Intravenous fluid therapy
Intravenous fluid therapy
Provide IV fluid therapy only for patients whose needs cannot be met by oral or enteral routes, and stop as soon as possible.
Skilled and competent healthcare professionals should prescribe and administer IV fluids, and assess and monitor patients receiving IV fluids.
When prescribing IV fluids, remember the 5 Rs: Resuscitation, Routine maintenance, Replacement, Redistribution and Reassessment.
Include the following information in IV fluid prescriptions:
· The type of fluid to be administered
· The rate and volume of fluid to be administered
When prescribing IV fluids and electrolytes, take into account all other sources of fluid and electrolyte intake, including any oral or enteral intake, and intake from drugs, IV nutrition, blood and blood products.
Assessment and Monitoring
Initial Assessment
Assess whether the patient is hypovolaemic. Indicators that a patient may need urgent fluid resuscitation include:
1.Systolic blood pressure is less than 100 mmHg
2.Heart rate is more than 90 beats per minute
3.Capillary refill time is more than 2 seconds or peripheries are cold to touch
4.Respiratory rate is more than 20 breaths per minute
5.National Early Warning Score (NEWS) is 5 or more
Passive leg raising suggests fluid responsiveness
Passive leg raising is a bedside method to assess fluid responsiveness in a patient. It is best undertaken with the patient initially semi-recumbent and then tilting the entire bed through 45°. Alternatively, it can be done by lying the patient flat and passively raising their legs to greater than 45°. If, at 30–90 seconds, the patient shows signs of haemodynamic improvement, it indicates that volume replacement may be required. If the condition of the patient deteriorates, in particular, breathlessness, it indicates that the patient may be fluid overloaded.
Assess the patient’s likely fluid and electrolyte needs from their history, clinical examination, current medications, clinical monitoring and laboratory investigations:
· History should include any previous limited intake, thirst, the quantity and composition of abnormal losses (see “Diagram of Ongoing Losses” in the full version of the guideline document), and any comorbidities, including patients who are malnourished and at risk of refeeding syndrome
· Clinical examination should include an assessment of the patient’s fluid status, including:
· Pulse, blood pressure, capillary refill and jugular venous pressure
· Presence of pulmonary or peripheral oedema
· Presence of postural hypotension
· Clinical monitoring should include current status and trends in:
· National Early Warning Score (NEWS)
· Fluid balance charts
· Weight
· Laboratory investigations should include current status and trends in:
· Full blood count
· Urea, creatinine and electrolytes
Reassessment
If patients are receiving IV fluids for resuscitation, reassess the patient using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure), monitor their respiratory rate, pulse, blood pressure and perfusion continuously, and measure their venous lactate levels and/or arterial pH and base excess according to guidance on advanced life support.
All patients continuing to receive IV fluids need regular monitoring. This should initially include at least daily reassessments of clinical fluid status, laboratory values (urea, creatinine and electrolytes) and fluid balance charts, along with weight measurement twice weekly. Be aware that:
· Patients receiving IV fluid therapy to address replacement or redistribution problems may need more frequent monitoring.
· Additional monitoring of urinary sodium may be helpful in patients with high-volume gastrointestinal losses. (Reduced urinary sodium excretion [less than 30 mmol/l] may indicate total body sodium depletion even if plasma sodium levels are normal. Urinary sodium may also indicate the cause of hyponatraemia, and guide the achievement of a negative sodium balance in patients with oedema. However, urinary sodium values may be misleading in the presence of renal impairment or diuretic therapy.)
· Patients on longer-term IV fluid therapy whose condition is stable may be monitored less frequently, although decisions to reduce monitoring frequency should be detailed in their IV fluid management plan.
If patients have received IV fluids containing chloride concentrations greater than 120 mmol/l (for example, sodium chloride 0.9%), monitor their serum chloride concentration daily. If patients develop hyperchloraemia or acidaemia, reassess their IV fluid prescription and assess their acid–base status. Consider less frequent monitoring for patients who are stable.
Resuscitation
If patients need IV fluid resuscitation, use crystalloids that contain sodium in the range 130–154 mmol/l, with a bolus of 500 ml over less than 15 minutes. Do not use tetra starch for fluid resuscitation.
Consider human albumin solution 4% to 5% for fluid resuscitation only in patients with severe sepsis.
Routine Maintenance
If patients need IV fluids for routine maintenance alone, restrict the initial prescription to:
· 25–30 ml/kg/day of water and
· Approximately 1 mmol/kg/day of potassium, sodium and chloride and
· Approximately 50–100 g/day of glucose to limit starvation ketosis.
For patients who are obese, adjust the IV fluid prescription to their ideal body weight. Use lower range volumes per kg (patients rarely need more than a total of 3 litres of fluid per day) and seek expert help if their BMI is more than 40 kg/m2.
Consider prescribing less fluid (for example, 20–25 ml/kg/day fluid) for patients who:
· Are older or frail
· Have renal impairment or cardiac failure
· Are malnourished and at risk of refeeding syndrome
When prescribing for routine maintenance alone, consider using 25–30 ml/kg/ day sodium chloride 0.18% in 4% glucose with 27 mmol/l potassium on day 1 (there are other regimens to achieve this). Prescribing more than 2.5 litres per day increases the risk of hyponatraemia. These are initial prescriptions and further prescriptions should be guided by monitoring.
Consider delivering IV fluids for routine maintenance during daytime hours to promote sleep and wellbeing.
Replacement and Redistribution
Adjust the IV prescription (add to or subtract from maintenance needs) to account for existing fluid and/or electrolyte deficits or excesses, ongoing losses or abnormal distribution.
Seek expert help if patients have a complex fluid and/or electrolyte redistribution issue or imbalance, or significant comorbidity, for example:
· Gross oedema
· Severe sepsis
· Hyponatraemia or hypernatraemia
· Renal, liver and/or cardiac impairment
· Post-operative fluid retention and redistribution
· Malnourished and refeeding issues
Consequences of Fluid Mismanagement to Be Reported as Critical Incidents
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Consequence of Fluid Mismanagement
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Identifying Features
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Time Frame of Identification
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Hypovolaemia
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· Patient’s fluid needs not met by oral, enteral or IV intake and
· Features of dehydration on clinical examination
· Low urine output or concentrated urine
· Biochemical indicators, such as more than 50% increase in urea or creatinine with no other identifiable cause
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Before and during IV fluid therapy
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Pulmonary oedema (breathlessness during infusion)
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· No other obvious cause identified (for example, pneumonia, pulmonary embolus or asthma)
· Features of pulmonary oedema on clinical examination
· Features of pulmonary oedema on X-ray
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During IV fluid therapy or within 6 hours of stopping IV fluids
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Hyponatraemia
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· Serum sodium less than 130 mmol/l
· No other likely cause of hyponatraemia identified
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During IV fluid therapy or within 24 hours of stopping IV fluids
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Hypernatraemia
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· Serum sodium 155 mmol/l or more
· Baseline sodium normal or low
· IV fluid regimen included 0.9% sodium chloride
· No other likely cause of hypernatraemia identified
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During IV fluid therapy or within 24 hours of stopping IV fluids
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Peripheral oedema
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· Pitting oedema in extremities and/or lumbar-sacral area
· No other obvious cause identified (for example, nephrotic syndrome or known cardiac failure)
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During IV fluid therapy or within 24 hours of stopping IV fluids
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Hyperkalaemia
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· Serum potassium more than 5.5 mmol/l
· No other obvious cause identified
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During IV fluid therapy or within 24 hours of stopping IV fluids
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Hypokalaemia
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· Serum potassium less than 3.0 mmol/l likely to be due to infusion of fluids without adequate potassium provision
· No other obvious cause (for example, potassium-wasting diuretics, refeeding syndrome)
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During IV fluid therapy or within 24 hours of stopping IV fluids
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