ABC of Intravenous Fluids, Electrolyte Disorders and AKI Management in Adults

WASD

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INTRAVENOUS FLUID
THERAPY IN ADULTS

Intravenous Fluids and Electrolyte (IVF) administration is an important, common

therapeutic intervention; water constitutes 60% of total body weight in men and 55%
in women[1]. It is crucial to prescribe the correct fluid type, volume, and administration
rate[1]. Adequate IVF prescribing necessitates a meticulous assessment of fluid
balance and a proper understanding of the physiology and pathophysiology of the
distribution of water and electrolytes in addition to the properties of common IVF[1, 2].
Intravenous fluids should be administered only if a patient’s requirements cannot
be fulfilled through the oral or enteral route; they should be stopped as soon as
possible[1]. Intravenous fluids should be administered under stringent monitoring of
the patient’s response through frequent recording of vital signs, at least daily fluid
balance charts/weight, and measurement of renal function; appropriate actions
should be taken when necessary[1, 2].
Prescription of intravenous fluid is usually carried by the most junior doctors[1, 3].
Uninitiated prescribing is a result of insufficient knowledge and training and could
induce serious complications. Excessive or inappropriate fluids may precipitate
pulmonary oedema or severe hyponatraemia, whereas under-resuscitation can
result in Acute Kidney Injury (AKI)[2, 4].

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Normal distribution of water in the body: a man of 70kg total body weight:

Total Body Water (TBW) volume542L, 60% body weight

(Mainly in muscles, less in fat)
ICF volume528L, ECF volume514L,
40% body weight (2/3 TBW) 20% body weight (1/3 TBW)
Interstitial fluid Plasma
volume511L, volume53L,
80% of ECF 20% ECF
Abbreviations: ICF5Intracellular Fluid; ECF5Extracellular Fluid

Daily fluid balance under normal conditions: a man of 70 kg total body weight:
Input Output
Source Volume (ml) Site of loss Volume (ml)
Water 1000 Urine 1000
Food 650 Skin (insensible) 500
Oxidation (insensible) 350 Lungs (insensible) 400
Faeces 100
Total 2000 Total 2000

Adapted from[5]. Daily (24 hour) fluid requirements of a healthy adult are 25–35ml/kg.

Daily electrolytes requirements:

Daily requirements (mmol/kg) For 70kg Adult
Sodium 1–2 70–140
Potassium 0.5–1 35–70
Calcium 0.2–0.3 1.4–2.1
Magnesium 0.35–0.45 24.5–31.5
Chloride Equal to Na Equal to Na
-
Bicarbonate/Acetate Use with Cl to balance cations Use with Cl to balance cations
and help PH and help PH

Daily glucose requirements are 50–1Y00g

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Fluid balance in disease and injury

It is worth remembering that the physiological difficulty in excreting an excess
sodium and water load becomes more pronounced in disease and injury. This is
driven by the non-specific metabolic responses to stress and inflammation[5, 6]:
1. The stress response to injury or surgery stimulates secretion of ADH, catecholamines
and activates Rennin-Angiotensin-Aldosterone System (RAAS). It results in Water
and Salt Retention (anti-diuresis and oliguria), even in the presence of volume
overload.
2. Increased systemic capillary permeability causes extravasation of albumin and
fluid into the interstitial space. It results in intravascular hypovolaemia, inducing
further sodium and water retention by activation of the RAAS and secretion of
ADH.

The multiple haemodynamic and non-haemodynamic stimuli for

ADH secretion place acutely ill in-patients at risk of developing
hyponatraemia[2, 7], and the simultaneous activation of the RAAS is
probably protective.

3. RAAS activity and cellular loss of potassium secondary to protein catabolism

causes potassium depletion that reduces the ability to excrete a sodium load[5, 6].
In addition[5, 6]:
4. Saline infusion causes Cl/Na overload. Hyperchloraemia induces renal
vasoconstriction and the reduced GFR compromises the ability of the kidney to
excrete sodium and water, see resuscitation below;
5. External pressure kidney (Abdominal Compartment Syndrome) plus increased
intra-capsular pressure due to oedematous renal tissue can precipitate AKI.

NB. It is crucial, post-surgery, to differentiate the harmless oliguria

caused by the stress response from that caused by AKI.

Further, normal fluid and electrolyte balance can also be significantly altered in
malnutrition, medical treatment (e.g., Diuretics, NSAIDs), and organ dysfunction
(e.g., Oedema in Heart Failure, Renal Failure, Liver Failure i.e. re-distribution)[5, 6].

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IV Fluid, Crystalloids and Colloids: constituents, properties and indications:

Na/Cl K Other Osmolarity PH/ Max Duration Indication
MWT dose (ml/ of ECV
(kDa) Kg/24h) expansion,
hour
NSa 154/154 0 0 308 5–5.5/0 None 1–4 Res (Fluid of
(isotonic) choice)

Hartmann’sa 131/111 5 Lactate 279 6.5/0 None 1–4 Res

(HM) (~ RL) (HCO3)/Ca: Rep (Fluid
29/2 of choice)
D5Wa 0/0 0 50g D/1L 280 4.5/0 Avoid NA RM–use D/S
(hypotonic) over
usage
Gelatinb 4% 154/120 0 Succinylated, 274 7.4/30 None 3–4 Consider for
(Gelofusine) Cross-linked Res
5% Albumenb 130–160/ 0 Protein 12.5g 310 7.4/69 None 12–24 Consider for
130–160 Res
a
5Crystalloid;
b
5Colloid
Abbreviations: MWT5Molecular Weight, kDa5Kilodalton, NS50.9% Normal Saline, Res5Resuscitation,
HM5Hartmenn’s, RL5Ringer’s Lactate, Rep5Replacement, D5%W55% Dextrose in Water, RM5Routine
Maintenance, D/S5Dextrose/Saline
*
D5%W infusion: has no effect on tonicity; dextrose is rapidly taken up by the cells and metabolised[2]. Thus,
the steady state effect is that of adding water, which dilutes plasma. An isotonic solution is that with a sodium
concentration [Na] approximately equal to serum [Na][2].

The Colloid Osmotic Pressure, [Oncotic Pressure], (mmHg) for: Plasma is 25;
Gelofusin is 26–29; 5% Albumen is 20; and 0 for Crystalloids.

Colloids vs Crystalloids for fluid resuscitation:

Crystalloids Colloids
MWT/IV persistence Low/short High/(retained IV)
Replacement volume required Large Less (increase BP more rapidly)
Interstitial oedema 111 1
Cost Low High
IV5Intravenous, Y5Yes, N5No

Despite their theoretical superiority over crystalloids, colloids’ effect

is less than expected due to capillary leak in acute illness[5]. Gelatins
have a low MWT as higher MWT solutions tend to gel[8], and is rapidly
excreted through the kidneys; hence short-term volume expansion.
Moreover, the substantially higher cost of colloids, their adverse side
effects’ profile and the lack of clinical superiority over crystalloids
deter their use in resuscitation[8–11].

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ASSESSMENT OF VOLUME STATUS

Assess and manage patients’ fluid and electrolyte needs as part of

at least every day ward review. Extra-vascular volume deficits do not
become clinically apparent until they reach 10% of body weight.

The pre- (rarely available) and post-fluid loss body weight is the most accurate
parameter for assessing total fluid deficit. There is no formula available for an
accurate estimation of total fluid deficit[12]. Hence, assessing hypovolaemia and IVF
requirement is a summation of:
a. History: fluid losses, e.g. diarrhoea and vomiting; co-morbidities; current
medications etc.;
b. Clinical examination: current status and trends in:

Clinical indicators of moderate/severe volume depletion:

ECF volume: Moderate deficit Severe deficit
General Decreased skin turgor Atonic muscles
Sunken eyes
National Early Warning Score
(NEWS)$5[1,13,14]
CVS Postural hypotension Hypotension (SBP,90)
Tachycardia (HR.90 bpm) Absent peripheral pulses
Collapsed veins
CNS/autonomic responses Fatigue/lethargy Cold extremities/Pallor
(the commonest symptoms) Stupor/coma
RR.20/minute[1].
GIT Anorexia Nausea and Vomiting
Anorexia
Ileus
Fluid balance charts UOP,30 ml/h suggest the need for IVF

c. Laboratory investigations – current status and trends:

Serum biochemistry Disproportionately high serum urea compared to creatinine

High serum lactate indicates tissue hypoperfusion
High Hct/Albumen (if not caused by bleeding)
Hypokalaemia indicates the need for potassium supplementation
Urine biochemistry u[Na] reflects renal perfusion, and a low value (,20 mmol/L)
indicates renal hypoperfusion.

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Proper assessment is a collective integration of history, physical

signs and laboratory findings – FBC and UEs[1], followed by clinical
monitoring of current status and the pattern of change in NEWS, fluid
balance charts, and weight[1]. The use of the conventional CVP/PWP
and sophisticated haemodynamic parameters has limitations.

If the assessment indicates the need for parenteral fluid:

Remember the five R's on prescribing intravenous fluids:
The 5 Rs. Indication Fluid of choice Volume

1. Resuscitation# Severe intravascular Isotonic crystalloids: A bolus of 500ml over

(to restore the depletion NS or ,15 minutes
intravascular volume HM[1, 2, 8, 15] Re-assess: give up to
and tissue perfusion) 2L of NS as rapidly
as possible–Senior
advice if no response

2. Routine maintenance Euvolaemic but, unable (5% D‡10.45% saline120 ~2L or

(RM)* to take PO or enterally KCl) – monitor for HoN/ Previous 24hr UOP1
(to maintain the ECV (e.g. NPO pre/post-op- HrN[12] insensible losses
and normal erative; on ventilator)
electrolyte balance) (switch to PO or enteral
asap)

3. Replacement 1Ongoing losses: D/V; HM[1] Adjust the IV RM:

post-AKI polyurea,/ (“increase”) to ac-
excessive sweating, count for the losses
high OP stoma, etc. Correct electrolyte
deficits (or excesses)

4. Re-distribution Abnormal fluid distribu- “Decrease”[1] Adjust the IV RM:

tion from the circulation (“decrease”) to account
to the tissues: for the 3rd spacing
e.g. Gross oedema Correct electrolyte
deficits (or excesses)

5. Re-assess and continuously monitor the clinical fluid status/response to therapy (at least daily):
a. History – fluid losses, co-morbidities, current medications etc.
b. Clinical examination – ABCDE (trends and context):
BP/PR: the most important parameters to guide the volume of fluid replacement required;
Body weight (base line and daily): the best measure for assessing and monitoring volume balance–
deficit/gain;
Fluid balance charts.
c. Laboratory investigations:
Laboratory values (UEs);
u[Na] may be helpful in patients with high volume GI losses:
Reduced u[Na] excretion (,30 mmol/L)5total body Na depletion
u[Na]: if,155persistent volume depletion and the need for more fluids
NB. u[Na] values may be misleading in the presence of renal impairment or diuretic therapy

Adapted from[1].
Abbreviations: NS5Normal Saline, HM5Hartmann’s Solution

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Resuscitation#: balanced crystalloids, such as Hartmann’s or Ringers lactate/

acetate, are favoured over normal saline as the first choice[6, 8] because comparative
human studies revealed that normal saline is associated with higher s[Cl] and
metabolic acidosis[16–18] as well as reduced renal blood flow[19]. In animal models,
hyperchloraemia was long known to produce renal vasoconstriction and reduced
glomerular filtration rate[20]. The data in relation to the effect on serum potassium
is conflicting. Compared to balanced crystalloids, normal saline was associated with
a comparable incidence of hyperkalaemia[21] in the most recent publication; higher
serum potassium[22], and hyperkalaemia[23] in peri-renal transplant patients. However,
this ‘physiological̕ superiority of balanced crystaloids is not yet borne out in the
available limited, small, ‘clinical’ trials. A Cochrane systematic review revealed that
the choice of non-buffered salt-based (e.g. normal saline) or buffered (modified with
adding bicarbonate or bicarbonate precursors – balanced crystaloids) intravenous
fluids in the peri-operative period has no influence on mortality, renal function and
blood loss; both are safe and effective[24]. The use of a buffered crystalloid compared
with normal saline, in intensive care units (mostly post-operative), did not reduce
the rate of AKI or renal replacement therapy[25]. Studies in kidney transplant patients
revealed no difference in the transplant outcome between patients receiving peri-
transplant normal saline or those receiving balanced solutions[18, 21–23]. There was a
tendency towards increased thrombotic propensity in the balanced solutions arm;
two patients lost their graft to transplant renal artery thrombosis[22].

Resuscitation: normal saline is preferred in patients with hyponatrae-

mia, alkalosis, cerebrovascular disease or brain injury[26].

Routine Maintenance*: the National Institute for Health and Care Excellence
(NICE) recommendation for starting routine maintenance fluids, by giving 25–35ml/
day of hypotonic crystaloids ([4% D/1/5 NS/27 mmol KCl]/L) under close monitoring
to provide 1mmol/kg of Na, Cl and K[1], has since been disapproved in a recent
North American publication[2]. Isotonic Fluids are recommended as the first choice,
because hypotonic (Na,130) IVF was the main ‘reported’ cause of hospital-acquired
hyponatraemia[2]. The ‘evidence-base’ for favouring isotonic fluids over hypotonic
fluids was from comparative prospective studies in a different population, children,
the majority of whom were surgical and critical care patients rather than acute
admission units or general wards[2]. Of the isotonic fluids ‘balanced’ crystalloids are
probably superior to normal saline[6, 8]. However, the disparity would confirm that
close clinical and biochemical monitoring is as important as the choice of intravenous
fluid type.

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Give less volume, ~20ml/Kg/day, for elderly and those with renal and
heart failure[1].

4–5% D‡5is given to prevent excess catabolism and limit starvation ketosis, 50–100g
of glucose/day[1, 2]. It prevents hypoglyacaemia, but does not provide complete
nutritional support[1, 2]. Involve the dietician to address nutritional needs[1].

Methods of parenteral fluid administration: IV, SC, IO (intraosseous–a rescue

technique in paediatrics mainly, safe, effective, reliable and relatively simple).

Fluid choice was historically guided mainly by a theoretical,

physiological rationale, and pre-clinical studies[1, 8]. The sparse evidence
and the controversy about the ideal IVF composition in different
clinical settings[1,2,5–8] necessitates conducting well-structured, large,
randomised, controlled trials. Currently, in either choice; judicious
administration of IVF under meticulous clinical and biochemical
monitoring is mandatory, and every case ought to be managed on its
own merits. International guidelines were a success in disciplines such
as renal medicine, and a call for guidelines in this field is pertinent.

DO NOT PRESCRIBE IVF FOR.24 HOURS

CONCLUSION

Prescribing IVF should be part of the core medical pre- and post-graduate training.
Hospitals need to appoint a senior medical staff members, doctors and nurses, as
intravenous fluid management champions, and arrange for periodical tutorials and
workshops on the subject. Monitor and Audit.

REFERENCES
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England Journal of Medicine (2015), Vol. 373, pp. 1350–60. DOI: 10.1056/NEJMra1412877.
[3] Lobo, D.N., Dube, M.G. and Neal, K.R. Problems with solutions: drowning in the brine of an
inadequate knowledge base. Clinical Nutrition (2001), Vol. 20, No. 2, pp. 125–130.

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