Intravenous fluid therapy in adults in hospital

Include the following information in IV fluid prescriptions:

• the type of fluid to be administered

• the rate and volume of fluid to be administered.

Patients should have an IV fluid management plan, which should include details of:

• the fluid and electrolyte prescription over the next 24 hours

• the assessment and monitoring plan.
  
  Initially, the IV fluid management plan should be reviewed by an expert daily. IV fluid management plans for patients on longer-term IV fluid therapy whose condition is stable may be reviewed less frequently.

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.

Patients have a valuable contribution to make to their fluid balance. If a patient needs IV fluids, explain the decision, and discuss the signs and symptoms they need to look out for if their fluid balance needs adjusting. If possible or when asked, provide written information (for example, NICE's information for the public), and involve the patient's family members or carers (as appropriate).

Assess whether the patient is hypovolaemic. Indicators that a patient may need urgent fluid resuscitation include:

• systolic blood pressure is less than 100 mmHg

• heart rate is more than 90 beats per minute

• capillary refill time is more than 2 seconds, or peripheries are cold to touch

• respiratory rate is more than 20 breaths per minute

• 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 to 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 the diagram of ongoing losses), and any comorbidities, including patients who are malnourished and at risk of refeeding syndrome (see the NICE guideline on nutrition support in adults).

• 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:

  • NEWS

  • fluid balance charts

  • weight.

• Laboratory investigations should include current status and trends in:

  • full blood count

  • urea, creatinine and electrolytes.

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 (Resuscitation Council UK, 2011).

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.

Clear incidents of fluid mismanagement (for example, unnecessarily prolonged dehydration or inadvertent fluid overload due to IV fluid therapy) should be reported through standard critical incident reporting to encourage improved training and practice (see the table on consequences of fluid mismanagement to be reported as critical incidents).

If patients are transferred to a different location, reassess their fluid status and IV fluid management plan on arrival in the new setting.