Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
Short Title:
Intravenous Fluids and Electrolytes
Full Title:
Date of production/Last revision:
Guideline for the management and monitoring of intravenous fluid and
electrolyte therapy in children and young people
June 2008
Explicit definition of patient group
to which it applies:
This guideline applies to all children and young people under the age of 19
years.
Name of contact author
Dr Lucy Cliffe, Paediatric SpR
Dr Damian Wood, Consultant Paediatrician
Ext: 67127
June 2010
Revision Date
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.
Paediatric Fluid and Electrolyte Management
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.
Lucy Cliffe
Page 1 of 21
June 2008
Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
Contents
Page
Assessment of Hydration and Fluid Requirements
2-5
Hyponatraemia
6-9
Hypernatraemia
10
Hyperkalaemia
11 -13
Hypokalaemia
15 – 16
References
17
Appendix
18
Lucy Cliffe
Page 2 of 21
June 2008
Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
Background
Assessment of Hydration and Fluid Requirements
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 dehydration Mild - Moderate
(<3% weight loss)
3-10%
Severe
>10%
Reduced urine output
No
Yes
Yes
Dry mouth
No
Yes
Yes
Sunken eyes
No
Yes
Yes
Reduced skin turgor
No
(Recoils instantly)
Yes
(1-2 seconds)
Yes
(> 2 seconds)
Prolonged capillary
refill time
No
May be slightly
prolonged
Drowsiness/
Irritability
No
Yes

Notes
Take care to differentiate urine
from watery stool
Mouth breathers may always
have dry mouth
May be less apparent in
hypernatraemic dehydration
(doughy skin)
Yes
CRT < 2 seconds taken as
cool / mottled /
normal
pale peripheries
Severe
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.
Lucy Cliffe
Page 3 of 21
June 2008
Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
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:
1st 10kg of weight
2nd 10kg of weight
All additional kg of weight
100mls/kg
50mls/kg
20mls/kg
4mls/kg/hr
2mls/kg/hr
1ml/kg/hr
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).
Lucy Cliffe
Page 4 of 21
June 2008
Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
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 can 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% saline 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% saline 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 CONDITIONS.
Do not use 0.18% saline with 4% glucose in any situation outside of specialist units. The low
sodium content increases the risk of the patient developing hyponatraemia.
Lucy Cliffe
Page 5 of 21
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Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
Some children are at high risk of hyponatraemia and the use of isotonic solutions (i.e.
0.9% saline) 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.
Lucy Cliffe
Page 6 of 21
June 2008
Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
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 child’s 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
-
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 21hydroxylase deficiency)
Other
-
Glucocorticoid deficiency
Hypothyroidism
Congestive heart failure
Cirrhosis
Nephrotic Syndrome
Diabetic ketoacidosis (Hyperosmolality
hyperglycaemia)
Iatrogenic
-
2
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.
Lucy Cliffe
Page 7 of 21
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Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
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% NaCl solution – 4ml/kg over 15-30 minutes. It is stored on
PICU. This will raise the serum sodium by 3 mmol/L and will usually stop the
seizures. 2.7% saline is hypertonic but can be given peripherally 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% NaCl.
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.
Lucy Cliffe
Page 8 of 21
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Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
Management of Hyponatraemia
Serum Na < 135
AND Seizures or CNS
Depression
(Child in DKA – see DKA
guideline)
No
Yes
Notify senior help
and refer to PICU
What is the child’s
volume status?
Resuscitate
ABC as
necessary
Moderate
dehydration
and Na 130 135
Normal or
increased
Restrict to
50%
maintenance
Give 0.9%
saline with
dextrose if oral
route not
possible
Oral/NG
rehydration –
calculate
maintenance and
deficit fluid
requirements
Severe
dehydration or
dehydration with
Na <130
Maintenance
and deficit
fluid
requirements
replaced with
0.9% saline
with dextrose
Give anticonvulsants if
required
Lorazepam 0.1ml.kg IV
(max 4mgs)
Or
Diazepam PR or
Midazolam Buccal
5mg/kg / (max 10mgs)
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
- Assess for signs of symptomatic hyponatraemia
and recheck U&Es urgently if suspected
- Neuro obs 2 hourly until Na in normal range
Measure Na after bolus
and repeat bolus until
seizures stop or NA>125
Transfer to PICU
Lucy Cliffe
Page 9 of 21
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Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
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% NaCl) 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% saline 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% NaCl with 5% dextrose.
3. The child with severe dehydration or dehydration with serum sodium <130mmol/L


Give intravenous 0.9% NaCl 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
Lucy Cliffe
Page 10 of 21
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Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
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 < 0.5
mmol/L per hour
NG fluid replacement or IV fluids can be used
If IV fluids used give 0.9% saline to ensure the drop in sodium is not too rapid.
Remember to also give maintenance and replace ongoing losses following
recommendations above
Repeat U&E every 4 hours until stable.
Lucy Cliffe
Page 11 of 21
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Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
Hyperkalaemia
Normal values of Potassium are:
birth - 2 weeks: 3.7 - 6.0 mmols/L
2 weeks - 3 months:
3.7 - 5.7 mmols/L
3 months and above: 3.5 - 5.0 mmols/L
Causes
-
Dehydration
Diabetic ketoacidosis
Acute renal failure
Acute cell destruction (trauma, tumour cell lysis or haemolysis)
Adrenal failure
Rare causes include mineralocorticoid deficiency, congenital adrenal hyperplasia and
Addison’s disease.
Do not forget drugs (oral or IV potassium supplements, potassium sparing diuretics, ACE
inhibitors and trimethoprim in the presence of mild renal failure).
Beware false positive hyperkalaemia e.g. traumatic haemolysed samples, delay in analysis,
contamination with EDTA and tumour lysis with cell breakdown in the sample tube.
Generally speaking, a potassium level between 5.0 and 6.0 mmols/L need not be treated
acutely but rather monitored.
ECG Changes of Hyperkalaemia
1. Tall “tented” T waves in V5:
<1 year - T wave amplitude >11mm
>1 year - T wave amplitude >14mm
3. Prolongation of PR interval
< 3 years
0.08 secs
> 3 years
0.10 secs
2. Prolongation of QRS duration
premature infants
full term infants
1-3 years
> 3 years
4. Disappearance of the P wave.
Lucy Cliffe
0.04 secs
0.05 secs
0.06 secs
0.07 secs
5. Wide, bizarre, diphasic QRS
Page 12 of 21
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Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
Potassium > 6mmol/L BUT < 7mmol/L
If also acidotic or has congenital heart disease consider treating as though K + > 7
Refer early to renal team if likely to need dialysis eg H.U.S.
1.
2.
3.
4.
5.
6.
7.
8.
Identify and treat underlying condition
Repeat blood specimen ensuring specimen not haemolysed.
Discontinue potassium enhancing medication, i.e.
 K+ supplements:
 K+ sparing diuretics
 NSAIDs:
 ACE Inhibitors
Perform an ECG
 If ECG changes are present treat according to K+ >7 protocol
as below. If no ECG changes present proceed to next step
Consider correction of metabolic acidosis, dietary restriction and urinary excretion
with furosemide (1 mg/kg)
Check K+ after 1-2 hours.
Consider Calcium Resonium (Calcium Polystyrene Sulphonate)
Dose: 1gram/kg, oral or rectal
This tends to be difficult to give in children and may be impractical.
Calcium Resonium can be continued at 6 hourly intervals
(250 milligrams/kg/dose) until K+ < 5.5.
Potassium > 7 mmol/L
Refer early to renal team if likely to need dialysis eg H.U.S.
1.
2.
3.
4.
5.
6.
Institute treatment immediately. DO NOT allow the logistics of organising
an ECG to delay treatment.
Consider PICU Admission.
Give intravenous 10% CALCIUM GLUCONATE (Cardioprotective)
0.5 ml/ kg (Maximum of 20 mls)
Dilute with equal amount of 5% dextrose and infuse over 2 minutes
While Calcium Gluconate is being drawn up, administer:
 nebulised SALBUTAMOL
o child < 25 kgs: 2.5mg
o child > 25 kgs : 5.0mg
 or intravenous SALBUTAMOL if ventilated
o 5 micrograms/Kg in 10mls WFI Infuse over 15 minutes
Perform an ECG. If abnormalities present, repeat the above Calcium Gluconate dose
and consider a Calcium Gluconate infusion.
Check K+ after 1 – 2 hours;
 if K+ remains > 7.0 repeat nebulised salbutamol and consult the renal
team for further management advice.
 if K+ < 7.0 give a dose of Calcium Resonium
Lucy Cliffe
Page 13 of 21
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Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
NOTE:
1. Calcium Gluconate does not lower the K+ but has a membrane stabilising effect,
thereby preventing life threatening cardiac arrhythmias. The exact mechanism of
action is unknown.
2. A glucose and insulin infusion should be used if the hyperkalaemia is refractory to
salbutamol (this is to be anticipated when the patient is on B-Blockers, where the effect of
salbutamol will be decreased ) OR IN THE CASE OF CONCOMITANT HYPERTENSION
OR CARDIAC DISEASE.
- 12 units short acting insulin in 100 mls of 20% dextrose
- run this solution at a rate of 5mls/kg over 30 minutes.
3. The efficacy of Sodium Bicarbonate in lowering K+ is in question. It may have a use in
severe hyperkalaemia associated with an acidosis.
- Dose: 1 mmol/kg intravenously
4. Dialysis may be necessary in severe or refractory hyperkalaemia
5. A combination of treatment regimens has a greater potassium lowering effect
6. Do NOT give a blood transfusion
Lucy Cliffe
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Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
Is the Potassium greater than 7
or
> than 6 with acidosis, congenital heart disease or ECG changes present?
Remove the Cause
Yes
No
Yes
Give iv 10% Calcium Gluconate
Repeat the sample
Is the K+ still greater than 6 and < 7
Give nebulised Salbutamol (or
intravenous if ventilated) CAUTION IN
CARDIAC DISEASE OR
HYPERTENSION
Yes
Calcium Resonium
K+ Refractory or Salbutamol contraindicated =>
Insulin and Dextrose infusion
Repeat cycle, consider Ca Gluconate
infusion and contact the renal team
Lucy Cliffe
Haemolysed Sample
Prompt treatment saves lives. Do not wait
for an ECG. If one treatment is not
available or is difficult to arrange then use
a quicker alternative
Is the K+ still greater than 7?
(Lab Sample)
Yes
No
No
Calcium Resonium and identify
underlying cause of hyperkalaemia
Page 15 of 21
June 2008
Repeat the potassium
after 1-2 hours
Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
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 Cushing’s 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 :
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:
Lucy Cliffe
Effervescent tablets
12 mmol of K+ and 8 mmol of Cl- per tablet
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Paediatric Clinical Guideline
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1.17 Intravenous Fluids
 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 (NB. 1gram KCL = 13.3 mmol KCL)
KCL can ONLY be added to intravenous fluid bags on PICU, NICU and E38 (Oncology)
Wards.
(Pharmacy can add KCl to bags for other wards but this must be a registrar
or consultant prescription)




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 is 0.2mmol/kg/hour. Higher rates may be justified in the intensive care
setting.
Higher concentrations but NOT HIGHER RATES may be administered centrally.
3) Intravenous Correction (NB 1gram KCL = 13.3 mmol KCL)

K+ < 2.5 mmol/L may be associated with significant cardiovascular compromise. In
the emergency situation, KCL can be administered in the form of an infusion.
Dose : initially 0.4 mmol/kg/hour into a central vein, until K + level restored.
Ideally this should occur in an intensive care setting with cardiac monitoring.
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% saline with dextrose unless special circumstances on PICU, NICU or specialist
unit (renal, oncology).
Lucy Cliffe
Page 18 of 21
June 2008
Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
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 Children’s 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.
2.
3.
4.
5.
6.
7.
8.
9.
Lucy Cliffe
McClure RJ et al. Treatment of hyperkalaemia using intravenous and nebulised
salbutamol. Arch Dis Child 1994;70:126-128.
Murdoch IA et al. Treatment of hyperkalaemia with intravenous salbutamol. Arch
Dis Child 1991;66:527-528.
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.
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):508514.
Howes LG. Which drugs affect potassium? [Review]. Drug Safety 1995
12(4):240-244.
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.
Anonymous. Hyperkalaemia - silent and deadly [Editorial] 1989 1(8649):1240.
Helfrich E et al. Salbutamol for hyperkalaemia in children. [Review] Acta
Paediatrica. 2001;90(11):1213-6
Halperin ML et al. Potassium. The Lancet. 1998; 352(7):135-140.
Page 19 of 21
June 2008
Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
Appendix 1
Table 1: Features of Commonly used Intravenous Fluids in the UK 1
Solution
Osmolarity
(mOsmol/L)
Sodium
content
mequiv/L)
Osmolality
(compared
to plasma)
Tonicity (with
reference
to cell
membrane)
Isotonic
Sodium chloride
0.9% with
glucose 5%
Sodium chloride
0.9%
Sodium chloride
0.45% with
glucose 5%
Glucose 5%
Glucose 10%
Hartmann’s *
Sodium chloride
0.18% with
glucose 4%
Sodium chloride
0.45% with
glucose 2.5%
4.5% human
albumin solution
586
150
Hyperosmolar
308
154
Isomolar
Isotonic
432
75
Hyperosmolar
Hypotonic
278
555
278
284
131
31
Isomolar
Hyperosmolar
Isomolar
Isomolar
Hypotonic
Hypotonic
Isotonic
Hypotonic
293
75
Isomolar
Hypotonic
275
100-160
Isomolar
Isotonic
*Compound Sodium Lactate
Intravenous Infusion BP
(Hartmann’s Solution)
Composition
Each 1000ml contains:
Sodium Chloride 6.00g
Sodium Lactate 3.12g
Potassium Chloride 0.40g
Calcium Chloride 2 H2O 0.27g
Electrolytes: mmol/l
Sodium 131
Potassium 5
Calcium
2
Chloride 111
Bicarbonate (as lactate) 29
Lucy Cliffe
Page 20 of 21
June 2008
Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
Title
Intravenous Fluids and Electrolytes
Guideline Number
Version
1.17
Draft
Distribution
All wards QMC and CHN
Authors
Dr Lucy Cliffe
Paediatric Specialist Registrar
Document Derivation
Dr Simon Robinson (Hyperkalaemia & Hypokalaemia)
Paediatric Specialist Registrar
First Issued
June 2007
Latest Version Date
June 2008
Ratified By
Audit
Lucy Cliffe
Review Date
June 2011
Date
Induction Programme
Page 21 of 21
Amendments
June 2008