A clinical pathway to standardize use of maintenance IV fluids

Reducing the risk of hyponatremia in hospitalized children


Clinical question

Can an evidence-based clinical pathway improve adherence to recent recommendations to use isotonic solutions for maintenance intravenous fluids in hospitalized children?


The traditional teaching regarding composition of maintenance intravenous fluids (IVF) in children has been based on the Holliday-Segar method.1 Since its publication in Pediatrics in 1957, concerns have been raised regarding the risk of iatrogenic hyponatremia caused by giving hypotonic fluids determined by this method,2 especially in patients with an elevated risk of increased antidiuretic hormone (ADH) secretion.3 Multiple recent systematic reviews and meta-analyses have confirmed that isotonic IVF reduces the risk of hyponatremia in hospitalized children.4

Study design

Interrupted time series analysis before and after pathway implementation.


370-bed tertiary care free-standing children’s hospital.


A multidisciplinary team was assembled, comprising physicians and nurses in hospital medicine, general pediatrics, emergency medicine, and nephrology. After a systematic review of the recent literature, a clinical algorithm and web-based training module were developed. Faculty in general pediatrics, hospital medicine, and emergency medicine were required to complete the module, while medical and surgical residents were encouraged but not required to complete the module. A maintenance IVF order set was created and embedded into all order sets previously containing IVF orders and was also available in stand-alone form.

Inclusion criteria (“pathway eligible”) included being euvolemic and requiring IVF. Exclusion criteria included fluid status derangements, critical illness, severe serum sodium abnormalities (serum sodium ≥150 mEq/L or ≤130 mEq/L) use of TPN or ketogenic diet. In the order set, IVF composition was determined based on risk factors for increased ADH secretion. Inclusion of potassium in IVF was also determined by the pathway.

Over the 1-year study period, 11,602 pathway-eligible encounters in 10,287 patients were reviewed. Use of isotonic maintenance IVF increased significantly from 9.3% to 50.6%, while use of hypotonic fluids decreased from 94.2% to 56.6%. Use of potassium-containing IVF increased from 52.9% to 75.3%. Dysnatremia continued to occur due to hypotonic IVF use.

Bottom line

A combined clinical pathway and training module to standardize the composition of IVF is feasible, and results in increased use of isotonic and potassium-containing fluids.


Rooholamini S, Clifton H, Haaland W, et al. Outcomes of a clinical pathway to standardize use of maintenance intravenous fluids. Hosp Pediatr. 2017 Dec;7(12):703-9.

Dr. Weijen W. Chang, pediatric editor of The Hospitalist, and chief of the division of pediatric hospital medicine at Baystate Children's Hospital, Springfield, Mass.

Dr. Weijen W. Chang

Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital in Springfield, Mass., and is the pediatric editor of The Hospitalist.


1. Holliday MA et al. The maintenance need for water in parenteral fluid therapy. Pediatrics 1957;19:823-32.

2. Friedman JN et al. Comparison of isotonic and hypotonic intravenous maintenance fluids: a randomized clinical trial. JAMA Pediatr. 2015;169:445-51.

3. Fuchs J et al. Current Issues in Intravenous Fluid Use in Hospitalized Children. Rev Recent Clin Trials. 2017;12:284-9.

4. McNab S et al. Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children. Cochrane Database. Syst Rev 2014:CD009457.

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