Fluid protocol #1—hyperhydration
dehydration, weight gain, hyponatremia, hyperhydration
DEHYDRATION, HYPONATREMIA
In this pathway, all eligible children are admitted for the administration of intravenous fluids. To rapidly and safely achieve intravascular volume expansion, based on existing evidence [The following specifics will form the basis of the fluid management protocol (Fig. The hyperhydration care pathway recommends the infusion of 200% maintenance fluids until a hematocrit reduction of 20% and weight gain of 10% occur. Patients may be discharged if the following criteria are met even if the targets are not achieved: (1) platelet count is > 50 × 10
Reversal of dehydration: initial rehydration strategies should focus on rapidly reversing dehydration.Infusion of 200% of maintenance fluids × 24 h provided, ideally, as a balanced crystalloid (e.g., PlasmaLyte™, Ringer’s Lactate) intravenous solution. Electrolytes and dextrose may be administered as deemed appropriate; customized solutions are permitted. Intravenous fluid solutions containing < 130 mEq/L sodium should be avoided as they increase the likelihood of developing hyponatremia and are less effective in achieving intravascular volume expansion.If the hematocrit reduction is < 20% from the initial value at 24 h, and the weight gain is < 10%, repeat step #2 (infusion of 200% maintenance intravenous fluids for 24 additional hours) unless the weight gain is ≥ 10% in which case move to step #5.Oral fluids permitted ad lib.If the target hematocrit reduction (20% decrease from baseline) AND a 10% weight gain are achieved, adjust total intravenous fluid volume to maintain targeted weight gain and prevent worsening fluid accumulation (i.e., replace insensible losses plus urine and stool output). If both targets are not achieved, then return to step #2.◦ Insensible losses will be estimated to be 400 mL/m◦ Daily weights should be performed and be used to guide the assessment of fluid status with additional fluid adjustments made, as required, to maintain the targeted weight gain.Complete blood count, electrolytes, and kidney function should be repeated every 24 h (or more frequently as deemed clinically indicated).Consider nephrology consultation for all children.