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Guideline No: 1/C/09:8070-01:03

Guideline: Intravenous Fluid Management

INTRAVENOUS FLUID MANAGEMENT


PRACTICE GUIDELINE

DOCUMENT SUMMARY/KEY POINTS

All staff who are responsible for the administration intravenous (IV) medication must be
appropriately qualified and trained to do so within the context of their practice1

Any IV fluid containing Potassium Chloride (KCl) must be administered independent of


any other IV medication, ie it is not to be used as a base solution to administer IV drugs.

IV cannula insertion site to remain clearly visible at all times.

Common Intravenous Fluid Types now come in 1L bags.

Common Intravenous Fluid Types are:


o

Maintenance : 0.45% (75mmol/L) sodium chloride and 5% glucose with or without


20mmol/L Potassium Chloride KCI

In Theatre maintenance: 0.9% (150mmol/L) sodium chloride with or without 1%


glucose (or Hartmanns with or without 1% glucose)

Rehydration/ Replacement: 0.9% (150mmol/L) sodium chloride and 5% glucose


with or without 20mmol/L KCI

Resuscitation: 0.9% (150mmol/L) sodium chloride with no glucose (or Hartmanns


or non-crystalloid e.g. Albumin)

NB: These fluid recommendations are not for neonates or infants < 3 months of age.

This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be
factors which cannot be covered by a single set of guidelines. This document does not replace the need for the
application of clinical judgement to each individual presentation.
Approved by:
Date Effective:
Team Leader:

SCHN Policy, Procedure & Guideline Committee


1st May 2012
Chair

Date of Publishing: 2 May 2012 10:46 AM


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This Guideline may be varied, withdrawn or replaced at any time.

Original endorsed by SMG 1999


Review Period: 1 year
Area/Dept: Medication Safety Committee

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Guideline No: 1/C/09:8070-01:03


Guideline: Intravenous Fluid Management

CHANGE SUMMARY

Added Intravenous Fluid Management section following CHA Recommendations; March


2010 including:
o

Intravenous Fluid Monitoring

Intravenous Fluid Types

Intravenous Fluid Volumes

Guide to Intravenous Fluid Calculation Based on Weight Chart,

READ ACKNOWLEDGEMENT

Training/Assessment Required
o

All registered nurses

All endorsed enrolled nurses

The following are required to Read and Acknowledge:


o

All medical staff (chapter 3 on IV Fluid Management )

All clinical Department Heads

All clinical staff prescribing/administering IV fluids.

This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be
factors which cannot be covered by a single set of guidelines. This document does not replace the need for the
application of clinical judgement to each individual presentation.
Approved by:
Date Effective:
Team Leader:

SCHN Policy, Procedure & Guideline Committee


1st May 2012
Chair

Date of Publishing: 2 May 2012 10:46 AM


K:\CHW P&P\ePolicy\Apr 12\IV Fluid Management.docx
This Guideline may be varied, withdrawn or replaced at any time.

Original endorsed by SMG 1999


Review Period: 1 year
Area/Dept: Medication Safety Committee

Date of Printing:

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Guideline No: 1/C/09:8070-01:03


Guideline: Intravenous Fluid Management

TABLE OF CONTENTS
Introduction ............................................................................................................................4
Inclusions................................................................................................................................4
1
Intravenous Medication Administration Accreditation ............................................ 5
1.1
Initial Accreditation ........................................................................................................ 5
1.2
Biennial Accreditation (ongoing) .................................................................................... 5
2
Administration of Intravenous Fluids ........................................................................ 6
2.1
Intermittent Line Changes ............................................................................................. 6
2.2
Intravenous Fluids ......................................................................................................... 6
2.3
Extravasation Monitoring and Management .................................................................. 6
3
Intravenous Fluid Management .................................................................................. 7
3.1
Intravenous Fluid Monitoring ......................................................................................... 7
3.2
Intravenous Fluid Types ................................................................................................ 7
3.3
Intravenous Fluid Volumes ............................................................................................ 8
Special circumstance: Gastroenteritis ................................................................................. 8
3.4
Maintenance .................................................................................................................. 9
3.5
Intravenous Fluid Calculation based on Weight .......................................................... 10
3.6
Intravenous Fluid Order Documentation ...................................................................... 10
4
Management of Intravenous Admixtures ................................................................ 11
4.1
Bolus (Push) ................................................................................................................ 11
4.2
Intermittent Infusion ..................................................................................................... 11
4.3
Infusion ........................................................................................................................11
5
Clinical Documentation............................................................................................. 12
6
Key Performance Indicators ..................................................................................... 12
References ............................................................................................................................13

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Guideline: Intravenous Fluid Management

Introduction
For the purpose of this document, all references will be made to the infusion of parenteral
fluids or medication via non-centrally located intravenous devices, e.g. peripheral cannula.

Inclusions
All staff who are responsible for the administration of intravenous (IV) medication at the
Childrens Hospital at Westmead (CHW) must be appropriately qualified and trained to do so
within the context of their practice4, i.e. some IV medications must only be given by
accredited staff and reference to these can be found in the Medication Management and
Handling Practice Guideline refer to points 4.1 & 4.2.
1. Administration of intravenous fluids line changes, use of IV sets and attachments,
management of additional drugs to the IV line, Infection Control
2. Intravenous Medication Administration Accreditation annual/biennial accreditation
process for all staff responsible for the administration of IV medication. (Section 1)
3. Management of administration of IV admixtures, including infusion and push
administration of drugs
4. Education of staff undertaking the care and management of any infant, child or young
person who has an IV cannula with or without fluids.

Exclusions
1. Intravenous Cannulation Procedure is not included in the scope of this document.
2. Parenteral Nutrition Practice Guidelines are not included within the scope of this
document.
3. Central Venous Access Device management is not included within the scope of this
document.
4. Transfusion of blood and blood components are not included within the scope of this
document.
5. Medication information and specific advice on management of IV medication is not
included within the scope of this document.
6. Intraosseus insertion and management is not included in this document
7. Arterial or umbilical line management is not included in this document
8. Intravenous Fluid Management for neonates and infants less than 3 months of age is
not included in the scope of this document.

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Guideline: Intravenous Fluid Management

1
1.1

Intravenous Medication Administration Accreditation


Initial Accreditation

Initial accreditation at commencement of employment at CHW consists of:


1. Completion of SAMUEL (via E-learning portal).
2. A documented record of twenty medication checks signed by a registered nurse
deemed competent (see section 1.2 below) to undertake the role. Also refer to
Appendix V Medication Management and Handling Practice Guideline.
3. Demonstrate competency in administration of IV medication clinical assessment.
Once these are completed staff are endorsed to be a first medication checker and may check
and administer IV medications and fluids. For further information on accreditation and
descriptions about what level of nursing staff are eligible to administer IV medication refer to
Medication Management and Handling Guideline.

1.2

Biennial Accreditation (ongoing)

Re-accreditation of demonstration of competency of IV medication clinical assessment is


completed:

every two (2) years for Registered Nurses and

annually for Endorsed Enrolled Nurses

The assessment may be performed by the CNE or an RN who has been deemed competent
to undertake the role of assessor; competency is endorsed by the Nursing Unit Manager or
Nurse Manager of the clinical area. The capacity for the RN to undertake the role of assessor
should include education on how to undertake a competency. (Refer to Appendix IV: Administration
of Intravenous Medications Clinical Assessment in the Medication Management and Handling Guideline)

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Guideline: Intravenous Fluid Management

Administration of Intravenous Fluids

Peripheral intravenous infusion sets are used for the administration of parenteral fluids and
must be changed every 96 hours2, however if they are disconnected or the intravenous
infusion set has been broken it must be replaced. Documentation must be included within
the clinical record which should include the following:

Date and time intravenous infusion set changed

Cannula site description e.g. patent, not inflamed or swollen etc should be
documented in the clinical record.

Date and time intravenous infusion set due to be changed


Position of intravenous cannula (e.g. right cubital fossa)
Cannula site checks are required every hour when continuous IV infusion is being
administered confirmation of site check is made by the staff member initialling on the
Fluid Balance Chart (in the sign column - M43B) or the Oncology flowchart (M66)

It is recommended that for any IV that is disconnected for bathing or showering purposes, the
IV intravenous infusion set must be discarded and a new intravenous infusion set used.

2.1

Intermittent Line Changes

All intravenous infusion sets used for intermittent administration of intravenous fluids or
medication must be discarded after each use where they are disconnected at the cannula site.
This excludes syringe pump extension tubing/T-pieces that remain insitu for next infusion.

Consider using syringe pumps/drives to administer intermittent IV fluids/medication as the


intravenous infusion set can be capped, not requiring discarding of the line for 96 hours
(see above).

2.2

Intravenous Fluids

IV fluids are administered using appropriate intravenous infusion sets and protocols. Any
bag of IV fluid must be changed every 24 hours. IV fluids containing Potassium Chloride
(KCl) are to be infused independent of any other IV medication, that is they are not to be
used as the base or mixing solution for administration of IV medication.

2.3

Extravasation Monitoring and Management

In accordance with the NSW Health Safety Notice all pumps used to deliver IV fluids or drugs
should have the capability to set pressure limits which will help reduce the risk of
extravasation5 with the following recommendations:

Set appropriate pressure limits


Check pressures hourly where applicable (& document)
Do not use an adult infusion pump for neonates or children under the age of 14 years

The key issue in managing extravasation is ensuring the above preventive measures are
taken, as well as ensuring close monitoring and recognition of extravasation including
swelling, redness or pain at the insertion site5. If any signs of extravasation are noted, stop
the infusion immediately; notify treating medical team and document in the clinical record.
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Guideline: Intravenous Fluid Management

Intravenous Fluid Management

Calculations of maintenance fluids and fluid replacement are based on very different
principles further information is available in the CHW Handbook Chapter 7. Fluid and
electrolyte therapy. It is important to remember that maintenance fluids are not directly
proportional to weight but to energy expenditure3.
When prescribing IV fluids, staff should consider:

Does this child need IV Fluid?

Where possible give enteral feeding to all children, even if sick, as this provides better
nutrition and offers additional safeguards in the management of patients.

If oral fluids are not tolerated, consider feeds via a nasogastric (or nasojejunal) tube.

IV fluids should be discontinued as soon as enteral options can be substituted. If both


are used for a transitional period, remember to base calculations on total fluid intake.

3.1

Intravenous Fluid Monitoring

Whenever IV fluids are administered ensure accurate prescribing and regular monitoring.

All children on IV fluids (except TKVO) should be weighed prior to commencement,


preferably again 6-8 hours after the infusion is commenced and then at least daily.

All children on IV fluids (except TKVO) for acute conditions other than elective surgery,
should have serum electrolytes and glucose checked before commencing the infusion,
and again within 24 hours while IV therapy continues or sooner if clinically indicated. If
IV therapy continues, serum electrolytes and glucose should be checked every 24-48
hours

Pay particular attention if weight changes by more than 5%, if serum sodium is less
than 135mmol/L or greater than 145mmol/L, or if serum sodium is rising or falling
quickly.

3.2

Intravenous Fluid Types

Fluid types for common scenarios when serum electrolytes are not significantly abnormal.

Maintenance : 0.45% (75mmol/L) sodium chloride and 5% glucose with or without


20mmol/L Potassium Chloride KCI

In Theatre maintenance: 0.9% (150mmol/L) sodium chloride with or without 1%


glucose (or Hartmanns with or without 1% glucose)

Rehydration (Not resuscitation): 0.9% (150mmol/L) sodium chloride and 5% glucose


with or without 20mmol/L KCI.

Resuscitation: 0.9% (150mmol/L) sodium chloride with no glucose (or Hartmanns or


non-crystalloid, e.g. Albumin)

The above fluid recommendations are not for neonates or infants < 3 months of age.
See below:
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Guideline: Intravenous Fluid Management
o

Infants < 3 months of age usually require their fluids to be made up to 10% glucose
e.g. for maintenance use 0.45% sodium chloride + 10% glucose.

For neonates in Grace Centre for Newborn Care, please see local guidelines.

These guidelines may not be applicable to special patient groups e.g. patients with diabetic
ketoacidosis. Refer to relevant policy for management.

3.3

Intravenous Fluid Volumes

It is vital to always monitor the Total Fluid Intake (oral, intravenous and drug/blood infusion
volumes) not just intravenously ordered volumes.

Resuscitation for Hypovolaemia 20 mL/kg as a bolus given as rapidly as possible.


(This may be repeated if inadequate improvement)

Deficit/Rehydration
To calculate the approximate deficit in mL, use the following formula:
(Weight [kg] x % clinical dehydration x 10 mL)
Divide this calculated deficit volume by 24 to get the hourly rate of infusion.
Use the table below to decide on the % dehydration.

Description of
Dehydration

Dehydration
(% of body weight)

No clinical sign of
dehydration

Mild

3%

Moderate

5%

Severe

10%

Signs and Symptoms


Reduced urine output
Thirsty
No physical signs
Reduced urine output
Thirsty
Dry mucous membranes
Mild tachycardia
Dry mucous membranes
Tachycardia
Abnormal respiratory pattern
Lethargy
Reduced skin turgor
Sunken eyes
Above signs +
Poor perfusion: Mottled, cool limbs/Slow capillary
refill/Altered consciousness
Shock: Thready peripheral pulses with marked
tachycardia & other signs of poor perfusion stated above

Special circumstance: Gastroenteritis


Oral then nasogastric rehydration are the usual first and second line methods of rehydrating
a child with gastroenteritis. However, when IV rehydration is being used for this purpose,
standard rehydration over 24 hours may be used as above. Alternatively, rapid IV rehydration
may be considered if:
o

Child is > 6 months of age

Diarrhoea is present

Serum Na >130 & <149mmol/L

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o

Child not severely dehydrated or shocked

Child has normal level of consciousness

Child has no medical condition making them at risk of fluid overload

Rapid rehydration is not a resuscitation bolus.

Rapid IV rehydration should not be used if the child has already received rapid NG
rehydration

Rapid IV rehydration should not be used for any other conditions apart from
gastroenteritis.

The same fluid should be used for rapid IV rehydration as for standard rehydration
(i.e. 0.9% sodium chloride + 5% glucose). It is given at a rate of 10mL/kg/hr for 4 hrs
then ceased.

For more detail please see NSW Ministry of Health Guideline: Children and Infants with
Gastroenteritis - Acute Management

3.4

Maintenance
Total Maintenance Fluid Volume for 24hrs:
o

100mL/kg for first 10kg of patients weight +

50mL/kg for second 10kg of patients weight +

20mL/kg for every kg of patients weight thereafter

Total Maintenance fluid volume may also be calculated using the 4,2,1 Rule, that is:
o

4mL/kg/hr for first 10kg of patients weight +

2mL/kg/hr for next 10kg of patients weight +

1mL/kg/hr for every kg of patients weight thereafter

Both methods for calculating maintenance fluid requirements are described in the table below:
Weight

Method A: Daily IV requirements

Method B: Hourly IV requirements

Fluid type

1-10kg

100mL/kg/24 hrs

4mL/kg/hr

10-20kg

1000mL+(50mL/kg for each kg over


10kg)/24 hrs

40mL+(2mL/kg/hr for each kg over


10kg)/hr

0.45%
sodium
chloride +
5% glucose

>20kg

1500mL+(20mL/kg for each kg over


20kg)/24 hrs

60mL+(1mL/kg/hr for each kg over


20kg)/hr

+/- 20mmol
potassium
chloride

The maximum is 2500mL/day of maintenance fluids (Resuscitation and Deficit/rehydration


Fluid is in addition to this volume)
In cases of CNS infection (encephalitis and meningitis) and acute lower respiratory infection
(e.g. pneumonia, bronchiolitis) correct any immediate circulatory deficit as per resuscitation

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guidelines then continue with reduced Total Fluid Intake at approximately -2/3
maintenance because of the risk of SiADH and monitor closely.

3.5

Intravenous Fluid Calculation based on Weight


Total Fluid Intake
(based on 4/2/1 rule)
mL/hr

Weight
3
4
6
8
10
12
14
16
18
20
25
30
35
40
45
50
55
60 and above

Starting Total Fluid Intake for children with:


Meningitis, Encephalitis, Bronchiolitis, Pneumonia
once immediate circulation rectified
maintenance
2/3 maintenance

12
16
24
32
40
44
48
52
56
60
65
70
75
80
85
90
95
100

6
8
12
16
20
22
24
26
28
30
33
35
38
40
43
45
48
50

8
11
16
21
26
29
32
34
37
40
43
46
50
53
56
60
63
66

IF IN DOUBT OR THE PATIENT IS NOT IMPROVING ALWAYS SEEK EARLY


ADVICE FROM A MORE SENIOR MEDICAL OFFICER.

3.6

Intravenous Fluid Order Documentation

All IV fluids must be prescribed by a Medical Officer or Authorised Nurse Practitioner on the
appropriate forms or systems (e.g. Critical Care Information System - CCIS). An IV fluid
order is valid for 24 hours and a new order is to be prescribed every 24 hours. If the patient
is clinically unstable, fluid orders may only be valid for 4-6 hours requiring medical review. A
fluid order is only valid with the following criteria:

Patient Identification documented (addressograph with patients name written


underneath, signed by MO or handwritten using blue or black ink)

Weight of patient clearly documented

Date and time of order

Legible handwriting (not applicable for CCIS)

Volume and rate in mL/hr documented

Name of prescriber legible and signature to confirm order is recorded. Include the pager
number if applicable.

Two (2) clinicians accredited to administer and/or check IV fluids must sign the fluid order
(M42A) and document time started and finished.
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Management of Intravenous Admixtures

A Cochrane Review published in 2008 looked at cannula life with continuous vs intermittent
infusions. Although results were inconclusive to determine clear practice guidelines, there
was no evidence to support the notion that cannula life is extended with continuous infusions
(e.g. TKVO), therefore the practice of intermittent and bolus infusions will allow greater
freedom for the child and most likely extend the life of the cannula if properly flushed and
managed1.

4.1

Bolus (Push)

Most intravenous medications can be given as a bolus; however there are a number of
medications where this may produce toxicity or severe reactions. Medications suitable for
bolus injection can be identified using CHW IV Guidelines available in most clinical areas or
refer to the MIMS on line or the Australian Injectable Drugs Handbook.

4.2

Intermittent Infusion

Sometimes it may be more appropriate to deliver IV medications as an infusion e.g.


Vancomycin, therefore it is important to ensure patient safety by using guidelines to
guarantee appropriate dilution and infusion times. Some literature refers to adequate
flushing volumes, therefore there is an imperative that these are managed and monitored
appropriately. Some handy hints:

Use syringe drive pumps to deliver intermittent drug infusions cap the line once the
flush after the infusion is complete, therefore ensuring the line remains in situ and
capped until the next IV medication is required.

If any intravenous giving set is used this must be discarded once disconnected.

Ensure the appropriate volume of flush is given after the volume of fluid containing the
medication is given.

The flush ensures the remainder of the IV medication is administered therefore it is important
to know what fluid volume is required to ensure all medication is delivered it is not
appropriate to guess or use 20 mL routinely unless there is clear evidence this is the dead
space in the IV line check manufacturer instructions.

4.3

Infusion

Usually continuous infusions are used because the patient requires IV fluids in addition to
those being required for administration of IV medication. Minimum fluid rates vary for each
patient and IV device please refer to CVAD Practice Guideline for further information.

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Clinical Documentation

All patients with an intravenous cannula capped or infusing IV fluid are to have
documentation notated in the clinical record for every shift (that is 2 or 3 times per day
depending on routine shift times). Documentation should include:

Position of cannula (e.g. left cubital fossa)

Any IV fluids or medication administered

Condition of the IV cannula insertion site to include:


o

Erythema

Tenderness

Swelling

Any adverse outcomes e.g. extravasation of IV fluids or medications (IIMS).

Day cannula has been insitu e.g. inserted __/__/___ now day 4.

Record of medical review and need for IV cannula to remain in place.

Document date of removal and condition of IV insertion site.

Key Performance Indicators


Annual review of reported incidents as recorded in IIMS regarding the following:
o

IV fluid administration

IV fluid ordering

Extravasation

IV cannulation

Quality of clinical documentation

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2.
3.
4.
5.
6.
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NSW Health CareSafe, Hand Hygiene Policy Statement (DRAFT ONLY), 2008
NSW Health Policy Directive (PD2007_036) Infection Control Policy.
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf (accessed May 2012)

Date of Publishing: 2 May 2012 10:46 AM


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This Guideline may be varied, withdrawn or replaced at any time.

Date of Printing:

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Guideline No: 1/C/09:8070-01:03


Guideline: Intravenous Fluid Management
25. Oncology Nursing Society 2nd Edition, Access device guidelines: recommendations for nursing practice
and education, National Guideline Clearing House, 2004 .
26. Powell J, Tarnow K, Perucca R, The Relationship Between Peripheral Intravenous Catheter Indwell Time
and the Incidence of Phlebitis, Journal of Infusion Nursing, 2008, Vol 31 No 1, pp39-45
27. Rickard C, Wallis S, Courtney M, Lipman J, Daley P, Intravascular administration sets are accurate and
in appropriate condition after 7 days of continuous use: an invitro study, Journal of Advanced Nursing,
37(4), pp 330-337
28. Rosenthal K, Documenting Peripheral IV therapy, Nursing 2005, Vol 35 (7), pp 28
29. Royal Childrens Hospital, Clinical Guidelines: Peripheral Intravenous (IV) Device Management,
http://www.rch.org.au/rchcpg/index.cfm?doc_id=9507&print=yes (accessed May 2012)

Copyright notice and disclaimer:


The use of this document outside The Children's Hospital at Westmead (CHW), or its reproduction in
whole or in part, is subject to acknowledgement that it is the property of CHW. CHW has done
everything practicable to make this document accurate, up-to-date and in accordance with accepted
legislation and standards at the date of publication. CHW is not responsible for consequences arising
from the use of this document outside CHW. A current version of this document is only available
electronically from the Hospital. If this document is printed, it is only valid to the date of printing.
Date of Publishing: 2 May 2012 10:46 AM
K:\CHW P&P\ePolicy\Apr 12\IV Fluid Management.docx
This Guideline may be varied, withdrawn or replaced at any time.

Date of Printing:

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