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Fluid management

Consider consulting a paediatric intensive care specialist if a child remains shocked after the
second rapid intravenous infusion
When symptoms and/or signs of shock resolve after rapid intravenous infusions, start
rehydration with intravenous fluid therapy.
If intravenous fluid therapy is required for rehydration (and the child is not hypernatraemic at
presentation):

• use an isotonic solution such as 0.9% sodium chloride, or 0.9% sodium chloride with 5%
glucose, for fluid deficit replacement and maintenance
• for those who required initial rapid intravenous fluid boluses for suspected or confirmed
shock, add 100 ml/kg for fluid deficit replacement to maintenance fluid requirements, and
monitor the clinical response
• for those who were not shocked at presentation, add 50 ml/kg for fluid deficit replacement
to maintenance fluid requirements, and monitor the clinical response
• measure plasma sodium, potassium, urea, creatinine and glucose at the outset, monitor
regularly, and alter the fluid composition or rate of administration if necessary
• consider providing intravenous potassium supplementation once the plasma potassium
level is known.
If intravenous fluid therapy is required in a child presenting with hypernatraemic dehydration:
• obtain urgent expert advice on fluid management
• use an isotonic solution such as 0.9% sodium chloride, or 0.9% sodium chloride with 5%
glucose, for fluid deficit replacement and maintenance
• replace the fluid deficit slowly – typically over 48 hours
• monitor the plasma sodium frequently, aiming to reduce it at a rate of less than 0.5 mmol/l
per hour.

Research recommendation on intravenous rehydration therapy
In children who require intravenous fluid therapy for the treatment of dehydration, is rapid
rehydration safe and cost-effective compared with the common practice of rehydration over
24 hours?
Why this is important
Most children with clinical dehydration should be treated with oral rehydration therapy, but
some require intravenous fluid therapy because they are shocked or they cannot tolerate
oral rehydration therapy. Rehydration with oral rehydration therapy is usually carried out
over a period of 4 hours. Rehydration with intravenous fluid therapy has traditionally been
undertaken slowly – typically over 24 hours. The National Patient Safety Agency has advised*
that intravenous fluid deficit replacement should be over 24 hours or longer. Consequently,
children will remain dehydrated and in hospital for a prolonged period. The WHO recommends
that intravenous rehydration should be completed in 3–6 hours.† Many experts now support
rapid intravenous rehydration, suggesting that it allows oral fluids to be starter earlier and can
shorten the duration of hospital treatment. Randomised controlled trials are needed urgently to
examine the safety and cost-effectiveness of rapid intravenous rehydration regimens compared
with slow intravenous rehydration.

Clinical questions
During rehydration, when should patients on IVT change to ORT?
Evidence overview

In the absence of any direct evidence to answer this question, information was again collected
from various studies which had described fluid regimens in which ORS solution was introduced

* National Patient Safety Agency. Alert no. 22, Ref: NPSA/2007/22. Issued: 28 March 2007.
† World Health Organization. The Treatment of Diarrhoea: a Manual for Physicians and Other Senior Health Workers. Geneva: WHO;
2005 [whqlibdoc.who.int/publications/2005/9241593180.pdf].

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