Chris Maloney, MD Revised 6/23/2001

Intravenous Fluid Orders– A Primer:

Maintenance fluids:

Maintenance fluids consist of water and electrolyte requirements for a 24-hour period.
These values have been determined through years of careful analysis and a thorough
understanding of what these numbers are is paramount to providing appropriate care to
any pediatric patient. Corners can be cut and you may see residents attempting some of
these short cuts. Cutting corners is a very bad practice as a medical student or intern,
because it will only hurt you in the years to come. A very good example of this is
attempting to determine what IV fluid should be hung on a patient with hypernatremic
dehydration. If one does not know how to calculate maintenance water, sodium, chloride
and potassium then it will be impossible to adequately care for the patient.

Water requirements:
100 cc/kg for the first 10 kg
50 cc/kg for the next 10 kg (11 – 20 kg)
20 cc/kg for the rest (> 20 kg)

Sodium requirements:
3 – 5 mEq/kg/day

Potassium requirements
1 – 3 mEq/kg/day

Chloride requirements
4 – 6 mEq/kg/day

If you use 4 mEq/kg/day for sodium requirements and 2 mEq/kg/day for potassium and
make both the chloride salt then the math is pretty easy.
An example may be most helpful.

ONLY GIVE POTASSIUM TO A PATIENT IF THEY ARE DEMONSTRATING

GOOD URINE FLOW. HYPERKALEMIA WILL KILL YOUR PATIENT;
HYPOKALEMIA WILL ONLY MAKE THEM WEAK.

See the next page for an example.

You should practice additional examples and I will be happy to work through them with
you if you are having problems or just want to see if you are doing it right.
Chris Maloney, MD Revised 6/23/2001

A 13 kg child is admitted with status asthmaticus and you want to make her NPO. Your
IV fluid order should be as follows:
You need 1150 cc of water for the day
1000 cc for the first 10 kg (100 cc * 10 kg = 1000)
150 cc for the next 3 kg (50 cc * 3 kg = 150)
You need 52 mEq/day of sodium (4 mEq/day * 13 kg = 52)
You need 26 mEq/day of potassium (2 mEq/day * 13 kg = 26 or ½ of the sodium)
Now you need to determine what fluid contains 52 mEq of sodium in 1150 cc.
Normal saline (0.9% saline) contains 154 mEq/L of sodium and chloride
0.45% saline contains 77 mEq/L of sodium and chloride
0.2% saline contains 38 mEq/L of sodium and chloride
You would choose 0.2% saline:
This fluid will provide roughly 44 mEq of sodium in 1150 cc over 24 hours.
If you remember that sodium requirements were between 3 and 5
mEq/kg/day then this 13 kg child needs between 39 and 65 mEq/day of
sodium. 44 mEq/day is right in the ballpark.
Now how do you write the order?
Here it is:
D5 .2 NS + 20 mEq/L tra (to run at) 46 cc/hr
The child needs 26 mEq/day of potassium (range 13 – 39) and adding 20
mEq/L will provide roughly 23 mEq/day.
Now what about the D5? Does it provide calories? NO. It does provide a source of
energy for enzymes so that they do not break down muscle. Remember that
carbohydrates provide 4 kcal/g. So providing 57.5 grams of dextrose (D5 is
5 grams of dextrose/ 100 cc of water = 11.5 * 5 == 57.5) multiply 57.5 by 4
and you get less than 500 kcal/day, hardly enough for growth, but it will
prevent catabolism. Another reason to add D5 is for the osmotic load. D5
provides approximately 252 milliosmoles/L. Adding this to a fluid that
contains 76 milliosmoles/L (0.2% saline [38 mEq/L of sodium and 38
mEq/L of chloride. Each is a monovalent ion therefore the osmolality is 76.]
252 + 76 = 328, which should be greater than the plasma osmolality, which
is between 280 and 290. This way you are not providing a hypotonic
solution that would potentially lyse cells.
How did we get the rate? Well there are two ways. One-way is to divide the total
amount of water by 24 (the number of hours in a day), in this case 1150/24
= 47.9. This is probably the most accurate way and the number should be
rounded to 48. I gave the number 46 and did this on purpose to make a
point. Many people use the 4, 2, 1 rule: 4 cc/kg for the first 10 kg; 2 cc/kg
for the next 10 kg and 1 cc/kg for the rest. This comes from dividing the
numbers above for water 100, 50 and 20 by 24. It really only works for
patients over 20 kg, but is probably close enough.

General rule of thumb: A child’s kidney is smarter than a clinician’s cortex.

You should perform these calculations on ALL patients needing IV fluids. They will
become second nature to you and benefit your patients in the long run.