Maintenance and Replacement Therapy

Maintenance Therapy

Children normally have large variations in their daily intake of water and electrolytes. The only exceptions are patients who receive fixed dietary regimens orally, via a gastric tube, or as IV total parenteral nutrition (TPN). Healthy children can tolerate significant variations in intake because of the many homeostatic mechanisms that can adjust absorption and excretion of water and electrolytes (see Chapter 68 ). The calculated water and electrolyte needs that form the basis of maintenance therapy are not absolute requirements. Rather, these calculations provide reasonable guidelines for a starting point to estimate IV therapy. Children do not need to be started on IV fluids simply because their intake is being monitored in a hospital and they are not taking “maintenance fluids” orally, unless there is a pathologic process present that necessitates high fluid intake.

Maintenance fluids are most often necessary in preoperative and postoperative surgical patients; many nonsurgical patients also require maintenance fluids. It is important to recognize when it is necessary to begin maintenance fluids. A normal teenager who is given nothing by mouth (NPO) overnight for a morning procedure does not require maintenance fluids because a healthy adolescent can easily tolerate 12 or 18 hr without oral intake. In contrast, a 6 mo old child waiting for surgery should begin receiving IV fluids within 8 hr of the last feeding. Infants become dehydrated more quickly than older patients. A child with obligatory high urine output from nephrogenic diabetes insipidus should begin receiving IV fluids soon after being classified as NPO.

Maintenance fluids are composed of a solution of water, glucose, sodium (Na ⁺ ), and potassium (K ⁺ ). This solution has the advantages of simplicity, long shelf life, low cost, and compatibility with peripheral IV administration. Such a solution accomplishes the major objectives of maintenance fluids ( Table 69.1 ). Patients lose water, Na ⁺ , and K ⁺ in their urine and stool; water is also lost from the skin and lungs. Maintenance fluids replace these losses, thereby avoiding the development of dehydration and Na ⁺ or K ⁺ deficiency.

The glucose in maintenance fluids provides approximately 20% of the normal caloric needs of the patient, prevents the development of starvation ketoacidosis, and diminishes the protein degradation that would occur if the patient received no calories. Glucose also provides added osmoles, thus avoiding the administration of hypotonic fluids that may cause hemolysis.

Maintenance fluids do not provide adequate calories, protein, fat, minerals, or vitamins. This fact is typically not problematic for a patient receiving IV fluids for a few days. A patient receiving maintenance IV fluids is receiving inadequate calories and will lose 0.5–1% of weight each day. It is imperative that patients not remain on maintenance therapy indefinitely; TPN should be used for children who cannot be fed enterally for more than a few days, especially patients with underlying malnutrition.

Prototypical maintenance fluid therapy does not provide electrolytes such as calcium, phosphorus, magnesium, and bicarbonate. For most patients, this lack is not problematic for a few days, although there are patients who will not tolerate this omission, usually because of excessive losses. A child with proximal renal tubular acidosis wastes bicarbonate in urine. Such a patient will rapidly become acidemic unless bicarbonate (or acetate) is added to the maintenance fluids. It is important to remember the limitations of maintenance fluid therapy.

Maintenance Water

Water is a crucial component of maintenance fluid therapy because of the obligatory daily water losses. These losses are both measurable (urine, stool) and not measurable ( insensible losses from the skin and lungs). Failure to replace these losses leads to a child who is thirsty, uncomfortable, and ultimately dehydrated.

The goal of maintenance water is to provide enough water to replace these losses. Although urinary losses are approximately 60% of the total, the normal kidney can greatly modify water losses, with daily urine volume potentially varying by more than a factor of 20. Maintenance water is designed to provide enough water so that the kidney does not need to significantly dilute or concentrate the urine. It also provides a margin of safety, so that normal homeostatic mechanisms can adjust urinary water losses to prevent overhydration and dehydration. This adaptability obviates the need for absolute precision in determining water requirements. This fact is important, given the absence of absolute accuracy in the formulas for calculation of water needs.

Table 69.2 provides a system for calculating maintenance water on the basis of the patient's weight and emphasizes the high water needs of smaller, less mature patients. This approach is reliable, although calculations based on weight do overestimate the water needs of an overweight child, in whom it is better to base the calculations on the lean body weight, which can be estimated by using the 50th percentile of body weight for the child's height. It is also important to remember that there is an upper limit of 2.4 L/24 hr in adult-sized patients. IV fluids are written as an hourly rate. The formulas in Table 69.3 enable rapid calculation of the rate of maintenance fluids.

Intravenous Solutions

The components of available solutions are shown in Table 69.4 . These solutions are available with 5% dextrose (D5), 10% dextrose (D10), or without dextrose. Except for Ringer lactate (lactated Ringer, LR), they are also available with added potassium (10 or 20 mEq/L). A balanced IV fluid contains a base (lactate or acetate), a more physiologic chloride concentration than NS, and additional physiologic concentrations of electrolytes such as potassium, calcium, and magnesium. Examples include LR and PlasmaLyte, and there is evidence suggesting benefit versus NS in certain clinical situations. A hospital pharmacy can also prepare custom-made solutions with different concentrations of sodium or potassium. In addition, other electrolytes, such as calcium, magnesium, phosphate, acetate, and bicarbonate, can be added to IV solutions. Custom-made solutions take time to prepare and are much more expensive than commercial solutions. The use of custom-made solutions is necessary only for patients who have underlying disorders that cause significant electrolyte imbalances. The use of commercial solutions saves time and expense.

A normal plasma osmolality is 285-295 mOsm/kg. Infusing an IV solution peripherally with a much lower osmolality can cause water to move into red blood cells, leading to hemolysis. Thus, IV fluids are generally designed to have an osmolality that is either close to 285 or greater (fluids with moderately higher osmolality do not cause problems). Thus, 0.2NS (osmolality = 68) should not be administered peripherally, but D5 0.2NS (osmolality = 346) or D5 NS + 20 mEq/L potassium chloride (KCl) with an osmolality of 472 can be administered.

Controversy surrounds the appropriate sodium content of maintenance fluids, considering the observation that hypotonic fluids may cause hyponatremia, which may have serious sequelae. Hypotonic fluids seem more physiologic given the low Na ⁺ content of breast milk and formula. However, hospitalized children often have impaired water excretion because of volume depletion or nonosmotic stimuli for antidiuretic hormone (ADH) production, such as respiratory disease, central nervous system (CNS) disease, stress, pain, nausea, and medications (e.g., narcotics). Hypotonic fluids increase the risk of hyponatremia; hence, isotonic fluids with 5% dextrose are recommended as standard maintenance fluid except in neonates .

Glucose

Maintenance fluids usually contain D5, which provides 17 calories/100 mL and nearly 20% of the daily caloric needs. This level is enough to prevent ketone production and helps minimize protein degradation, but the child will lose weight on this regimen. The weight loss is the principal reason why a patient needs to be started on TPN after a few days of maintenance fluids if enteral feedings are still not possible. Maintenance fluids are also lacking in such crucial nutrients as protein, fat, vitamins, and minerals.