Intravenous (IV) Fluid Prescribing in Adults

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Intravenous (IV) fluid prescribing in adults is something that most doctors do on a daily basis and it’s certainly something you need to understand as a medical student. It can, at first glance, appear intimidating, but the current NICE guidelines are fairly clear and specific, with a handy algorithm you can follow. This article is based upon those guidelines, with some additional information surrounding fluid types, assessment of fluid status and how to apply the guidelines (using a worked example).

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Indications for IV fluids

Intravenous (IV) fluids should only be prescribed for patients whose needs cannot be met by oral or enteral routes. Where possible oral fluid intake should be maximised and IV fluid only used to supplement the deficit.

Examples of when IV fluids may be required:

• A patient is nil by mouth (NBM) for medical/surgical reasons (e.g. bowel obstruction, ileus, pre-operatively)
• A patient is vomiting or has severe diarrhoea
• A patient is hypovolaemic as a result of blood loss (blood products will likely be required in addition to IV fluid)

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Types of fluids

IV fluids can be categorised into 2 major groups:

• Crystalloids: solutions of small molecules in water (e.g. sodium chloride, Hartmann’s, dextrose)
• Colloids: solutions of larger organic molecules (e.g. albumin, Gelofusine)

Colloids are used less often than crystalloid solutions as they carry a risk of anaphylaxis and research has shown that crystalloids are superior in initial fluid resuscitation. ²

Commonly used fluids

FLUID TYPE	TONICITY	Na + (mmol/L)	K + (mmol/L)	Cl – (mmol/L)	HCO3– (mmol/L)	GLUCOSE (mmol/L)
Human plasma (for comparison)	N/A	135-145	3.5- 5.0	100-110	22-26	3.5-7.8
Sodium chloride 0.9% (Normal saline)	Isotonic Used for resuscitation/maintenance	154		154
Hartmann’s solution	Isotonic Used for resuscitation/maintenance	131	5	111	29
Sodium chloride 0.18% / Glucose 4%	Hypotonic Used for maintenance	30		30		40g/L
5% Dextrose	Hypotonic Used for maintenance					50g/L

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Introduction to prescribing IV fluids

When prescribing IV fluids, remember the 5 Rs:

• Resuscitation
• Routine maintenance
• Replacement
• Redistribution
• Reassessment

To decide what fluids to prescribe, we need to carry out an initial assessment, as discussed in the next section.

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Initial assessment

The initial assessment involves assessing the patient’s likely fluid and electrolyte needs from their history, clinical examination and available clinical monitoring (e.g. vital signs, fluid balance). Your clinical examination and review of available clinical monitoring should be performed using the ABCDE approach, with a focus on the patient’s fluid status.

History

Fluid intake:

• Assess if the patient’s fluid intake been adequate.

Symptoms suggestive of dehydration:

• Thirst
• Dizziness/syncope

Fluid loss:

• Vomiting (or NG tube loss)
• Diarrhoea (including stoma output)
• Polyuria
• Fever
• Hyperventilation
• Increased drain output (e.g. biliary drain, pancreatic drain)

 Co-morbidities:

• Heart failure
• Renal failure

Clinical examination and review of clinical monitoring

Airway

• Is the airway patent?

Breathing

• Respiratory rate and oxygen saturation
• Auscultate the lung fields

Findings suggestive of hypervolaemia include:

• Increased respiratory rate (>20 breaths per minute)
• Decreased oxygen saturations
• Bilateral crackles on auscultation

Circulation

• Pulse and blood pressure
• Capillary refill time
• Jugular venous pressure (JVP)
• Peripheral oedema

Findings suggestive of hypovolaemia include:

• Increased heart rate (>90 bpm)
• Hypotension (systolic BP <100 mmHg)
• Prolonged capillary refill time
• Non-visible JVP

Findings suggestive of hypervolaemia include:

• Hypertension
• Elevated JVP 

Disability

• GCS

Findings suggestive of hypovolaemia include

• Decreased GCS may be noted if the patient is significantly volume depleted.

Exposure

• Wounds
• Drains
• Catheter output
• Abdominal distension/peripheral oedema
• Fluid balance charts/weight charts
• Other losses (e.g. rectal bleeding)

Findings suggestive of hypovolaemia include:

• Increased output from wounds and drains 
• Decreased urine output (<30mls/hr)
• A fluid chart showing a negative fluid balance
• Weight loss
• Other sources of fluid loss (e.g. rectal bleeding, diarrhoea, vomiting)

Findings suggestive of hypervolaemia include:

• Increased urine output
• Abdominal distension (ascites) and peripheral oedema 
• A fluid chart showing a positive fluid balance
• Weight gain

Next steps

If after your initial assessment you feel there is evidence of hypovolaemia your next step would be to initiate fluid resuscitation as shown in the next section. If however, the patient appears stable and normovolaemic you can skip this step and move straight to calculating maintenance fluids. If you consider the patient to be hypervolaemic, do not administer IV fluids.

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Resuscitation fluids

Ok, so you’ve performed your initial assessment and things aren’t looking great, the patient has clinical signs suggestive of hypovolaemia you, therefore, need to prescribe some resuscitation fluids. In addition, you need to start considering the cause of the deficit and take appropriate actions to treat it (e.g. the patient is septic so antibiotics need to be administered).

Initial fluid bolus

1. Administer an initial 500 ml bolus of a crystalloid solution (e.g NaCl 0.9%/Hartmann’s solution) over less than 15 minutes. 

Reassess the patient

2. After administering the initial 500 ml fluid bolus you should reassess the patient using the ABCDE approach, looking for evidence of ongoing hypovolaemia as you did in your initial assessment (if you find yourself unsure about whether any further fluid is required you should seek senior input).

3. If the patient still has clinical evidence of ongoing hypovolaemia give a further 250-500 ml bolus of a crystalloid solution, then reassess as before using the ABCDE approach:

• You can repeat this process if there is ongoing clinical evidence suggestive of the need for fluid resuscitation up until you’ve given a total of 2000 ml of fluid.
• If despite giving 2000ml you reassess and find there is still an ongoing need for fluid resuscitation (i.e. persistent hypovolaemia), you should seek expert help.
• If patients have complex medical comorbidities (e.g. heart failure, renal failure) and/or are elderly then you should apply a more cautious approach to fluid resuscitation (e.g. giving fluid boluses of 250 ml rather than 500 ml and seeking expert help earlier).
• If the patient appears normovolaemic but has signs of shock you should seek expert help immediately.

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Daily requirements

Once the patient is haemodynamically stable their daily fluid and electrolyte requirements can be considered.

You should review the patient as discussed in the initial assessment section, but also review key laboratory results to better understand the patient’s current fluid and electrolyte status:

• History
• Clinical examination
• Clinical monitoring
• Laboratory monitoring (e.g. electrolytes/renal function/haemoglobin)

Once you have collected the above information you need to decide if you feel the patient can meet their fluid and/or electrolyte needs orally or enterally.

Patient able to meet their fluid and/or electrolyte needs orally/enterally

No further IV fluids should be required.

Patient unable to meet their fluid and/or electrolyte needs orally/enterally

Consider if they have any of the following issues:

• Complex fluid issues
• Electrolyte replacement issues
• Abnormal fluid distribution issues

Those patients who have any of the above issues will likely require fluid replacement and/or redistribution (explained in the associated section below).

Those patients who do not have any of the above issues but are unable to meet their fluid requirement should receive routine maintenance IV fluids (see next section).

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Routine maintenance fluids

If a patient is haemodynamically stable but unable to meet their daily fluid requirements via oral or enteral routes you will need to prescribe maintenance fluids. If possible these fluids should be administered during daytime hours to prevent sleep disturbance.

Calculating maintenance fluids

Daily maintenance fluid requirements (as per NICE guidelines):

• 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 (however note this will not address the patient’s nutritional needs)

Weight-based potassium prescriptions should be rounded to the nearest common fluids available. Potassium should NOT be manually added to fluids as this is dangerous.

Other factors to consider prior to prescribing

Obese patients

When prescribing routine maintenance fluids for obese patients you should adjust the prescription to their ideal body weight. You should use the lower range for volume per kg (e.g. 25 ml/kg rather than 30 ml/kg) as patients rarely need more than 3 litres of fluid per day.

Other patient groups where you should consider prescribing less fluid 

For the following patient groups you should use a more cautious approach to fluid prescribing (e.g. 20-25 ml/kg/day):

• Elderly patients
• Patients with renal impairment or cardiac failure
• Malnourished patients at risk of refeeding syndrome

Reassessment and monitoring

Continue to monitor the patient and reassess regularly:

• Bloods: electrolytes/renal function/haemoglobin
• Clinical examination: hydration status assessment

Stop intravenous fluids once they are no longer required.

Nasogastric fluids or enteral feeding is preferable when maintenance needs are more than 3 days.

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Replacement and redistribution of fluids

Some patients will require a slightly different approach than the routine fluid maintenance regimen explained in the previous section.

These are patients who have one or more the following:

• Existing fluid or electrolyte deficits or excesses
• Ongoing abnormal fluid or electrolyte losses
• Redistribution and other complex issues

Existing fluid or electrolyte deficits/excesses

Patients with existing fluid or electrolyte abnormalities require a more tailored approach to fluid prescribing (see basic examples below):

• Dehydration – will require more fluid than routine maintenance
• Fluid overload – will require less fluid than routine maintenance 
• Hyperkalaemia – will require less potassium 
• Hypokalaemia – will require more potassium

Estimate any fluid or electrolyte deficits/excesses:

• Add or subtract these estimates from the standard routine maintenance fluid regimen discussed in the last section to provide a more tailored fluid prescription.

Ongoing abnormal fluid or electrolyte losses

Recognising ongoing abnormal fluid or electrolyte losses can allow you to tailor your fluid prescription to prevent later complications (e.g. hypokalaemia). 

Consider the following sources of ongoing fluid or electrolyte loss:

• Vomiting/NG tube loss
• Diarrhoea
• Stoma output loss (colostomy, ileostomy)
• Biliary drainage loss
• Blood loss (e.g. malaena/haematemesis)
• Sweating/fever/dehydration (reduced or absent oral intake)
• Urinary loss (e.g. diabetes insipidus/post-AKI polyuria)

Estimate amount of ongoing fluid or electrolyte losses (see table for estimates):

• Add or subtract these estimates from the standard routine maintenance fluid regimen discussed in the last section to provide a more tailored fluid prescription.
• The table below is based upon the recent NICE guidelines, check out the diagram that also demonstrates various sources of ongoing losses here.

TYPE OF FLUID LOSS	APPROXIMATE ELECTROLYTE CONTENT
Vomiting/NG tube loss	20-40 mmol Na+/ l 14 mmol K+/l 140 mmol Cl–/l 60-80 mmol H+/l
Diarrhoea/excess colostomy loss	30-140 mmol Na+/ l 30-70 mmol K+/l 20-80 mmol HCO3–/l
Jejunal loss (stoma/fistula)	140 mmol Na+/ l 5 mmol K+/l 135 mmol Cl–/l 8 mmol HCO3–/l
High volume ileal loss via new stoma, high stoma or fistula	100-140 mmol Na+/ l 4-5 mmol K+/l 75-125 mmol Cl–/l 0-30 mmol HCO3–/l
Lower volume ileal loss via established stoma or low fistula	50-100 mmol Na+/ l 4-5 mmol K+/l 25-75 mmol Cl–/l 0-30 mmol HCO3–/l
Pancreatic drain or fistula loss	125-138 mmol Na+/ l 8 mmol K+/l 56 mmol Cl–/l 85 mmol HCO3–/l
Biliary drainage loss	145 mmol Na+/ l 5 mmol K+/l 105 mmol Cl–/l 30 mmol HCO3–/l
Inappropriate urinary loss	Highly variable – monitor serum electrolytes closely. Match hourly urine output (minus 50ml) to avoid intravascular depletion.
“Pure” water loss (e.g. fever, dehydration, hyperventilation)	Very little electrolyte content. Can result in potential hypernatraemia.

Redistribution and other complex issues

Patients can have issues with fluid distribution (e.g. fluid in the wrong compartment) and a collection of other complex issues which should also be considered prior to prescribing IV fluids:

• Gross oedema
• Severe sepsis
• Hypernatraemia/hyponatraemia
• Renal, liver and/or cardiac impairment
• Post-operative fluid retention and redistribution
• Malnourishment and refeeding issues

You should seek senior input for patients with complex issues such as those above to ensure appropriate fluids are prescribed.

Summary

After assessing the patient for:

• existing fluid or electrolyte deficits or excesses
• ongoing abnormal fluid or electrolyte losses
• redistribution and other complex issues

You should:

• prescribe fluid by adding or subtracting any deficits or excesses from routine fluid maintenance, in addition to adjusting for all other sources of fluid and electrolytes (e.g. oral, enteral and medications).
• continue to monitor fluid and biochemical status by clinical and laboratory monitoring, adjusting replacement as appropriate.

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Reassessment

Reassessment plays a vital role in fluid prescribing, in both fluid resuscitation and ongoing daily maintenance. A patient’s fluid status is highly dynamic and therefore frequent reassessment will allow you to adjust your fluid prescription to best suit a patient’s needs. It’s particularly important to review if intravenous fluids are still required, to prevent unnecessary administration. Often fluid prescribing guides tell you to decide on a fluid regimen that spans the next 24 hours, however, it is often difficult to predict the clinical course of a patient over that time period. In reality, you would reassess the patient several times over this period and make changes as necessary based on clinical findings and laboratory results.

Reassessing a patient involves repeating the steps discussed in the initial assessment section:

• History
• Clinical examination – fluid status
• Clinical monitoring – vital signs/observations
• Laboratory monitoring (blood tests) – electrolytes/renal function/haemoglobin 

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Worked example

Mr Smith is a 45-year-old gentleman who has presented to A&E with severe vomiting. He is suspected of having viral gastroenteritis and isn’t currently able to tolerate any oral fluids.

Initial assessment

What questions might be useful to ask? What signs on clinical examination may suggest hypovolaemia? What piece of documentation might be useful to review when estimating fluid losses?

Fluid resuscitation

You’ve performed your initial assessment and the patient has evidence of hypovolaemia, so you need to begin fluid resuscitation (download a blank fluid prescription chart here).

What would you prescribe initially? Attempt this on your chart After giving the initial IV fluid bolus, you reassess this gentleman and feel he still has clinical evidence of hypovolaemia as he remains hypotensive and tachycardic. What would your next step be? Prescribe this on your chart

Daily requirements

The gentleman is now haemodynamically stable, so no further resuscitation fluids are required.

What would be your next step in prescribing fluid for this gentleman?

Existing fluid or electrolyte deficits/ongoing abnormal losses

What existing fluid or electrolyte deficits does this gentleman have? What potential ongoing abnormal losses might this gentleman have? What else do we need to consider before prescribing maintenance fluid? What might be a suitable maintenance fluid prescription for this gentleman, factoring in previous deficits and ongoing losses? Write out your maintenance fluid regimen on your prescription chart

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References

1. National Institute for Health and Care Excellence (2013 (updated 2016)). Intravenous Fluid Therapy In Adults In Hospital. Available at: [LINK].
2. National Institute for Health and Care Excellence (2013 (updated 2016)). Intravenous Fluid Therapy In Adults In Hospital. Research recommendations. Available at: [LINK].

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