Pediatrics iv fluids rule When what where and how much to use

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Pediatric IV Fluids - Complete Guide

The Core Framework: Three Questions

Every pediatric IV fluid order must answer:

Why (indication) - maintenance, resuscitation, deficit replacement, or special condition
What (fluid type) - which solution to use
How much & how fast (rate/volume) - calculated by formula

PART 1 - WHEN to Use IV Fluids

IV fluids are indicated when oral/enteral rehydration is not possible or has failed:

Shock or severe dehydration (>9% in older children, >15% in infants)
Intractable vomiting preventing adequate oral intake
Altered mental status
Hypoglycemia requiring IV dextrose
Electrolyte derangements (severe hypo/hypernatremia, hypokalemia)
Surgical NPO status / perioperative management
Inability to tolerate ORT after 8 hours trial

Key point: Oral rehydration therapy (ORT) is always preferred over IV for mild-moderate dehydration. IV fluids are a step up when ORT fails or is contraindicated.

PART 2 - WHAT Fluid to Use

Current Standard: ISOTONIC fluids for maintenance

The 2018 AAP guidelines updated decades of practice - isotonic normal saline (0.9% NaCl) or Lactated Ringer's are now the preferred maintenance fluids for most hospitalized children, replacing the old 1/4 NS (0.225%) standard. This change came after evidence showed hypotonic maintenance fluids caused hospital-acquired hyponatremia.

Fluid	Na⁺ (mEq/L)	Use
0.9% NaCl (Normal Saline)	154	Resuscitation bolus, isotonic maintenance
Lactated Ringer's	130	Resuscitation, surgery, preferred where Cl⁻ load is a concern
Plasmalyte	140	Balanced, near-physiologic
0.45% NaCl (1/2 NS)	77	Ongoing repletion after resuscitation (with caution)
0.225% NaCl (1/4 NS)	38.5	Largely abandoned for routine maintenance
D5W	0	Free water only; risk of hyponatremia - not for resuscitation
D5 0.9% NaCl	154	Post-resuscitation repletion with glucose
D10W	0	Neonatal hypoglycemia

Potassium: Add KCl 20 mEq/L (or up to 40 mEq/L) to maintenance fluids only after urine output is confirmed.

Dextrose: Added to maintenance fluids for ongoing caloric/glucose needs (especially in infants and neonates). NOT added to resuscitation boluses.

PART 3 - HOW MUCH (Volume Calculations)

A. Maintenance Fluids - The Holliday-Segar Method ("4-2-1 Rule")

The most widely used formula, based on caloric expenditure:

Weight	Rate (hourly)	Rate (daily)
First 10 kg	4 mL/kg/hr	100 mL/kg/day
Second 10 kg	+ 2 mL/kg/hr	+ 50 mL/kg/day
Each kg >20 kg	+ 1 mL/kg/hr	+ 20 mL/kg/day

Maximum recommended rate: 120 mL/hr (in absence of cardiac, hepatic, or renal disease)

Important: Holliday-Segar is NOT suitable for neonates <14 days old - it overestimates their needs. See neonatal fluid protocols separately.

Worked example (25 kg child):

First 10 kg: 4 × 10 = 40 mL/hr
Second 10 kg: 2 × 10 = 20 mL/hr
Remaining 5 kg: 1 × 5 = 5 mL/hr
Total = 65 mL/hr (or 1600 mL/day)

B. Dehydration Assessment - Grading

Sign	Mild	Moderate	Severe
Older child	3% (30 mL/kg)	6% (60 mL/kg)	9% (90 mL/kg)
Infant	5% (50 mL/kg)	10% (100 mL/kg)	15% (150 mL/kg)
Mental status	Alert	Normal	Lethargic/obtunded
Eyes	Normal	Deep set	Sunken
Tears	Present	Reduced	None
Mucosa	Normal/dry	Dry	Parched/cracked
Fontanelle	Flat	Soft	Sunken

Calculating deficit:

Fluid deficit (mL) = % dehydration × 10 mL/kg × weight (kg) 1% dehydration = 10 mL/kg fluid deficit

C. Resuscitation Phase (Emergency Phase - Shock/Severe Dehydration)

Goal: Rapid restoration of intravascular volume

Bolus: 20 mL/kg of isotonic crystalloid (0.9% NaCl or LR) IV/IO as fast as possible
Reassess every 5-15 minutes
Repeat boluses of 20 mL/kg PRN until shock resolves
If >60 mL/kg without improvement: investigate for cardiogenic shock, septic shock, hemorrhage, or adrenal insufficiency

Glucose correction ("Rule of 50"):

Dextrose % × mL/kg = 50
Neonate: D10W at 5 mL/kg
1 month - ~8 yr (up to 25 kg): D25% at 2 mL/kg
Older child: D50% at 1 mL/kg
D10% is safe at all ages and preferred if extravasation risk exists

D. Deficit Replacement Phase (Repletion Phase - 24 hours)

The 3-phase replacement approach:

Phase	Action
Phase I - Stabilization	20 mL/kg isotonic bolus (subtract from deficit)
Phase II - Deficit + Maintenance	Replace 1/2 remaining deficit over first 8 hr + maintenance; Replace 2nd half over next 16 hr + maintenance
Phase III - Recovery	Continue maintenance + replace ongoing losses

Ongoing losses replacement:

Each diarrheal stool: replace 10 mL/kg
Each vomiting episode: replace 2 mL/kg

Worked example (15 kg child, 10% dehydration, isonatremic):

Maintenance: 1250 mL/24 hr (52 mL/hr)
Deficit: 10% × 10 mL/kg × 15 kg = 1500 mL
If 20 mL/kg bolus given (300 mL): remaining deficit = 1200 mL
- First 8 hr: 600 mL/8 hr (75 mL/hr) + 52 mL/hr maintenance = 127 mL/hr
- Next 16 hr: 600 mL/16 hr (38 mL/hr) + 52 mL/hr maintenance = 90 mL/hr

PART 4 - SPECIAL CONSIDERATIONS

Isonatremic Dehydration (Na 130-150 mEq/L)

Use isotonic fluid (NS or LR) for replacement per the 3-phase protocol above.

Hyponatremic Dehydration (Na <130 mEq/L)

Use isotonic NS; avoid hypotonic solutions
Correct sodium slowly to prevent osmotic demyelination syndrome (central pontine myelinolysis)
Target correction: no faster than 8-12 mEq/L per 24 hours

Hypernatremic Dehydration (Na >150 mEq/L)

Use isotonic NS initially; correct slowly
Overly rapid correction causes cerebral edema
Target correction: no faster than 10-12 mEq/L per 24 hours
Replace deficit over 48-72 hours, not 24 hours

Neonates (<14 days old)

Holliday-Segar does NOT apply - overestimates needs
Start D10W for glucose needs
Consult neonatal fluid protocols

DKA

10-20 mL/kg isotonic NS bolus in shock
Avoid excessive fluid boluses (cerebral edema risk)
Switch to specific DKA protocol

Quick Reference Summary

Scenario	Fluid	Rate/Volume
Maintenance	0.9% NaCl or LR ± dextrose	4-2-1 rule (Holliday-Segar)
Shock resuscitation	0.9% NaCl or LR	20 mL/kg bolus, repeat PRN
Mild dehydration	ORT preferred; if IV: NS or LR	Deficit over 24 hr + maintenance
Moderate dehydration	0.9% NaCl or LR	Phase I bolus + Phase II deficit replacement
Severe dehydration	0.9% NaCl	Aggressive boluses + 24 hr deficit replacement
Hypoglycemia	D10W (safe all ages) / D25% / D50%	Rule of 50
Hyponatremia maintenance	0.9% NaCl (isotonic)	Slow correction
Hypernatremic dehydration	0.9% NaCl, then 0.45% NS	Correct over 48-72 hr

Sources: The Harriet Lane Handbook, 23rd ed. (Johns Hopkins), p. 389-395 | Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 1732 | Rosen's Emergency Medicine, p. 3260-3262

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mkdir -p /home/daytona/workspace/peds-iv-fluids && ls /home/daytona/workspace/peds-iv-fluids/

Writing File

~/peds-iv-fluids/generate_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import mm
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import PageBreak

OUTPUT = "/home/daytona/workspace/peds-iv-fluids/Pediatric_IV_Fluids.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=18*mm, rightMargin=18*mm,
    topMargin=16*mm, bottomMargin=16*mm
)

W = A4[0] - 36*mm   # usable width

# ── Colour palette ──────────────────────────────────────────────────────────
NAVY   = colors.HexColor("#0D3B66")
TEAL   = colors.HexColor("#1A7A8A")
LTBLUE = colors.HexColor("#D6EAF8")
MINT   = colors.HexColor("#D5F5E3")
AMBER  = colors.HexColor("#FEF9E7")
RED    = colors.HexColor("#C0392B")
GREY   = colors.HexColor("#F2F3F4")
WHITE  = colors.white
BLACK  = colors.black
ORANGE = colors.HexColor("#E67E22")
PURPLE = colors.HexColor("#7D3C98")

# ── Styles ───────────────────────────────────────────────────────────────────
base = getSampleStyleSheet()

def S(name, **kw):
    s = ParagraphStyle(name, **kw)
    return s

title_style = S("Title",
    fontName="Helvetica-Bold", fontSize=18,
    textColor=WHITE, alignment=TA_CENTER,
    spaceAfter=2, leading=22)

subtitle_style = S("Subtitle",
    fontName="Helvetica", fontSize=9,
    textColor=WHITE, alignment=TA_CENTER,
    spaceAfter=0, leading=12)

section_style = S("Section",
    fontName="Helvetica-Bold", fontSize=10,
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body_style = S("Body",
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bold_style = S("Bold",
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note_style = S("Note",
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footer_style = S("Footer",
    fontName="Helvetica-Oblique", fontSize=6.5,
    textColor=colors.HexColor("#777777"), alignment=TA_CENTER,
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th_style = S("TH",
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td_style = S("TD",
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tdb_style = S("TDB",
    fontName="Helvetica-Bold", fontSize=7.5,
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tdc_style = S("TDC",
    fontName="Helvetica", fontSize=7.5,
    textColor=BLACK, alignment=TA_LEFT, leading=10)

# ── Helper builders ──────────────────────────────────────────────────────────
def section_header(text, color=NAVY):
    tbl = Table([[Paragraph(text, section_style)]], colWidths=[W])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), color),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 6),
        ("RIGHTPADDING",  (0,0), (-1,-1), 6),
        ("ROUNDEDCORNERS", [3]),
    ]))
    return tbl

def rule():
    return HRFlowable(width="100%", thickness=0.5,
                      color=colors.HexColor("#CCCCCC"), spaceAfter=4, spaceBefore=2)

def sp(h=4):
    return Spacer(1, h)

def bullet(text, indent=8):
    return Paragraph(f"<bullet bulletIndent='{indent}'>•</bullet> {text}", body_style)

def note(text):
    return Paragraph(f"⚠ {text}", note_style)

def make_table(headers, rows, col_widths, header_color=NAVY,
               alt_color=GREY, bold_first=False):
    data = []
    header_row = [Paragraph(h, th_style) for h in headers]
    data.append(header_row)
    for i, row in enumerate(rows):
        cells = []
        for j, cell in enumerate(row):
            if j == 0 and bold_first:
                cells.append(Paragraph(cell, tdb_style))
            else:
                cells.append(Paragraph(cell, tdc_style))
        data.append(cells)

    t = Table(data, colWidths=col_widths)
    style = [
        ("BACKGROUND",   (0,0), (-1,0),  header_color),
        ("TEXTCOLOR",    (0,0), (-1,0),  WHITE),
        ("FONTNAME",     (0,0), (-1,0),  "Helvetica-Bold"),
        ("ALIGN",        (0,0), (-1,-1), "CENTER"),
        ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
        ("GRID",         (0,0), (-1,-1), 0.4, colors.HexColor("#AAAAAA")),
        ("TOPPADDING",   (0,0), (-1,-1), 3),
        ("BOTTOMPADDING",(0,0), (-1,-1), 3),
        ("LEFTPADDING",  (0,0), (-1,-1), 4),
        ("RIGHTPADDING", (0,0), (-1,-1), 4),
    ]
    for i in range(1, len(data)):
        bg = WHITE if i % 2 == 1 else alt_color
        style.append(("BACKGROUND", (0,i), (-1,i), bg))
    t.setStyle(TableStyle(style))
    return t

# ── TITLE BANNER ─────────────────────────────────────────────────────────────
title_banner = Table(
    [[Paragraph("PEDIATRIC IV FLUIDS — COMPLETE REFERENCE", title_style)],
     [Paragraph("When · What · How Much · Special Scenarios", subtitle_style)]],
    colWidths=[W]
)
title_banner.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), NAVY),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("LEFTPADDING",   (0,0), (-1,-1), 10),
    ("RIGHTPADDING",  (0,0), (-1,-1), 10),
]))

# ══════════════════════════════════════════════════════════════════════════════
# BUILD STORY
# ══════════════════════════════════════════════════════════════════════════════
story = []

story.append(title_banner)
story.append(sp(8))

# ── SECTION 1: WHEN ──────────────────────────────────────────────────────────
story.append(section_header("1.  WHEN TO USE IV FLUIDS  (Indications)", TEAL))
story.append(sp(4))

indications = [
    ["Shock / Circulatory Failure", "Immediate IV access; bolus therapy"],
    ["Severe dehydration (>9% older child / >15% infant)", "Cannot correct orally; IV replacement needed"],
    ["Intractable vomiting / unable to maintain ORT", "ORT failed after attempt; switch to IV"],
    ["Altered mental status / decreased consciousness", "Airway protection; ORT unsafe"],
    ["Hypoglycemia requiring dextrose bolus", "Glucose emergency; IV dextrose required"],
    ["Electrolyte derangements (severe hypo/hypernatremia)", "Controlled IV correction needed"],
    ["Surgical / procedural NPO status", "Perioperative maintenance fluids"],
    ["ORT failure after 8-hour trial", "Insufficient volume repletion orally"],
]
story.append(make_table(
    ["Indication", "Rationale"],
    indications,
    [W*0.45, W*0.55],
    header_color=TEAL, bold_first=True
))
story.append(sp(3))
story.append(note("ORT (Oral Rehydration Therapy) is ALWAYS preferred over IV for mild-moderate dehydration. IV = step up when ORT fails or is contraindicated."))
story.append(sp(8))

# ── SECTION 2: WHAT ──────────────────────────────────────────────────────────
story.append(section_header("2.  WHAT FLUID TO USE", NAVY))
story.append(sp(4))

story.append(Paragraph("<b>Current Standard (AAP 2018 Guidelines): Isotonic fluids for maintenance</b> — replaces old ¼ NS practice to prevent hospital-acquired hyponatremia.", body_style))
story.append(sp(4))

fluids = [
    ["0.9% NaCl (Normal Saline)", "154", "Isotonic", "Resuscitation bolus, isotonic maintenance"],
    ["Lactated Ringer's (LR)", "130", "Isotonic", "Resuscitation, surgery; lower Cl⁻ load"],
    ["Plasmalyte", "140", "Isotonic", "Balanced, near-physiologic; ideal for maintenance"],
    ["0.45% NaCl (½ NS)", "77", "Hypotonic", "Post-resuscitation repletion (with caution)"],
    ["0.225% NaCl (¼ NS)", "38.5", "Hypotonic", "LARGELY ABANDONED for routine maintenance"],
    ["D5W / D10W", "0", "Hypotonic", "Neonatal hypoglycemia; NOT for resuscitation"],
    ["D5 0.9% NaCl", "154", "Isotonic", "Post-resuscitation repletion with glucose support"],
    ["3% NaCl (Hypertonic saline)", "513", "Hypertonic", "Symptomatic severe hyponatremia ONLY (ICU)"],
]
story.append(make_table(
    ["Fluid", "Na⁺ (mEq/L)", "Tonicity", "Use"],
    fluids,
    [W*0.24, W*0.13, W*0.13, W*0.50],
    header_color=NAVY, bold_first=True
))
story.append(sp(3))
story.append(note("Potassium (KCl 20 mEq/L, max 40 mEq/L): Add to maintenance fluids ONLY after urine output is confirmed."))
story.append(note("Dextrose: Add to maintenance fluids for caloric/glucose needs — especially in infants/neonates. Do NOT add to resuscitation boluses."))
story.append(sp(8))

# ── SECTION 3: HOW MUCH ──────────────────────────────────────────────────────
story.append(section_header("3.  HOW MUCH — VOLUME CALCULATIONS", PURPLE))
story.append(sp(5))

# 3A – Holliday-Segar
story.append(Paragraph("<b>A. Maintenance Fluids — Holliday-Segar Method (4-2-1 Rule)</b>", bold_style))
story.append(sp(3))

hs = [
    ["First 10 kg",       "4 mL/kg/hr",  "100 mL/kg/day"],
    ["Second 10 kg",      "+ 2 mL/kg/hr","+ 50 mL/kg/day"],
    ["Each kg above 20 kg","+ 1 mL/kg/hr","+ 20 mL/kg/day"],
]
story.append(make_table(
    ["Weight Category", "Hourly Rate", "Daily Rate"],
    hs,
    [W*0.40, W*0.30, W*0.30],
    header_color=PURPLE, bold_first=True
))
story.append(sp(3))

# Worked example box
ex_data = [[
    Paragraph("<b>Worked Example — 25 kg child:</b>", tdb_style),
    Paragraph(
        "First 10 kg: 4×10 = 40 mL/hr  |  Second 10 kg: 2×10 = 20 mL/hr  |  Remaining 5 kg: 1×5 = 5 mL/hr<br/>"
        "<b>Total = 65 mL/hr  (1,600 mL/day)</b>  |  Maximum rate: 120 mL/hr (no cardiac/hepatic/renal pathology)",
        tdc_style)
]]
ex_box = Table(ex_data, colWidths=[W*0.27, W*0.73])
ex_box.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), AMBER),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#F0C040")),
    ("VALIGN",     (0,0), (-1,-1), "MIDDLE"),
    ("TOPPADDING", (0,0), (-1,-1), 5),
    ("BOTTOMPADDING", (0,0), (-1,-1), 5),
    ("LEFTPADDING",(0,0), (-1,-1), 6),
]))
story.append(ex_box)
story.append(sp(3))
story.append(note("Holliday-Segar is NOT suitable for neonates <14 days old — overestimates fluid needs. Use neonatal protocols instead."))
story.append(sp(6))

# 3B – Dehydration assessment
story.append(Paragraph("<b>B. Dehydration Assessment & Grading</b>", bold_style))
story.append(sp(3))

deh = [
    ["Mental status",       "Alert",          "Normal → drowsy",       "Lethargic / obtunded"],
    ["Eyes",                "Normal",          "Deep set",              "Sunken"],
    ["Tears",               "Present",         "Reduced",               "Absent"],
    ["Buccal mucosa/lips",  "Normal / dry",    "Dry",                   "Parched / cracked"],
    ["Fontanelle (infant)", "Flat",            "Soft depression",       "Sunken"],
    ["Capillary refill",    "< 2 sec",         "2–3 sec",               "≥ 3 sec"],
    ["Skin turgor",         "Normal",          "Slightly reduced",      "Tenting"],
    ["Heart rate",          "Normal",          "Mildly elevated",       "Tachycardia"],
    ["Urine output",        "Normal",          "Reduced",               "Markedly decreased / none"],
    ["<b>Older child</b>",  "<b>3% (30 mL/kg)</b>","<b>6% (60 mL/kg)</b>","<b>9% (90 mL/kg)</b>"],
    ["<b>Infant</b>",       "<b>5% (50 mL/kg)</b>","<b>10% (100 mL/kg)</b>","<b>15% (150 mL/kg)</b>"],
]
story.append(make_table(
    ["Clinical Sign", "Mild", "Moderate", "Severe"],
    deh,
    [W*0.30, W*0.23, W*0.23, W*0.24],
    header_color=TEAL, bold_first=True
))
story.append(sp(3))

formula_data = [[
    Paragraph("<b>Deficit formula:</b>", tdb_style),
    Paragraph("Fluid deficit (mL) = % dehydration × 10 mL/kg × weight (kg)<br/><i>1% dehydration = 10 mL/kg fluid deficit</i>", tdc_style)
]]
formula_box = Table(formula_data, colWidths=[W*0.22, W*0.78])
formula_box.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), MINT),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#27AE60")),
    ("VALIGN",     (0,0), (-1,-1), "MIDDLE"),
    ("TOPPADDING", (0,0), (-1,-1), 5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 5),
    ("LEFTPADDING",(0,0), (-1,-1), 6),
]))
story.append(formula_box)
story.append(sp(8))

# ── SECTION 4: PHASES OF MANAGEMENT ─────────────────────────────────────────
story.append(section_header("4.  THREE-PHASE IV FLUID MANAGEMENT", ORANGE))
story.append(sp(4))

phases = [
    ["Phase I\nStabilization",
     "Rapid expansion of intravascular volume",
     "20 mL/kg isotonic NS or LR  IV/IO as fast as possible\nRepeat every 5-15 min PRN until shock resolves\nIf >60 mL/kg no improvement → investigate other causes"],
    ["Phase II\nDeficit + Maintenance\n(24 hr)",
     "Correct fluid deficit + provide maintenance",
     "Subtract any Phase I bolus from total deficit\n½ remaining deficit over first 8 hr + maintenance rate\n½ remaining deficit over next 16 hr + maintenance rate\nReplace ongoing losses: 10 mL/kg/stool, 2 mL/kg/emesis"],
    ["Phase III\nRecovery",
     "Sustain homeostasis; replace ongoing losses",
     "Continue maintenance rate\nReplace ongoing losses as they occur\nTransition to oral fluids as tolerated"],
]

phase_rows = []
for row in phases:
    phase_rows.append([
        Paragraph(row[0], tdb_style),
        Paragraph(row[1], tdc_style),
        Paragraph(row[2], tdc_style),
    ])

phase_tbl = Table(
    [[Paragraph("Phase", th_style), Paragraph("Goal", th_style), Paragraph("Action", th_style)]] + phase_rows,
    colWidths=[W*0.16, W*0.27, W*0.57]
)
phase_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), ORANGE),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#AAAAAA")),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("TOPPADDING",    (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
    ("BACKGROUND",    (0,1), (-1,1), WHITE),
    ("BACKGROUND",    (0,2), (-1,2), GREY),
    ("BACKGROUND",    (0,3), (-1,3), WHITE),
]))
story.append(phase_tbl)
story.append(sp(5))

# Worked example Phase II
ex2_data = [[
    Paragraph("<b>Phase II Example:</b>\n15 kg child, 10% dehydration, isonatremic:", tdb_style),
    Paragraph(
        "Maintenance = 1,250 mL/24 hr (52 mL/hr)  |  Deficit = 10% × 10 mL/kg × 15 kg = <b>1,500 mL</b><br/>"
        "After 20 mL/kg bolus (300 mL): remaining deficit = 1,200 mL<br/>"
        "First 8 hr: 600÷8 = 75 mL/hr + 52 mL/hr maintenance = <b>127 mL/hr</b><br/>"
        "Next 16 hr: 600÷16 = 38 mL/hr + 52 mL/hr maintenance = <b>90 mL/hr</b>",
        tdc_style)
]]
ex2_box = Table(ex2_data, colWidths=[W*0.32, W*0.68])
ex2_box.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), AMBER),
    ("GRID",       (0,0), (-1,-1), 0.4, colors.HexColor("#F0C040")),
    ("VALIGN",     (0,0), (-1,-1), "MIDDLE"),
    ("TOPPADDING", (0,0), (-1,-1), 5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 5),
    ("LEFTPADDING",(0,0), (-1,-1), 6),
]))
story.append(ex2_box)
story.append(sp(8))

# ── SECTION 5: HYPOGLYCEMIA ───────────────────────────────────────────────────
story.append(section_header("5.  HYPOGLYCEMIA — RULE OF 50  (Dextrose % × mL/kg = 50)", RED))
story.append(sp(4))

gluc = [
    ["Neonate", "D10W", "5 mL/kg", "Safe tonicity; lowest extravasation risk"],
    ["1 month – ~8 yr (up to 25 kg)", "D25%", "2 mL/kg", "Peripheral IV acceptable; monitor site"],
    ["Older child / adolescent", "D50%", "1 mL/kg", "Higher tonicity — caution with peripheral IV"],
    ["All ages (if extravasation concern)", "D10W", "5 mL/kg", "Safest option at all ages for peripheral IV"],
]
story.append(make_table(
    ["Age Group", "Solution", "Dose", "Notes"],
    gluc,
    [W*0.30, W*0.12, W*0.12, W*0.46],
    header_color=RED, bold_first=True
))
story.append(sp(3))
story.append(note("Monitor glucose every 30-60 min until stable. Recurrent hypoglycemia → consider sepsis, adrenal insufficiency, fatty acid oxidation defect."))
story.append(sp(8))

# ── SECTION 6: SPECIAL SCENARIOS ─────────────────────────────────────────────
story.append(section_header("6.  SPECIAL SCENARIOS", TEAL))
story.append(sp(4))

special = [
    ["Isonatremic dehydration\n(Na 130–150 mEq/L)",
     "0.9% NaCl or LR",
     "Standard 3-phase protocol above. Correct over 24 hr."],
    ["Hyponatremic dehydration\n(Na < 130 mEq/L)",
     "0.9% NaCl (isotonic)\nAVOID hypotonic fluids",
     "Correct Na⁺ slowly: max 8–12 mEq/L per 24 hr\nRisk: osmotic demyelination syndrome (central pontine myelinolysis) if too fast"],
    ["Hypernatremic dehydration\n(Na > 150 mEq/L)",
     "0.9% NaCl initially\nthen 0.45% NaCl",
     "Correct Na⁺ slowly: max 10–12 mEq/L per 24 hr\nReplace deficit over 48–72 hr (NOT 24 hr)\nRisk: cerebral edema if corrected too rapidly"],
    ["DKA",
     "0.9% NaCl",
     "10–20 mL/kg bolus for shock only\nAvoid excess fluids (cerebral edema risk)\nFollow dedicated DKA protocol for ongoing management"],
    ["Neonates < 14 days",
     "D10W",
     "Do NOT use Holliday-Segar — overestimates needs\nUse neonatal-specific protocols\nMonitor glucose closely"],
    ["Septic shock",
     "0.9% NaCl or LR",
     "20 mL/kg boluses; reassess after each\nAvoid albumin routinely unless specific indication\nEarly vasopressors if fluid-refractory"],
]

sp_rows = []
for row in special:
    sp_rows.append([
        Paragraph(row[0], tdb_style),
        Paragraph(row[1], tdc_style),
        Paragraph(row[2], tdc_style),
    ])

sp_tbl = Table(
    [[Paragraph("Scenario", th_style), Paragraph("Fluid of Choice", th_style), Paragraph("Key Points", th_style)]] + sp_rows,
    colWidths=[W*0.25, W*0.22, W*0.53]
)
sp_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,0), TEAL),
    ("TEXTCOLOR",     (0,0), (-1,0), WHITE),
    ("GRID",          (0,0), (-1,-1), 0.4, colors.HexColor("#AAAAAA")),
    ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ("TOPPADDING",    (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 4),
    ("RIGHTPADDING",  (0,0), (-1,-1), 4),
]))
for i in range(1, len(sp_rows)+1):
    bg = WHITE if i % 2 == 1 else GREY
    sp_tbl._argH  # force layout
    sp_tbl.setStyle(TableStyle([("BACKGROUND", (0,i), (-1,i), bg)]))

story.append(sp_tbl)
story.append(sp(8))

# ── SECTION 7: QUICK REFERENCE TABLE ─────────────────────────────────────────
story.append(section_header("7.  QUICK REFERENCE SUMMARY", NAVY))
story.append(sp(4))

qr = [
    ["Maintenance (all hospitalized children)",  "0.9% NaCl or LR ± dextrose", "4-2-1 Rule (Holliday-Segar)"],
    ["Shock / circulatory failure",              "0.9% NaCl or LR",            "20 mL/kg bolus IV/IO; repeat PRN"],
    ["Mild dehydration",                         "ORT preferred; if IV: NS/LR", "Deficit over 24 hr + maintenance"],
    ["Moderate dehydration",                     "0.9% NaCl or LR",            "Phase I bolus → Phase II deficit"],
    ["Severe dehydration",                       "0.9% NaCl",                  "Aggressive boluses + 24 hr replacement"],
    ["Hypoglycemia",                             "D10W / D25% / D50%",         "Rule of 50 (% dextrose × mL/kg = 50)"],
    ["Hyponatremia",                             "0.9% NaCl (isotonic)",       "Correct ≤ 8-12 mEq/L per 24 hr"],
    ["Hypernatremia",                            "0.9% NaCl → 0.45% NaCl",    "Correct ≤ 10-12 mEq/L per 24 hr; 48-72 hr"],
    ["Neonate < 14 days",                        "D10W (neonatal protocol)",   "Do NOT use Holliday-Segar"],
    ["DKA",                                      "0.9% NaCl",                  "10-20 mL/kg bolus; dedicated DKA protocol"],
]
story.append(make_table(
    ["Clinical Scenario", "Fluid", "Rate / Volume"],
    qr,
    [W*0.35, W*0.27, W*0.38],
    header_color=NAVY, bold_first=True
))
story.append(sp(6))

# ── FOOTER ────────────────────────────────────────────────────────────────────
story.append(rule())
story.append(Paragraph(
    "Sources: Harriet Lane Handbook 23rd ed. (Johns Hopkins) · Roberts & Hedges' Clinical Procedures in Emergency Medicine · "
    "Rosen's Emergency Medicine · AAP 2018 Maintenance IV Fluid Guidelines  |  For clinical use — always verify with current institutional protocols.",
    footer_style
))

# ── BUILD ─────────────────────────────────────────────────────────────────────
doc.build(story)
print(f"PDF saved to: {OUTPUT}")

Running Command

cd /home/daytona/workspace/peds-iv-fluids && python generate_pdf.py 2>&1

Running Command

ls -lh /home/daytona/workspace/peds-iv-fluids/Pediatric_IV_Fluids.pdf

Your A4 print-ready PDF is ready! Download it here:

Pediatric IV Fluids

PDF Document · PDF

What's included in the PDF (A4, print-optimised):

When to Use IV Fluids - indications table with rationale
What Fluid to Use - all common solutions (NS, LR, Plasmalyte, D5W, etc.) with Na⁺ content, tonicity, and clinical use
How Much - Holliday-Segar 4-2-1 Rule - with worked example (25 kg child)
Dehydration Grading Table - clinical signs for mild/moderate/severe with deficit volumes
Three-Phase Management - stabilization, deficit+maintenance, recovery with a full worked example (15 kg, 10% dehydrated child)
Hypoglycemia Rule of 50 - dextrose dosing by age
Special Scenarios - isonatremic, hyponatremic, hypernatremic dehydration, DKA, neonates, septic shock
Quick Reference Summary - one-glance table for all clinical scenarios

Color-coded by section for easy reading when printed.

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