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Intravenous fluid therapy in children and young people in hospital N29
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    Use of 0.9% saline as maintence fluid is bad medicine
    • Graham C Smith, Paediatric Nephrologist University Hospital of Wales, Cardiff

    I read with interest the review by Green and Lillie[1] of the NICE guideline (N29) on intravenous fluid therapy in children[2]. The new guideline correctly questions the routine use of the Holliday-Segar formula for calculation of maintenance fluids[3], but the recommendation of 0.9% saline as the maintenance fluid must still be questioned.

    The review opens with two contradictory statements in the first two paragraphs:

    “The prescription of intravenous fluids requires an understanding of fluid homeostasis and should be tailored to the individual, the disease and the intended therapeutic goal.”

    and, in reference to the NICE guideline:

    “…its aim was to offer a ‘standardised approach to assessing patient’s fluid and electrolyte status and prescribing IV fluid therapy in term neonates, children and young people’.”

    I agree wholeheartedly with the first statement but it does not fit with the second proposal of a “standardised” approach. The problem hinges around the idea of “replacement” and “maintenance” fluids and this was reviewed in an excellent paper by Malcolm Coulthard in 2007 when he questioned the switch from 0.18% saline to 0.45% saline as the recommended maintenance fluid[4]. The arguments he used are now doubly relevant when you move to 0.9% saline.

    Patients who need fluid “replacement” need an iv fluid matching extracellular fluid composition and 0.9% saline fits the bill. Patients who need iv “maintenance” fluid need some...

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    Conflict of Interest:
    None declared.