Paediatric Clinical Guideline

Emergency
1.17 Intravenous Fluids

Guideline for 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 guidelines for Renal patients, Diabetes Mellitus and Insipidus and
Hypoglycaemia. There is a separate Burns guideline for the A&E department and the
Burns Unit.

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

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 Paediatric Clinical Guideline
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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 at presentation 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:-

No dehydration Mild - Moderate Severe

Clinical Sign Notes
(<3% weight loss) 3-10% >10%
Take care to differentiate urine
Reduced urine output No Yes Yes
from watery stool
Mouth breathers may always
Dry mouth No Yes Yes
have dry mouth
Sunken eyes No Yes Yes
May be less apparent in
No Yes Yes
Reduced skin turgor hypernatraemic dehydration
(Recoils instantly) (1-2 seconds) (> 2 seconds)
(doughy skin)
Yes
Prolonged capillary May be slightly CRT < 2 seconds taken as
No cool / mottled /
refill time prolonged normal
pale peripheries
Drowsiness/
No Yes Severe
Irritability

• Prolonged capillary refill time, abnormal skin turgor and absent tears have be en 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.

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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 100mls/kg 4mls/kg/hr

2nd 10kg of weight 50mls/kg 2mls/kg/hr
All additional kg of weight 20mls/kg 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).

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.

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1.17 Intravenous Fluids

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.

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.

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1.17 Intravenous Fluids

• 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.

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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

Iatrogenic - 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 21-
hydroxylase deficiency)
Other - Glucocorticoid deficiency
- Hypothyroidism
- Congestive heart failure
- Cirrhosis
- Nephrotic Syndrome
- Diabetic ketoacidosis (Hyperosmolality 2°
hyperglycaemia)

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.

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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.

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Emergency
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Management of Hyponatraemia

Serum Na < 135

AND Seizures or CNS
Depression
(Child in DKA – see DKA
guideline)

No Yes

Notify senior help

What is the and refer to PICU
child’s volume
status?
Resuscitate
ABC as
necessary
Normal Moderate Severe
or dehydration dehydration or
increased and Na 130 - dehydration
135 with Na <130 Give anticonvulsants
if required
Lorazepam 0.1ml.kg
Restrict to Oral/NG Maintenance IV (max 4mgs)
50% rehydration – and deficit Or
maintenance calculate fluid Diazepam PR or
Give 0.9% maintenance and requirements Midazolam Buccal
saline with deficit fluid replaced with 5mg/kg / (max 10mgs)
dextrose if requirements 0.9% saline
oral route not with dextrose
possible
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 Measure Na after
- Assess for signs of symptomatic bolus and repeat bolus
hyponatraemia and recheck U&Es urgently if until seizures stop or
suspected NA>125
- Neuro obs 2 hourly until Na in normal range

Transfer to PICU

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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

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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 - Gastroenteritis

loss - 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 - Inappropriately prepared infant formula
intake - 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.

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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: 3. Prolongation of PR interval

<1 year - T wave amplitude >11mm < 3 years 0.08 secs
>1 year - T wave amplitude >14mm > 3 years 0.10 secs

2. Prolongation of QRS duration 4. Disappearance of the P wave.

premature infants 0.04 secs
full term infants 0.05 secs 5. Wide, bizarre, diphasic QRS
complexes.
1-3 years 0.06 secs
> 3 years 0.07 secs

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. Identify and treat underlying condition

2. Repeat blood specimen ensuring specimen not haemolysed.
3. Discontinue potassium enhancing medication, i.e.

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
K+ supplements:

K+ sparing diuretics
 NSAIDs:
 ACE Inhibitors
4. 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
5. Consider correction of metabolic acidosis, dietary restriction and urinary excretion with
furosemide (1 mg/kg)
6. Check K+ after 1-2 hours.
7. 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.
8. 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. Institute treatment immediately. DO NOT allow the logistics of organising

an ECG to delay treatment.
2. Consider PICU Admission.
3. 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
4. While Calcium Gluconate is being drawn up, administer:
nebulised SALBUTAMOL or intravenous SALBUTAMOL if
ventilated
child < 25 kgs : 2.5mg (5 micrograms/Kg in 10mls WFI)
child > 25 kgs : 5.0mg Infuse over 15 minutes
5. Perform an ECG. If abnormalities present, repeat the above Calcium Gluconate dose
and consider a Calcium Gluconate infusion.
6. 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
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

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6. Do NOT give a blood transfusion

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1.17 Intravenous Fluids

Is the Potassium greater than 7

or
Remove the Cause greater than 6 with acidosis, congenital heart disease or ECG changes
presnet?
Yes No
Repeat the sample
Give iv 10% Calcium Gluconate Is the K+ still greater than 6 and < 7

Give nebulised Salbutamol (or

Yes No
intravenous if ventilated) CAUTION
IN CARDIAC DISEASE OR Calcium Resonium Haemolysed Sample
HYPERTENSION

K+ Refractory or Salbutamol contraindicated

=> Insulin and Dextrose infusion Prompt treatment saves lives. Do not
wait for an ECG. If one treatment is not
available or is difficult to arrange then
Is the K+ still greater than 7? use a quicker alternative
(Lab Sample)

Yes No

Repeat cycle, consider Ca Gluconate Calcium Resonium and identify Repeat the potassium
infusion and contact the renal team underlying cause of hyperkalaemia
after 1-2 hours

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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 Cushings 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: Effervescent tablets

12 mmol of K+ and 8 mmol of Cl- per tablet

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• 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).

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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 Childrens 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 amd 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. McClure RJ et al. Treatment of hyperkalaemia using intravenous and nebulised

salbutamol. Arch Dis Child 1994;70:126-128.
2. Murdoch IA et al. Treatment of hyperkalaemia with intravenous salbutamol.
Arch Dis Child 1991;66:527-528.
3. 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.
4. Allon M et al. Effect of bicarbonaate administration on plasma potassium in
dialysis patients:interactions with insulin and albuterol. Am J Kidney Dis
1996;28(4):508-514.
5. Howes LG. Which drugs affect potassium? [Review]. Drug Safety 1995
12(4):240-244.
6. 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.
7. Anonymous. Hyperkalaemia - silent and deadly [Editorial] 1989 1(8649):1240.
8. Helfrich E et al. Salbutamol for hyperkalaemia in children. [Review] Acta Paediatrica.
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9. Halperin ML et al. Potassium. The Lancet. 1998; 352(7):135-140.

Lucy Cliffe Page 17 of 19 June 2008

Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids
Appendix 1
Table 1: features of commonly used intravenous fluids in the UK1
Solution Osmolarity Sodium Osmolality Tonicity
(mOsmol/L) content (compared (with
mequiv/L) to plasma) reference
to cell
membrane)
Sodium 586 150 Hyperosmolar Isotonic
chloride 0.9%
with glucose
5%
Sodium 308 154 Isomolar Isotonic
chloride 0.9%
Sodium 432 75 Hyperosmolar Hypotonic
chloride
0.45% with
glucose 5%
Glucose 5% 278 - Isomolar Hypotonic
Glucose 10% 555 - Hyperosmolar Hypotonic
Hartmann’s * 278 131 Isomolar Isotonic
Sodium 284 31 Isomolar Hypotonic
chloride
0.18% with
glucose 4%
Sodium 293 75 Isomolar Hypotonic
chloride
0.45% with
glucose 2.5%
4.5% human 275 100-160 Isomolar Isotonic
albumin
solution

*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 18 of 19 June 2008

Paediatric Clinical Guideline
Emergency
1.17 Intravenous Fluids

Title
Intravenous Fluids and Electrolytes
Guideline Number Version Distribution
1.17 Draft All wards QMC and CHN

Authors Document Derivation

Dr Lucy Cliffe
Paediatric Specialist Registrar

Dr Simon Robinson (Hyperkalaemia & Hypokalaemia)

Paediatric Specialist Registrar

First Issued Latest Version Date Review Date

June 2007 June 2008 June 2011

Ratified By Date

Audit Induction Programme Amendments

Lucy Cliffe Page 19 of 19 June 2008