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Gloucestershire Hospitals

NHS Foundation Trust

TRUST CLINICALGUIDELINE
In the case of hard copies of this policy the content can only be assured to be accurate on the date
of issue marked on the document.
The Policy framework requires that the policy is fully reviewed on the date shown, but it is also
possible that significant changes may have occurred in the meantime.
The most up to date policy will always be available on the Intranet Policy web site and staff are
reminded that assurance that the most up to date policy is being used can only be achieved by
reference to the Policy web site.

10 March 2010

Intravenous Fluid Management in Adults

Keywords: Intravenous

This document may be made available to the public and persons outside of the Trust as part of the Trust's
compliance with the Freedom of Information Act 2000

Date of Issue:

March 2010

Review Date: March 2013

Gloucestershire Hospitals
NHS Foundation Trust
TRUST CLINICAL POLICIES
Authorisation Form
Intravenous Fluid Management in Adults

Authorisation

Name and Position

Date Approved
March 2010

Tom Perris / Tim Bowles


Responsible Author
March 2010
Policy Sponsor

Shn South
Assistant Director of Nursing
Policy & Practice Development

Assured by

Clinical Policy Group

March 2010

Consideration at authorised groups (e.g. Board, Board sub committees, Policy Group,
Clinical policies Sub Group, Departmental meetings etc)

Name of Group
Gloucestershire Intensive
Therapists
Clinical Policy Group

Minute details
Email Correspondence

Intravenous Fluid Management in Adults


Sponsor/Author: Shn South/Tom Perris
Issue Date:

Date considered
August 09
February 2010

Page 2 of 10

Gloucestershire Hospitals
NHS Foundation Trust

EQUALITY IMPACT ASSESSMENT


INITIAL SCREENING
1. Lead

Name : Dr Tom Perris


Job Title : Consultant Anaesthetist

2. Is this a new or existing policy, service strategy, procedure or function?


New

3. Who is the policy/service strategy, procedure or function aimed at?


Patients

4. Are any of the following groups adversely affected by this policy:


If yes is this high, medium or low impact (see attached notes):
Disabled people:
Race, ethnicity & nationality:
Male/Female/transgender:
Age, young or older people:
Sexual orientation:
Religion, belief & faith:

No
No
No
No
No
No

x
x
x
x
x
x

Yes
Yes
Yes
Yes
Yes
Yes

If the answer is yes to any of these proceed to full assessment.


If the answer is no to all categories, the assessment is now complete.

Date of assessment:

14/09/09 Completed by: Dr T Perris

Signature:

Job title: Consultant Anaesthetist

Director:

Signature:

This EIA will be published on the Trust website. A completed EIA must accompany a new policy or a
reviewed policy when it is confirmed by the relevant Trust Committee, Divisional Board, Trust Director
or Trust Board.

Executive Directors are responsible for ensuring that EIAs are completed in

accordance with this procedure.

Intravenous Fluid Management in Adults


Sponsor/Author: Shn South/Tom Perris
Issue Date:

Page 3 of 10

Gloucestershire Hospitals
NHS Foundation Trust

Intravenous Fluid Management in Adults


1.

Aim
This document aims to guide clinicians in the management of intravenous fluid therapy for
adult inpatients. It is intended as a guide, to be used in conjunction with clinical assessment
of an individual patient, rather than as a prescriptive protocol. A suggested algorithm for the
management of fluid therapy is included.

2.

Introduction
Whilst avoidance of hypovolaemia is important, there is an increasing recognition that
inappropriate fluid and electrolyte administration is a major cause of perioperative morbidity,
organ failure and mortality and contributes to length of hospital stay. In response, a UK
consensus document on IV fluid therapy in adult surgical patients (GIFTASUP) has been
written, which forms the basis for this guideline. We recommend every prescribing clinician
reads this document or at least the summary pages.

3.

Target Group
This guideline is primarily intended for adult surgical patients, although the principles could
equally be applied to many general medical patients. They should be used with caution in
those with significant co-morbidity, particularly cardiac and renal disease.

4.
4.1

Key Points
No intravenous fluid infusion should be continued for longer than clinically essential. The oral
or enteral route is preferred. In patients with normal gastric emptying undergoing elective
surgery, clear fluids should be encouraged until two hours pre-operatively. Postoperatively, in
patients who are euvolaemic and haemodynamically stable, a return to oral/enteral fluid
administration should be achieved as soon as possible.
Because of the risk of inducing hyperchloraemic acidosis, when crystalloid resuscitation or
replacement is indicated, balanced salt solutions e.g. Ringers lactate or Hartmanns
solution should replace 0.9% saline, except in cases of hypochloraemia e.g. from vomiting or
gastric drainage. Saline should not be routinely prescribed.
Solutions such as 5% dextrose are important sources of free water for maintenance,
but should be used with caution as excessive amounts may cause dangerous
hyponatraemia, especially in the elderly. These solutions are not appropriate for
resuscitation or replacement therapy except in conditions of significant free water
deficit e.g. diabetes insipidus. However, it is important that sufficient free water be provided
either by the oral (preferred) or intravenous route to allow sufficient diuresis to clear
electrolytes and waste products.
Critically ill patients have a reduced capacity for sodium excretion. Care must always be
taken to balance sodium needs with sodium load infused. A simple daily input / output
calculation is possible if urinary electrolytes are measured
Where pre-operative bowel preparation is used, fluid and electrolyte derangements
commonly occur and should be corrected by simultaneous intravenous fluid therapy
with balanced salt solutions. Sufficient Potassium replacement should be prescribed.
Prescription of fluid for maintenance or correction of chronic loss is the responsibility of the
patients normal team, and should be based on regular clinical and biochemical assessment.
Electrolytes should be monitored regularly, preferably daily.
Input and output volumes should be charted accurately for all patients receiving intravenous
fluids.

4.2

4.3

4.4

4.5

4.6

4.7

Intravenous Fluid Management in Adults


Sponsor/Author: Shn South/Tom Perris
Issue Date:

Page 4 of 10

5.
5.1

Choice of Fluid and Volume


Distinction should be made between (a.) resuscitation of acute intravascular hypovolaemic
states, (b.) replacement of fluid and electrolyte deficit including replacement of abnormal
losses and (c.) fluid and electrolytes required for normal existence (daily maintenance)
including sufficient water.

5.2

No single type of fluid is appropriate for all indications. Thought should be given as to which
indication fluid is being prescribed.

5.3

Maintenance fluid and electrolyte therapy should not be a standardised regime; it should be
tailored to the individual patients needs on the basis of clinical hydration status and
biochemical trends.

5.4

If using Colloid solutions for correction of hypovolaemia, choice of fluid should be based on
maximal effect with minimum volume, sodium and chloride administration. At the current time,
Volulyte a starch based colloid in balanced salt solution is the colloid of choice. Gelatine
based fluids such as Gelofusine or Haemaccel should be avoided as they are considerably
less effective and have significant other disadvantages.

6.
6.1

Resuscitation of Acute Intravascular Hypovolaemia


Hypovolaemia due predominantly to blood loss should be treated with a suitable
colloid until packed red cells are available. In an emergency, balanced crystalloid could be
used until more appropriate resuscitation fluid is available. Again, the intention is to maximise
the effectiveness of volume replacement with the minimal possible infusion of Sodium,
Chloride and Water. Urgent haemostasis should be achieved.

6.2

Relative hypovolaemia due to severe inflammation such as infection, peritonitis, pancreatitis


or burns should be treated with either a suitable colloid or a balanced crystalloid.

6.3

In either clinical scenario, care must be taken to administer sufficient balanced


crystalloid and colloid to normalise haemodynamic parameters and minimise overload.
Clinical judgement or more invasive monitoring can be used to assess the adequacy of
volume replacement.

6.4

When the diagnosis of hypovolaemia is in doubt, the response to a bolus infusion of a


suitable colloid or crystalloid can be assessed. The clinical response may be monitored by
heart rate, capillary refill, CVP/JVP and blood pressure before and immediately after receiving
the infusion. This procedure should be repeated until there is no further improvement in the
clinical situation. Should the patient fail to improve or even deteriorate following attempts at
fluid challenge, it is appropriate to seek senior help as the patient may become increasingly
unstable.

7.
7.1

Replacement of Abnormal Losses


Abnormal fluid loss should normally be replaced volume for volume, with regular assessment
of the degree of ongoing loss.

7.2

The choice of fluid for replacement is determined by the electrolyte composition of the fluid
being lost:
Most gastrointestinal fluid loss approximates plasma in composition, and can usually be
replaced with Hartmanns solution.
Gastric secretions are relatively hyperchloraemic, and significant nasogastric drainage or
vomiting could be replaced with 0.9% Saline.
Estimation of volume requirement can be made clinically and from an accurate fluid
balance chart. Electrolyte requirements can be assessed by regular measurement of
U&Es.

8.

Daily Maintenance

Intravenous Fluid Management in Adults


Sponsor/Author: Shn South/Tom Perris
Issue Date:

Page 5 of 10

8.1

The majority of postoperative patients will initially be in a positive balance for total body water
and sodium. However, they may still be hypovolaemic. This should be corrected prior to an
assessment of daily maintenance requirements.

8.2

Hormonal changes following surgery (the Stress Response) will tend to cause retention of
Water and Sodium. Avoidance of excessive sodium infusion will help prevent oedema
formation and encourage diuresis. Saline is thus not an appropriate fluid to be used for daily
maintenance.

8.3

Normal requirements:
Fluid:
1500 2400 mL / 24hrs
Sodium:
50- 100 mmoL / 24hrs
Potassium:
40 80 mmoL / 24 hrs

8.4

In most patients these requirements will be met by administering predominantly salt-poor fluid
such as 5% dextrose with potassium supplementation as guided by U + Es. Adequate
sodium could generally be provided by a litre of balanced crystalloid such as Hartmanns on
alternate days.

9.
9.1

Monitoring
All patients receiving IV fluids should have their volaemic status clinically assessed and
documented daily
All patients on IV fluids must have accurate fluid balance documented.

9.2
9.3

U&Es should be assessed daily in the immediate post operative period and if the patient is
metabolically unstable e.g. septic or pyrexial. When stable, U&Es can be measured less
frequently but fluid balance should continue to be measured whilst the patient receives IV
fluids.

10. Training and Competence


10.1 Training and competence assessment should be provided within individual departments.
Advice / Teaching is readily available from the Critical Care Department upon request.
11.

Implementation
It is intended to implement these changes including the provision of appropriate fluids to all
areas ASAP.

12.

References
Tuck JP, Gosling P, Lobo D, Allison S, Carlson G, Gore M, et al. British Consensus
Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients;. Available from:
http://www.renal.org/pages/media/Guidelines/GIFTASUP%20FINAL_31-10-08.pdf. (Or
search Google for GIFTASUP)

Intravenous Fluid Management in Adults


Sponsor/Author: Shn South/Tom Perris
Issue Date:

Page 6 of 10

Appendix 1

Assess patient volume status:


Peripheral perfusion
HR/ BP
JVP
Peripheral oedema
Urine output ( If< 0.5mL/kg/hr, refer to
oliguria algorithm)
Fluid chart, consider insensible loss

Hypovolaemia

Euvolaemia

Consider nature of fluid loss

Aim to replace with


appropriate fluid:

Balanced crystalloid

Colloid

Blood

200mL fluid bolus


Reassess volume status
immediately

Ongoing Hypovolaemia?

Yes

No

Hypervolaemia

Daily maintenance requirements:


Fluid: 1500-2400 mL/24hrs
Sodium: 50-100 mmoL/24hrs
Potassium:40 80 mmoL/24hrs

Enteral intake?

Yes

No

Ensure oral intake


sufficient to meet
daily
requirements, stop
IVI if so.

Nasogastric
tube

Ensure NG intake
sufficient to meet daily
requirements, stop IVI if
so.

Assess fluid intake,


including drugs and
nutrition

Restrict sodium and


fluid intake or stop IV
fluids, consider
nutritional support, use
diuretics only with
great care

Intravenous
infusion

Prescribe IV infusion
sufficient to meet daily
requirements, avoiding
salt and water
overload:
Salt poor fluid
Balanced crystalloid

Adapted from British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical
Patients

Intravenous Fluid Management in Adults


Sponsor/Author: Shn South/Tom Perris
Issue Date:

Page 7 of 10

From British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical
Patients

Intravenous Fluid Management in Adults


Sponsor/Author: Shn South/Tom Perris
Issue Date:

Page 8 of 10

Gloucestershire Hospitals
NHS Foundation Trust
Monitoring and Compliance of Policies/Guidelines
When developing or updating policies, procedures or guidelines the author and sponsor must develop and implement a plan for effective Monitoring and compliance
of the key standards, as recommended by the NHSLA and CNST Maternity Standards.
Any monitoring and compliance needs relating to a Trust Policy must be identified by completing a monitoring and compliance analysis that identifies the levels of audit
required, and identifying who is responsible.
Once completed the monitoring and compliance analysis will form a part of every policy, guideline or protocol, as necessary. The Audit department will have a copy for
their records and development of necessary audit proformas.
All monitoring and compliance that is deemed essential will be orchestrated in conjunction with the Audit department Lead.
It is proposed that there are 4 potential levels of Monitoring and compliance for audit:A = ACI reporting and collation of data by Risk Management lead
B= Annual audit/collation of data retrospectively
C = Ongoing prospective audit/data collection
D= Tri annual audit linking with guideline amendments
It is proposed that all audits for monitoring and compliance are set using the attached matrix.
*Levels of Monitoring and Compliance or Audit required
A = ACI reporting and collation of data B = Annual audit/collation of data
by Risk Management lead
retrospectively

C = Ongoing prospective
audit/data collection

D = Tri annual audit

Monitoring and Compliance (M & C) Form: Completed on.By..


*Level of
Key standards for
Frequency of
M&C
monitoring and
Division / Department
Audit Method
Lead responsible for Audit
Audit
required
compliance via audit
Adherence to
recommendations. Serum
Annual or ACI
chloride level etc. Reports to Surgical / Medical
Notes /Chart review
Dr Sean Elyan
c
received
Director of Surgical Division
/ Medical Director.
Intravenous Fluid Management in Adults
Sponsor/Author: Shn South/Tom Perris
Issue Date:

Page 9 of 10

Gloucestershire Hospitals
NHS Foundation Trust
Learning & Development Department
Redwood Education Centre

Training Needs Analysis for Completed on.By..


*Level of
training
required

Staff Group / s

Division / Department

Frequency of
training /
update

Method of training
delivery

Lead and department


responsible for provision of
training

All junior staff

All

On induction

Lecture / Act course

Dr T Perris / Anaesthesia

Consultants

All

Once only

Lecture

Dr T Perris

Prescribing Nurses /PGD


users

All

Once only

Lecture / ACT course

Dr T Perris

*Levels of Training
A = Awareness
(Micro-teach, drop in session, e-learning)

Intravenous Fluid Management in Adults


Sponsor/Author: Shn South/Tom Perris
Issue Date:

B= day (2.5 3 hours)


(workshop, training event, e-learning)

C = Full day (5-6 hours)


(workshop, training event)

Page 10 of 10

D= Course
(more than one day training)