AAP Recommends Isotonic Maintenance IV Fluids

Full text: Feld LG et al. Pediatrics 2018; 142: pii:e20183083: Clinical Practice Guideline: Maintenance Intravenous Fluids in Children

Key Recommendation:

The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (evidence quality: A; recommendation strength: strong)

Isotonic and Hypotonic Fluids:

  • Examples of isotonic/near isotonic fluids listed in Table 1 include D5 Normal Saline (0.9%), D5 Lactated Ringer’s which have osmolarities of 308 mOsm/L (same as human plasma) and 273 mOsm/L respectively.
  • Examples of hypotonic fluids include D5 1/2 Normal Saline (0.45%) and D5 1/4 Normal Saline (0.2%) which have osmolarities of 154 mOsm/L and 78 mOsm/L respectively

“The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia… in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward.”

Excluded from these recommendations: “Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old”

My take: It remains commonplace for patients to receive hypotonic fluids which place them at unnecessary risk for iatrogenic hyponatremia.

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