8/12/2016

Calculating Maintenance Fluid Rates

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Nursing
Calculating Maintenance Fluid Rates
Although it is the physicians responsibility to calculate and order daily uid requirements for
patients, Registered Nurses are responsible for double checking the order for accuracy. Below are
two different methods used in calculating paediatric maintenance uid rates.
Formula Method

(100 ml for each of the rst 10kg) + ( 50ml for each kg 11-20) + (20 ml for each additional kg) /
24hour
Example:
Calculate the hourly maintenance uid rate for a child
who weighs 25kg
(100mL x 10kg) + (50mL x 10kg) + (20mL x 5kg) / 24hrs
(1000mL) + (500mL) + (100mL) = 1600mL / 24hrs =
66.7ml/hr
Using this formula the hourly uid maintenance for this
child is 67mL/hr
4 / 2 / 1 Method

(4ml/kg for the rst 10kg) + (2ml/kg for kg 11-20) + (1ml/kg for every kg above 20) = hourly rate
Example:
Calculate the hourly maintenance uid rate for a child
who weighs 25kg
(4ml x 10kg) + (2ml x 10kg) + (1ml x 5kg) = hourly rate
40ml + 20ml + 5ml = 65ml/hr
Using the 4/2/1 method, this child's hourly maintenance
uid rate is 65mL/hr

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8/12/2016

Clinical Practice Guidelines : Intravenous uids

Intravenous uids
This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

IV Fluids - for children beyond the newborn period

See also:
Guideline on Neonatal Fluid Requirements
Checklist of commonly used uids
Dehydration
Hyponatraemia Guideline
Hypernatraemia Guideline

Background:
Whenever possible the enteral route should be used for uids. These guidelines only apply to children who
cannot receive enteral uids.
The safe use of IV uid therapy in children requires accurate prescribing of uid and careful monitoring
Always check orders that you have written, and ensure that you double check on orders written by other staff
when you take over the child's care
Incorrectly prescribed or administered uids are potentially very dangerous. More adverse events are
described from uid administration than for any other individual drug. If you have any doubt about a child's uid
orders - ask a senior doctor.
Remember to check compatibility of intravenous uid with any intravenous drugs that are being coadministered.

Assessment of uid requirements: Unwell children (+/- abnormal hydration)

How much Fluid?
If required, administer an initial bolus(es) of uid to correct intravascular depletion then:
Hypovolaemia
Give boluses of 10-20ml/kg of 0.9% sodium chloride (normal saline), which may be repeated.
Do not include this uid volume in any subsequent calculations

Maintenanceplus
Decit(dehydration guidelines), plus
Ongoing losses(dehydration guidelines)

Maintenance
This guideline should be used as a starting point and will need to be adjusted in ALL unwell children.

http://www.rch.org.au/clinicalguide/guideline_index/Intravenous_Fluids/

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Clinical Practice Guidelines : Intravenous uids

Generally 2/3 of maintenance rate should be used in unwell children unless they are dehydrated. This is because they
are likely to be secreting anti-diuretic hormone (ADH), so will need less uid. Children with meningitis or other acute
CNS conditions will likely require additional uid restriction seek senior advice.
For uid options in the dehydrated child see dehydration guidelines.
Weight (kg)

Full Maintenance (mL/hour)

Well child eg fasting for theatre

2/3 maintenance (mL/hour)

Most unwell children eg pneumonia, meningitis

20

13

10

40

27

15

50

33

20

60

40

25

65

43

30

70

47

35

75

50

40

80

53

45

85

57

50

90

60

55

95

63

60

100

67

REMEMBER to consider decit and ongoing losses - especially in severe gastroenteritis, if there are drain losses,
ileostomies etc.
Which Fluid?
Some good uid solutions for sick children include:
Fluid

Alternative
names

Uses

0.9% sodium chloride

Normal
saline

Initial boluses
Replacement of decit
Replacement of losses

Plasma-Lyte148 and 5% Glucose

Maintenance hydration

(contains 5mmol/L of potassium)

(this should be the standard maintenance

uid prescribed at RCH)
Replacement of decit
Replacement of losses

Plasma-Lyte148 and 5% Glucose with 20mmol/L

potassium

http://www.rch.org.au/clinicalguide/guideline_index/Intravenous_Fluids/

Maintenance hydration - should only be

used for children with hypokalaemia

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Clinical Practice Guidelines : Intravenous uids

(15mmol/L of KCl will need to be added to a

standard bag to bring the concentration to
20mmol/L)

0.9% sodium chloride and 5% Glucose +/20mmol/L KCl

Replacement of decit
Replacement of losses

Normal
saline with
glucose

Maintenance
Replacement of decit
Replacement of losses

Consider whether potassium is required in the uid. This should be avoided, if possible, unless premade uid
bags containing potassium are available. Adding potassium to bags of uid on the ward is a safety risk.
Hypotonic uid (containing a sodium concentration less than plasma) is no longer recommended in children. These
uids have been associated with morbidity/mortality secondary to hyponatraemia. Fluids that should NOT be given
include:
0.18% NaCl with 4% glucose +/- KCl 20mmol/L (or 4% and 1/5 NS) should NOT be given

Monitoring
All children on IV uids should be weighed prior to the commencement of therapy, and daily afterwards. Ensure
you request this on the treatment orders.
Children with ongoing dehydration/ongoing losses may need 6 hourly weights to assess hydration status
All children on IV uids should have serum electrolytes and glucose checked before commencing the infusion
(typically when the IV is placed) and again within 24 hours if IV therapy is to continue.
For more unwell children, check the electrolytes and glucose 4-6 hours after commencing, and then according
to results and the clinical situation but at least daily.
Pay particular attention to the serum sodium on measures of electrolytes. If <135mmol/L (or falling signicantly
on repeat measures) see Hyponatraemia Guideline. If >145mmol/L (or rising signicantly on repeat measures)
see Hypernatraemia guideline.
Children on iv uids should have a uid balance chart documenting input, ongoing losses and urine output.

Special uids
Outside the newborn period, do not use these uids apart from exceptional circumstances and check the
serum sodium regularly
10% Dextrose
Used in neonates (sometimes with additional NaCl). Used in ICU for patients under 12 months (with 0.45% saline).
Sometimes used by infusion in neonates and children with metabolic disorders. Check blood glucose regularly.
15-20% Dextrose
Very occasionally used by infusion in children with metabolic disorders. Check blood glucose regularly.
25% and 50% Dextrose
Rarely required in children, misuse can cause severe adverse events.Only used in discussion with senior staff as
bolus or low volume infusions (1-2 ml/hr) to correct refractory hypoglycaemia.

Consider consultation with local paediatric team when:

-Unsure of which uid/how much uid to use
-Electrolyte abnormalities
-Using a non-standard 'special' uid

Consider transfer when:

http://www.rch.org.au/clinicalguide/guideline_index/Intravenous_Fluids/

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Clinical Practice Guidelines : Intravenous uids

-Children requiring care above the level of comfort of the local hospital.
-Severe electrolyte or glucose abnormalities
For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency
Retrieval (PIPER) Service: 1300 137 650.
Information Specic to RCH
From February 2016, Plasma-Lyte148 and 5% Glucose will be the standard maintenance uid prescribed.
0.45% sodium chloride and 5% glucose +/- KCl (or 5% and NS) should NOT be given.
Children on intravenous uids need daily electrolyte monitoring.
20-50% dextrose should not be given outside the ICU or NNU setting without discussion with a consultant.

Calculating maintenance uid:

Calculating Maintenance uid rate:
Most unwell children should have a restriced (2/3) maintenance rate prescribed. The basis from which calculations
are made are detailed below
daily uid intake which replaces the insensible losses (from breathing, through the skin, and in the stool)
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.
volume calculated per kilo.
Patients weight

Full Maintenance mls/day

mls/hour

3 to 10kg

100 x wt

4 x wt

10 - 20kg

1000 plus 50 x (wt-10)

40 plus 2 x (wt-10)

>20kg

1500 plus 20 x (wt-20)

60 plus 1 x (wt-20) [S1]

100mls/hour (2400mls/day) is the normal maximum amount.

Additional notes
There is often confusion about the difference between oral and iv uid requirements for young infants. The water
requirement is identical for both routes of administration. The relatively low energy density of milk means that infants
need 150-200mls/kg/day to obtain adequate nutrition. That is why they pass more dilute urine than older children.

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http://www.rch.org.au/clinicalguide/guideline_index/Intravenous_Fluids/

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How to calculate IV ow rates

HowtocalculateIVflowrates:
Intravenousfluidmustbegivenataspecificrate,neithertoofastnortooslow.Thespecificratemaybe
measuredasml/hour,L/hourordrops/min.Tocontroloradjusttheflowrateonlydropsperminuteareused.
Theburettecontainsaneedleorplasticdropperwhichgivesthenumberofdropsperml(thedropfactor).A
numberofdifferentdropfactorsareavailable(determinedbythelengthanddiameteroftheneedle).
Commondropfactorsare:
10drops/ml(bloodset),15drops/ml(regularset),60drops/ml(microdrop).
Tomeasuretheratewemustknow:
(a)thenumberofdrops
(b)timeinminutes.
Theformulaforworkingoutflowratesis:
volume(ml)Xdropfactor(gtts/ml)
=gtts/min

(flowrate)
time(min)
Example:
1500mlIVSalineisorderedover12hours.Usingadropfactorof15drops/ml,howmanydropsper
minuteneedtobedelivered?
1500(ml)X15(gttss/ml)
=31gtts/minute
12x60(givesustotalminutes)

http://www.unc.edu/~bangel/quiz/testivh.htm

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