![]() ![]() Most hyponatremia in patients who are hospitalized is hospital acquired and related to the administration of hypotonic IVFs in the setting of elevated AVP concentrations. The dose of fluid during these 4 phases of fluid therapy needs to be adjusted on the basis of the unique physiologic needs of each patient, and a specific protocoled dose is not able to be applied to all patients. ![]() Finally, the convalescent phase reflects the period when exogenous fluid administration is stopped, and the patient returns to intrinsic fluid regulation. The maintenance phase accounts for fluids administered during the previous 2 stabilization phases and is a time when fluids should be supplied to achieve a precise homeostatic balance between needs and losses. The titration phase is the time when IVFs are transitioned from boluses to maintenance this is a critical window to determine what intravascular repletion has been achieved and the trajectory of fluid gains versus losses in children who are acutely ill. The resuscitative phase is the acute presentation window, when IVFs are needed to restore adequate tissue perfusion and prevent or mitigate end-organ injury. 5, – 7 Four distinct physiology-driven time periods exist for children requiring IVFs. Recent literature has emerged in which researchers describe the context-dependent use of IVFs, which should be prescribed, ordered, dosed, and delivered like any other drug. Guidelines for maintenance IVF therapy in children have primarily been opinion based, and evidence-based consensus guidelines are lacking. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVF could prevent the development of hyponatremia. The administration of hypotonic IVF has been the standard in pediatrics. Because maintenance IVFs may have both potential benefits and harms, they should only be administered when clinically indicated. For the purposes of this document, specifying appropriate maintenance IVFs includes the composition of IVF needed to preserve a child’s extracellular volume while simultaneously minimizing the risk of developing volume depletion, fluid overload, or electrolyte disturbances, such as hyponatremia or hypernatremia. ![]() IVFs are required if sufficient fluids cannot be provided by using enteral administration for reasons such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state, or being moribund from an acute or chronic illness. Maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. The Key Action Statement of the subcommittee is as follows:ġA: 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) We specifically address the tonicity of maintenance IVFs in children. 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 are excluded. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward. Our goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia. The administration of hypotonic IVFs has been the standard in pediatrics. Despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. ![]() ![]()
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