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LETTERS

CORRESPONDENCE

CORRESPONDENCE
Calculating the Maintenance Fluid Rate
The 4-2-1 rule is routinely used to
calculate the maintenance fluid rate
for children. The formula states that
for the first 10 kg of body weight, 4
mL of fluid are administered per kg,
per hour. For the second 10 kg, 2
mL/kg/hr are administered, and for
each additional kg over 20 kg, 1 mL/
kg/hr should be given.1 The formula
comes from elegant work done in the
1950s that correlated caloric expenditure with fluid loss. It was found
that the number of calories utilized
per day was mass-dependent. Each
kg in the first 10 kg accounted for
100 cal/day, each kg in the second 10
kg accounted for 50 cal/day, and
each remaining kg above 20 kg accounted for 20 cal/day. The total
number of calories used per day determined the amount of insensible
and renal fluid loss.2
The formula is perhaps most
commonly thought of as relevant to
children; however, it is just as accurate for adults. In addition, there exists a mathematically equivalent
shortcut that to our knowledge has
not been previously published. By
simply adding 40 mL/hr to the mass
in kg of a patient who is more than
20 kg, an accurate calculation of
maintenance rate can be attained.
For example, a 37-kg patient would

need 37 mL/hr 40 mL/hr, or 77

mL/hr. A 52-kg patient would need
92 mL/hr.
The proof is as follows: Let the
rate of maintenance fluid needed =
R. We can call the patients mass X
in the long formula and Y in the
shortcut. We should then be able to
prove that for any size patient, the
rate of maintenance fluid needed (R)
should be the same, no matter which
method is used to calculate it. Or, in
other words, the mass that solves
the equations for any given rate (R)
should be the same in both formulas.
Therefore, when the equations are
set equal to one another, X should
equal Y.
For all X > 20 kg, the long formula is:
(10 kg 4 mL/kg/hr)
(10 kg 2 mL/kg/hr)

kg/hr] = Y 40 mL/hr
2. 40 mL/hr 20 mL/hr (X 20
mL/hr) = Y 40 mL/hr
3. 60 mL/hr (X 20 mL/hr) = Y
40 mL/hr
4. 20 mL/hr (X 20 mL/hr) = Y
5. X = Y
The rule is, of course, just a rule
and specific patient circumstances
such as renal pathology or burn injury should be considered when applying it. However, the shortcut is
mathematically equivalent to, and
clearly faster than, the long formula.
It should be used when calculating
the maintenance fluid rates for all
applicable patients who weigh more
than 20 kg. A. KARL BARNETT,
MD (karlbarnett@aol.com), Department of Emergency Medicine, University of Massachusetts, Worcester,
MA; and SERGEI NIKIFOROV, MD,
Department of Anesthesiology, Penn
State University, Hershey, PA
Key words. maintenance fluid; fluid
rate; formula.

[(X 20 kg) 1 mL/kg/hr] = R

References
And the shortcut is:
Y 40 mL/hr = R
Therefore:
1. (10 kg 4 mL/kg/hr) (10 kg
2 mL/kg/hr) [(X 20 kg) 1 mL/

1. Aker J, OSullivan C. The selection

and administration of perioperative intravenous fluids for the pediatric patient.
J Perianesth Nurs. 1998; 13:17281.
2. Holliday MA, Segar WE. The maintenance need for water in parenteral
fluid therapy. Pediatrics. 1957; 19:823
32.