Intended for healthcare professionals

Practice Guidelines

Intravenous fluid therapy for adults in hospital: summary of NICE guidance

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f7073 (Published 10 December 2013) Cite this as: BMJ 2013;347:f7073

This article has a correction. Please see:

  1. Smita Padhi, senior research fellow and project manager1,
  2. Ian Bullock, chief operating officer1,
  3. Lilian Li, health economist1,
  4. Mike Stroud, consultant in gastroenterology and internal medicine2
  5. on behalf of the Guideline Development Group
  1. 1National Clinical Guideline Centre, Royal College of Physicians, London NW1 4LE, UK
  2. 2Southampton University Hospitals NHS Trust, Southampton SO16 6YD, UK
  1. Correspondence to: S Padhi smita.padhi{at}rcplondon.ac.uk

Many hospital staff who prescribe intravenous (IV) fluids have not received adequate training on the subject despite the fact that fluid management is one of the commonest tasks in hospital involving complex decisions on optimal volume, rate, and type of fluid to be given. Although inappropriate fluid therapy is rarely reported as being responsible for patient harm, a 1999 report from the National Confidential Enquiry into Perioperative Deaths (NCEPOD) suggested that as many as 1 in 5 patients receiving IV fluids in hospital suffered complications or morbidity due to their inappropriate administration.1 A more recent NCEPOD report in 2011 highlighted that patients were at an increased risk of death within thirty days of having an operation if they had received inadequate or excessive IV fluids in the preoperative period.2

This article summarises recent recommendations from the National Institute for Health and Care Excellence (NICE).3

Recommendations

NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Principles and protocols for intravenous fluid therapy

The assessment and management of patients’ fluid and electrolyte needs are fundamental to good patient care.

  • Assess and manage patients’ fluid and electrolyte needs as part of every ward review. Provide intravenous (IV) fluid therapy only for patients whose needs cannot be met by oral or enteral routes, and stop as soon as possible. [Based on the experience and opinion of the Guideline Development Group (GDG)]

  • Skilled and competent healthcare professionals should prescribe and administer IV fluids and assess and monitor patients receiving IV fluids. [Based on the experience and opinion of the GDG]

  • When prescribing IV fluids, remember the five Rs: resuscitation, routine maintenance, replacement, redistribution, and reassessment. [Based on the experience and opinion of the GDG]

  • Offer IV fluid therapy as part of a protocol (see figure):

    • - Assess patients’ fluid and electrolyte needs following algorithm 1 (assessment)

    • - If patients need IV fluids for resuscitation, follow algorithm 2 (fluid resuscitation)

    • - If patients need IV fluids for routine maintenance, follow algorithm 3 (routine maintenance)

    • - If patients need IV fluids to address existing deficits or excesses, ongoing abnormal losses, or abnormal fluid distribution, follow algorithm 4 (replacement and redistribution).

    • [Based on very low quality evidence from randomised clinical trials on the effectiveness of protocol based care and the experience and opinion of the GDG]

  • Include the following information in IV fluid prescriptions:

    • - The type of fluid to be administered

    • - The rate and volume of fluid to be administered.

    • [Based on the experience and opinion of the GDG]

  • 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 receiving longer term IV fluid therapy whose condition is stable may be reviewed less frequently.

    • [Based on the experience and opinion of the GDG]

  • 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. [Based on the experience and opinion of the GDG]

  • 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). [Based on the experience and opinion of the GDG]

Figure1

Algorithms for IV fluid therapy

Assessment and monitoring

Initial assessment

  • Assess whether the patient is hypovolaemic. Algorithm 1 (see figure) outlines the indicators that a patient may need urgent fluid resuscitation. [Based on evidence informing the National Early Warning Score (NEWS),4 clinical evidence underpinning the NICE clinical guideline for acutely ill patients in hospital (CG50),5 and the experience and opinion of the GDG]

  • Assess the patient’s likely fluid and electrolyte needs from their history, clinical examination, current medications, clinical monitoring, and laboratory investigations—see Algorithm 1. [Based on evidence informing the National Early Warning Score (NEWS)4 and the experience and opinion of the GDG]

Reassessment

  • If the patient is receiving IV fluids for resuscitation, reassess the patient using the ABCDE approach (airway, breathing, circulation, disability, exposure); monitor respiratory rate, pulse, blood pressure, and perfusion continuously; and measure venous lactate level or arterial pH and base excess according to the Resuscitation Council’s guidance on advanced life support.6 [Based on guidance issued from the Resuscitation Council6 and the experience and opinion of the GDG]

  • 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 (<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; but urinary sodium values may be misleading in the presence of renal impairment or diuretic therapy

    • - Patients receiving 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.

    • [Based on the experience and opinion of the GDG]

  • If patients have received IV fluids containing chloride concentrations >120 mmol/L (such as 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. [Based on very low quality evidence from randomised clinical trials and observational studies and the experience and opinion of the GDG]

  • 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. [Based on the experience and opinion of the GDG]

  • If patients are transferred to a different location, reassess their fluid status and IV fluid management plan on arrival in the new setting. [Based on the experience and opinion of the GDG]

Fluid 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 (see Algorithm 2 in the figure for details). [Based on moderate quality evidence from randomised clinical trials and evidence of cost effectiveness]

  • Do not use tetrastarch for fluid resuscitation. [Based on moderate quality evidence from randomised clinical trials and evidence of cost effectiveness]

  • Consider human albumin solution 4-5% for fluid resuscitation only in patients with severe sepsis. [Based on high quality evidence from randomised clinical trials in hospitalised patients]

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. (This quantity will not address patients’ nutritional needs; see NICE clinical guideline on nutrition support in adults (CG32).7)

    • See Algorithm 3 in figure for detail.

    • [Based on low quality evidence from randomised clinical trials and the experience and opinion of the GDG]

  • 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 body mass index is >40. [Based on the experience and opinion of the GDG]

  • 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 (see NICE clinical guideline on nutrition support in adults (CG32)7).

    • [Based on the experience and opinion of the GDG]

  • 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 >2.5 L/day increases the risk of hyponatraemia. These are initial prescriptions, and further prescriptions should be guided by monitoring. [Based on very low quality evidence from randomised clinical trials and evidence of cost effectiveness and the experience and opinion of the GDG]

  • Consider delivering IV fluids for routine maintenance during daytime hours to promote sleep and wellbeing. [Based on the experience and opinion of the GDG]

Replacement and redistribution

  • Adjust the IV prescription (add to or subtract from maintenance needs) to account for existing fluid or electrolyte deficits or excesses, ongoing losses, or abnormal distribution (see Algorithm 4 in figure). [Based on the experience and opinion of the GDG]

  • Seek expert help if patients have a complex fluid or electrolyte redistribution issue or imbalance, or substantial comorbidity (Algorithm 4 outlines examples, including gross oedema and severe sepsis). [Based on the experience and opinion of the GDG]

Training and education

  • Hospitals should establish systems to ensure that all healthcare professionals involved in prescribing and delivering IV fluid therapy are trained on the principles covered in this guideline, and are then formally assessed and reassessed at regular intervals to demonstrate competence in:

    • - Understanding the physiology of fluid and electrolyte balance in patients with normal physiology and during illness

    • - Assessing patients’ fluid and electrolyte needs (the five Rs: resuscitation, routine maintenance, replacement, redistribution, and reassessment)

    • - Assessing the risks, benefits, and harms of IV fluids

    • - Prescribing and administering IV fluids

    • - Monitoring the patient response

    • - Evaluating and documenting changes

    • - Taking appropriate action as required.

    • [Based on a narrative review of the evidence from qualitative studies and the experience and opinion of the GDG]

  • Healthcare professionals should receive training and education about, and be competent in, recognising, assessing, and preventing consequences of mismanaged IV fluid therapy, including:

    • - Pulmonary oedema

    • - Peripheral oedema

    • - Volume depletion and shock.

    • [Based on a narrative review of the evidence from qualitative studies and the experience and opinion of the GDG]

  • Hospitals should have an IV fluids lead, responsible for training, clinical governance, audit, and review of IV fluid prescribing and patient outcomes. [Based on the experience and opinion of the GDG]

Overcoming barriers

Implementing this guideline will require all clinicians to acknowledge and understand that intravenous fluid therapy is a key area of patient care, and to make consistent efforts to ensure compliance with the recommendations. Challenges to the identification of adverse events in hospitals as consequences of mismanagement of intravenous fluid therapy will include difficulties in establishing causal relationships between the two. However, careful monitoring of patients in line with the recommendations and recording of relevant observations will establish safe and effective care, removing the current variations in both practice and outcome. Perceptions among clinicians with regard to the use of tetrastarch for fluid resuscitation will also need re-evaluation in light of the evidence presented.

Further information on the guidance

Currently, no standardised guidance exists on the management of IV fluid therapy in hospitalised patients. With the lack of emphasis on the training and education of healthcare professionals on the topic, there is wide variation in clinical practice. It is thus essential to provide evidence shaped guidance on the management of patients receiving IV fluid therapy in hospital. The evidence base for most parts of this guideline was limited. The guideline reviews the available evidence and relies on the fundamental principles of physiology and pathophysiology of fluid balance for its recommendations.

A review of the evidence suggested that protocol based care was best for improving patient outcomes. Based on this evidence and the experience and opinion of the Guideline Development Group (GDG), an algorithm to aid thinking and provide a rationale for IV fluid prescribing among healthcare professionals is also presented in the guideline (see figure).

Methods

The GDG followed the standard NICE methods in the development of this guideline (www.nice.org.uk/aboutnice/howwework/developingniceclinicalguidelines/developing_nice_clinical_guidelines.jsp). The GDG comprised three anaesthetists, two lay members, a critical care nurse, an advanced nurse practitioner, a gastroenterologist (chair), a gastrointestinal surgeon, a nephrologist, an emergency medicine physician, a respiratory physician, a chemical pathologist, and a pharmacist.

The group developed clinical questions, collected and appraised clinical evidence, and evaluated the cost effectiveness of proposed interventions through literature review and original economic analysis. The draft guideline went through rigorous reviewing, in which stakeholder organisations were invited to comment; the group took all comments into consideration when producing the final version of the guideline. Quality ratings of the evidence were based on GRADE methodology (www.gradeworkinggroup.org). These relate to the quality of the available evidence for assessed outcomes rather than the quality of the clinical study. Where standard methodology could not be applied, a customised quality assessment was undertaken. These were either presented as a narrative summary of the evidence or in customised GRADE tables.

Many sections of the guideline include areas where no evidence was identified. In such cases, the recommendations were based on the experience and opinion of the GDG. Certain areas of this guideline were unique in that they were based on fundamental principles of fluid management, and it was not possible to undertake any systematic literature reviews for these topics.

As this was a cross-cutting guideline (with a broad scope including different populations and settings), the evidence for many of the topic areas was indirect. Analysis and interpretation of this evidence for the target population was challenging for several reasons, including:

  • Most trials on the use of IV fluids have been conducted in operating theatres and critical care units, whereas the primary aim of this guidance was to improve IV fluid management in admission units and general ward settings

  • Many of the widely accepted practices of IV fluid prescribing were developed for historical reasons rather than through clinical trials and have no evidence base

  • Trials claiming to evaluate best first line treatment for acute fluid resuscitation actually evaluate therapy choices made after initial resuscitation or examine situations of hypovolaemia induced by anaesthesia.

Cost effectiveness analysis for intravenous fluid management

Acquisition costs were identified for 14 different types of intravenous fluid used for routine fluid maintenance. The number of major complications that need to be avoided per 1000 patients to render each fluid cost neutral was estimated. A similar exercise was conducted for 16 fluids used in resuscitation.

The staff costs associated with eight different IV fluid monitoring strategies were estimated. These strategies varied in terms of the frequency of weight measurement and the presence or absence of chart recording of fluid balance. Again the number of complications that would need to be avoided in order to render each strategy cost neutral was estimated.

These analyses did not provide definitive evidence of cost effectiveness but were considered by the GDG in reaching their recommendations. The GDG sought to promote effective and cost effective healthcare by (a) recommending some of the lowest cost fluids available (in the absence of evidence of improved effectiveness for higher cost fluids), (b) encouraging the stopping of IV fluids for patients who are able to take oral fluids, (c) prescribing lower volumes of fluid than is currently practised, and (d) alerting healthcare professionals to the signs of fluid related complications.

Future research

The GDG identified the following areas as needing further research:

  • What is the incidence of complications during, and as a consequence of, IV fluid therapy?

  • For fluid resuscitation of patients with acute hypovolaemic shock, are balanced solutions superior to sodium chloride 0.9%?

  • For fluid resuscitation of patients with acute hypovolaemic shock, are balanced crystalloids superior to a combination of a balanced crystalloid and a gelatin suspended in a balanced solution?

  • For maintenance in hospitalised adults, does a higher sodium content IV fluid regimen reduce the risk of developing hyponatraemia and volume depletion without increasing the risk of volume overload?

  • Are fluid related complications, and associated healthcare costs, reduced by the introduction of hospital systems that ensure

    • - All hospital healthcare professionals involved in prescribing and delivering IV fluid therapy are appropriately trained in the principles of fluid prescribing?

    • - All IV fluid therapy related complications are reported?

Notes

Cite this as: BMJ 2013;347:f7073

Footnotes

  • This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

  • The members of the Guideline Development Group were Mike Stroud (chair), Reem Al-Jayyousi, Paul Cook, Richard Leach, Dileep Lobo, Tom McLoughlin-Yip, Patrick Nee, Jerry Nolan, Fleur North, Katie Scales, Rebecca Sherratt, Neil Soni, and Mark Tomlin. Andrew Lewington and Michael Mythen were expert advisors to the GDG. The technical team at the National Clinical Guideline Centre included Joanna Ashe, Sara Bucknor, Ian Bullock, Lee Yee Chong, Varo Kirthi, Susan Latchem, Jennifer Layden, Lilian Li, Julie Neilson, Smita Padhi, and David Wonderling.

  • Contributors: SP wrote the first draft. All authors reviewed the draft, were involved in writing further drafts, and reviewed and approved the final version for publication. SP acts as guarantor.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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