NHS

GUIDANCE FOR INTRAVENOUS FLUID AND ELECTROLYTE PRESCRIPTION IN ADULTS

Fluid prescriptions are very important. Prescribing the wrong type or amount of fluid can do serious harm. Assessment of fluid requirements needs care and attention, with adjustment for the individual patient. This is as important as safe drug prescribing. This document guides fluid and electrolyte management in medical and surgical ADULT patients. Exclusions: Children: consult paediatrician or paediatric resuscitation guidelines. Diabetic patients: use diabetic fluid protocol for maintenance. Pregnant women: consult obstetrician. Head injury patients: avoid fluids containing dextrose. Renal failure patients: consult senior doctor.
Produced by the Fluid Prescription Working Group. 2nd edition November 2012. www.scottishintensivecare.org.uk/nutrition/guidelines.htm

Basic physiology of sick patients it is very easy to give patients salt and water but very difficult to remove them. Serum sodium may fall due to excess water load. Even healthy patients take >12 hours to excrete the sodium load of 2 litres of 0.9%NaCl with a gain in weight of 1kg after 6 hours. In sick patients with leaky capillaries this fluid retention is worse and contributes to complications such as ileus, nausea and vomiting, pressure sores, poor mobility, pulmonary oedema, wound and anastomotic breakdown. Urine output naturally decreases after a traumatic insult such as surgery due to increased sodium retention by the kidney. High sodium-containing fluid regimens exacerbate the problem. Cellular dysfunction and potassium loss result. Excess chloride leads to renal vasoconstriction and increased sodium retention, worsening oedema. Urine output is a poor guide to fluid requirements in sick patients. It is vital that sick patients receive THE RIGHT AMOUNT OF THE RIGHT FLUID AT THE RIGHT TIME. Maintenance fluid requirement: approx 30ml/kg/24hrs of water. Questions to ask before prescribing fluid: 1. Is my patient euvolaemic, hypovolaemic or hypervolaemic? 2. Does my patient need IV fluid? Why? 3. How much? 4. What type(s) of fluid does my patient need?

1.

Assess the patient

Euvolaemic: veins are well filled, extremities are warm, blood pressure and heart rate are normal (depending on other pathology). Hypovolaemic:The patient may have cold hands and feet, absent veins, hypotension, tachycardia, oliguria and confusion. History of fluid loss or low intake. Hypervolaemic: Patient is oedematous, may have inspiratory crackles; history of poor urine output or fluid overload. 2. Does my patient need IV fluid?

NO: he may be drinking adequately, may be receiving adequate fluid via NG feed or TPN, or may be receiving large volumes with drugs or drug infusions (or a combination of these). ALLOW PATIENTS TO DRINK IF AT ALL POSSIBLE. Hypervolaemic: may need fluid restriction or gentle diuresis. YES: not drinking, has lost, or is losing fluid So WHY does the patient need fluid? Maintenance fluid only patient does not have excess losses above insensible loss. If no other intake he needs approximately 30ml/kg/24hrs. He may only need part of this if receiving other fluid. Patients having to fast for over 8-12 hours should be started on IV maintenance fluid. Replacement of losses, either previous or current. If losses are predicted it is best to replace these later rather than give extra fluid in anticipation of losses which may not occur. This fluid is in addition to maintenance fluid. Check blood gases. Resuscitation: The patient is hypovolaemic as a result of dehydration, blood loss or sepsis and requires urgent correction of intravascular depletion to correct the deficit

3. How much fluid does my patient need? a. Obtain weight (estimate if required). Maintenance fluid requirement approximately 30ml/kg/24hours. (Table 1). b. Review recent U&Es, other electrolytes and Hb. c. Recent events e.g. fasting, intake, losses, sepsis, operations, fluid overload. Check fluid balance charts. Calculate how much loss has to be replaced and work out which type of fluid has been lost: e.g. GI secretions, blood, inflammatory losses. Note urine does not need to be replaced unless excessive (diabetes insipidus, recovering renal failure). Post-op: high urine output may be due to excess fluid; low urine output is common and may be normal due to antidiuretic hormone release. Assess fully before giving extra fluid. 4. What type of fluid does my patient need? MAINTENANCE FLUID IV fluid should be given via volumetric pump if a patient is on fluids for over 6 hours or if the fluid contains potassium. Always prescribe as ml/hr not x hourly bags. Never give maintenance fluids at more than 100ml/hour. Weight kg 35-44 45-54 55-64 65-74 75 Table 1 Fluid Requirement in mls/day Rate in ml/hour 1200 50 1500 65 1800 75 2100 85 2400 100 (max)

Preferred maintenance fluids: 0.18%saline/4%dextrose with or without added potassium (KCl 10/ 20 mmol) in 500ml. 1 litre bags are available. This fluid if given at the correct rate (Table 1) provides all water and Na + /K+ requirements until the patient can eat and drink or be fed. Excess volumes of this fluid (or any) fluid may cause hyponatraemia. Alternatively 5% dextrose 500ml and 0.9% NaCl 500ml may be used in a ratio of 2 bags of 5% dextrose to 1 bag of 0.9% NaCl. Prescribe each bag with added potassium (KCl 20mmol) if patient has normal or low potassium. Patients with renal failure: Consult a senior doctor for fluid advice. If the serum potassium is above 5mmol/l or rising quickly do not give potassium containing fluids. Electrolyte requirements Sodium 1 mmol/kg/24hrs (approx. 1x500ml 0.9%NaCl) Potassium 1 mmol/kg/24hrs (give KCl 20mmol in each bag) Calories: minimum of 400kcal/24hrs to help with electrolyte handling and to help avoid insulin resistance. Magnesium, calcium and phosphate may fall in sick patients monitor and replace as required. REPLACEMENT FLUID Fluid losses may be due to diarrhoea, vomiting, fistulae, drain output, bile leaks, high stoma output, ileus, blood loss or excessive sweating. Inflammatory losses in the tissues are hard to quantify and are common in pancreatitis, sepsis, burns and abdominal emergencies. It is vital to replace high gastro-intestinal (GI) losses. Patients may otherwise develop severe metabolic derangement with acidosis or alkalosis and hypokalaemia. Hypochloraemia occurs with upper GI losses.

Urinary and insensible losses are covered by the maintenance part of the prescription. In the recovery phase patients start to pass more urine as they mobilise excess fluid. Hyponatraemia is common: in the absence of large GI losses causes are too much fluid, SIADH or chronic diuretic use. Potassium replacement: A potassium level in the normal range does not mean that there is no total body potassium deficit. 20 mmol may be given in 500ml 0.9%NaCl at 125ml/hr. In critical care only give up to 40mmol in 100ml bags via a central line at 25ml/hr. Ensure IV cannulae work. Potassium-containing fluids must be given via a pump. Give KayCee-L or Sando-K orally. Estimate replacement fluid/electrolyte requirements (see table below) by adding up all the losses over the previous 24 hours and give this volume as Hartmanns solution or PlasmaLyte 148 (PL148). Use 0.9% NaCl with KCl for upper GI or bile loss. Otherwise avoid it as it causes fluid retention.

Content Na+ K+ mmol/l mmol/l Fluid Gastric 50 15 content Bile Small bowel content Ileostomy Colostomy Diarrhoea Table 2 145 140 50 60 30140 5 11 4 15 30-70

Normal Cl Bic mmol/l mmol/l volume/ 24hr 2-3 140 0-15 litres 0.5-1 100 38 litre 70-130 var 25 40 20-80 var 0.5 litre 0.1-0.2 litre Abnrml

RESUSCITATION FLUID For severe dehydration, sepsis or haemorrhage leading to hypovolaemia and hypotension. For urgent resuscitation use Hartmanns, PlasmaLyte 148 or colloid (gelatin/ albumin). Hartmanns and PL148 are balanced electrolyte solutions and are better handled by the body than 0.9%NaCl. See Fluid Challenge Algorithm below. Priorities: Stop the bleeding: consider surgery/endoscopy. Treat sepsis. CALL FOR HELP! For severe blood loss initially use colloid or Hartmanns/ PL148 until blood/clotting factors arrive. Use O Negative blood for torrential bleeding. Severely septic patients with circulatory collapse may need inotropic support in a critical care area. Their blood pressure may not respond to large volumes of fluid; excess volumes may be detrimental. Electrolyte contents for common fluids (mmol per litre) Osm = Osmolality Fluid/Content 0.9%NaCI 0.18%saline 4%dextrose 0.45%saline 5%dextrose Gelofusine Hartmanns PlasmaLyte 148 5%dextrose Na K 154 0 30 0 77 0 CI Mg 154 0 30 0 77 0 Ca 0 0 0 0 2 0 0 Lactate 0 0 0 Osm. 308 284 406

154 0 154 0 131 5 111 0 140 5 98 1.5 0 0 0 0

0 274 29 278 Acetate27 297 190kcal/l 278

IN SUMMARY: assess, why, how much, which? Take your time; consult senior if you are unsure. Patients on IV fluids need regular blood tests. Patients should be allowed food and drink ASAP

Fluid Challenge Algorithm

Hypovolaemia: low BP, tachycardia, low CVP/JVP, oliguria, reduced skin turgor, poor tissue perfusion, capillary refill time >4sec. Note patients with epidurals may need vasoconstriction rather than fluid but must be assessed for other causes of hypotension.

Is there a concern regarding fluid challenge e.g. severe LV dysfunction/cardiogenic shock?

YES

NO
Give 250ml IV fluid challenge with colloid or Hartmanns over 2-5 mins Are there continued signs of hypovolaemia with low likelihood of fluid overload?

YES

NO
Adequate response?

NO

NO

Have you reached 2000ml limit?

YES
Decide on continued fluid prescription and management

YES
Patient has complex pathology seek senior/ critical care opinion urgently

Plasma-Lyte 148 is another balanced crystalloid and may be used instead of Hartmanns when available.
References: Southampton Fluid Guidance 2009 British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients http://www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdf