Experiments on the blood in cholera. Lancet. 1831; 17:490. O’Shaughnessy WB. Proposal of a new method of treating The Blue Epidemic of Cholera. Lancet. 1831;18: 366-371.
Important milestones in
intravenous fluid therapy
1832 1833 1840-50s 1855 1876 1901
1914-
Barsoum N, Kleeman C. Now and then, the history of parenteral fluid administration. American Journal of Nephrology. 2002;22:284-89. Millam D. The history of intravenous therapy. Journal of Intravenous Nursing. 1996;19:5-14.
Maintenance fluids in the 1950s
- Fluid needs stem from metabolism
- Pathways of water and electrolytes losses:
- Skin and lungs (insensible heat losses and
sweat)
- Urine (renal load of solutes from protein
metabolism)
- GI tract (stool water is negligible in fasting)
- Give dextrose to decrease protein
catabolism and ketosis.
Darrow DC, Pratt EL. Fluid Therapy: relation to tissue composition and the expenditure of water and electrolyte. JAMA. 1950;143:365-373.
Amount of water for renal solute
Darrow DC, Pratt EL. Fluid Therapy: relation to tissue composition and the expenditure of water and electrolyte. JAMA. 1950;143:365-373.
Approximating caloric expenditure
- Calories/kg = 100 – 3 x age in years
- Body surface area (1500 cal/m^2 /day)
- Caloric expenditure method
- Holliday-Segar
“High precision in parenteral therapy is impossible and unnecessary. Even with complex measurements of balance the clinician is always a day late in setting requirements” –William M. Wallace, M.D.
Wallace WM. Quantitative requirements of the infant and child for water and electrolyte under varying conditions. American Journal of Clinical Pathology. 1953;23: 1133-1141.
Basal metabolic rate, normal activity and average
hospitalized patient
Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19:823-32.
What to put in the water?
• Goal: prevent catabolism and
hypoglycemia.
• Minimal catabolism achieved by giving
4-5 g of dextrose per 100 calories
metabolized.
• D5W has 5 g dextrose per 100 ml
water.
• D5W can be safely given through a PIV.
What about electrolytes?
Regimen mEq/100 cal
Na Cl K Human Milk 1.0 1.2 2. Cow’s Milk 3.5 4.5 6. Recommended 3.0 2.0 2. Recommended (Darrow) 3.0 2.0 3. Recommended Adult (Welt) 3.0 3.0 1.
Recommend adding 3 ml of molar sodium lactate and 1 ml of 2 molar potassium chloride to every 100 ml of D5W to obtain maintenance fluid.
Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19:823-32.
Typical Daily Intakes of Water and
Sodium
Age
Daily intakes Sodium
Concentration
Water(ml/kg) Sodium(mmol/kg ) (mmol/L)
Newborn 150 3 20
1 year 100 2.5 25
5 years 75 2 27
12 years 50 1 20
Coultard MG. Will changing maintenance intravenous fluid from 0.18% to 0.45% saline do more harm than good? Arch Dis Child. 2008;93:335-340.
So why don’t we use D5 0.2 NS
for all hospitalized patients?
- Case report of hyponatremic infant
after CNS injury
- 1 st^ published report of SIADH
McCrory, et. al. Pediatrics 1957
ADH elevated in hospitalized children
- ADH my be appropriately elevated
with:
- Dehydrated patients
- Sepsis
- Post-surgical patients
- Mechanically ventilated children
- In presence of hypotension
- Stress
Moritz, et. al. Pediatrics 2003 Neville, et. al. Pediatrics 2005