IV Fluid guideline (adults) SaTH

Ref No: 2910

Lead Person: Dr Ashley Miller - Trust IV fl uid lead

Care Group: All

Implemented: July 2020

Last updated: July 2020

Last reviewed: July 2020

Planned review: July 2022

Keywords: Fluid, resuscitation, maintenance, shock, hypovolaemia,

electrolyte, acute kidney injury

Comments:
Contents:

Introduction 3
Background physiology 3
Hypervolaemia 4
Key points 5
Shock 5
Hypovolaemia 6
Vasodilatory 8
Cardiogenic 8
Obstructive 8
Clinical signs in shock 9
Key points 9
Prescribing 9
Maintenance 9
Resuscitation 10
Bleeding 10
Dehydration 11
Fluid loss 11
Hypotension from other causes 11
Prescribing algorithms 11
Electrolyte compositions of common fluids 12
Think 12
Special circumstances 13
Post-operative patients: 13
GI losses 13
Electrolyte abnormalities 14
Liver failure 15
Renal failure 15
Cardiac failure 15
Sepsis / pancreatitis 16
DKA 16
Brain injured patients 16
Burns 16
Critical incident reporting 17
Roles and responsibilities 18
Introduction

This document should be read in conjunction with the NICE clinical guideline ‘Intravenous fluid
therapy in adults in hospital’

https://www.nice.org.uk/guidance/cg174/resources/intravenous-fluid-therapy-in-adults-in-
hospital-pdf-35109752233669

These Trust guidelines add information on important physiology and include some minor
adjustments based on the best current available evidence.

Why is this important?

Hypovolaemia and particularly hypervolaemia cause signifi cant morbidity and mortality.
Hypervolaemia is poorly understood and has been identifi ed in numerous cases within this and
other hospitals as causing signifi cant harm.
Surveys in this Trust and in the wider NHS have shown that many staff who prescribe IV fluids
know neither the likely fluid and electrolyte needs of individual patients, nor the specific
composition of the many choices of IV fluids available to them. Standards of recording and
monitoring IV fluid and electrolyte therapy are also poor. IV fluid management in hospital is
often delegated to junior and inexperienced medical staff who may have received little or no
specific training on the subject.
Fluids are drugs, and should be thought of as such, with care given to their prescribing.

IV fluids should be given to:

• Maintain water and electrolyte homeostasis in those who are ‘nil by mouth’ - maintenance
fluid
• Treat hypovolaemic shock - resuscitation fluid

These are guidelines only and individual cases may need expert review and management.

Background physiology

Humans need:

25-30 ml/kg/24h water

1 mmol/kg/24h sodium, potassium and chloride

50-100 g/day glucose (1L 5% glucose contains 50g) - this does not supply nutritional needs but
will limit ketosis
Hypervolaemia

Excess water (assuming normal renal function) is easily excreted. Very small changes (1-2%) in
plasma osmolality are rapidly detected, which inhibits ADH, increasing dilute urine volume.
Large amounts of water have to be taken to overwhelm this mechanism and cause
hyponatraemia. This is why if you quickly drink 2 litres of water you just urinate more rather than
becoming oedematous or hyponatraemic.

Excess sodium is much harder for the body to deal with. Sodium containing fluids which have a
similar osmolality to plasma (compound sodium lactate and 0.9% sodium chloride) trigger little
change in plasma osmolality and so don’t activate the same mechanism to excrete any excess
fluid that has been given. Volume receptors are much less sensitive than osmoreceptors
(needing a change of >10% to be activated). Excess IV fluid also raises capillary pressures
causing increased filtration into the tissues, limiting intravascular volume increase, but producing
tissue oedema. In evolutionary terms humans have adapted to have powerful sodium
conserving mechanisms but have poor capacity to excrete excess sodium. Water stays with
sodium in the body so excess sodium, hypervolaemia and oedema go together. Hypervolaemia
causes reduced organ perfusion and therefore organ dysfunction in the following ways:

1. Pressure gradient (fl ow). Organ perfusion is determined by the pressure gradient from the
arterial to the venous side of the organ. Arterioles tightly regulate perfusion pressure on the
arterial side between a wide range of blood pressures (in the kidney, for example, perfusion
pressure is constant between a mean arterial pressure of 60-180). This means that as long as
very low blood pressure is avoided, altering arterial pressure will have no effect on organ
perfusion. Venous pressures however are not auto-regulated in the same way. High right
atrial pressures (CVP) are transmitted back through the venous system and will therefore
reduce organ perfusion.

2. Cardiac effects. The right heart is relatively compliant but its pressure will go up with fl uid
overload. Venous return to the heart is dependent on the pressure gradient from the veins to
the right atrium which is why in health right atrial pressure is so low (0-2 mmHg). Once its
compliance has been overwhelmed, the pressure in the right heart will go up more than the
venous pressure with fl uid administration, which will reduce venous return and therefore
cardiac output. Also, as the heart is contained in the non compliant pericardium, any increase
in right heart volume will necessarily cause a reduction in left heart volume and therefore
stroke volume and cardiac output. For these reasons, the old teaching that increasing CVP
increases venous return and stroke volume is wrong as has been demonstrated in countless
studies since the 1970s. A high CVP is always pathological.

3. Oedema. Venous congestion causes fl uid leak with tissue and organ oedema. Peripheral
oedema is the visible manifestation of fl uid overload. If this is present then there will also be
oedema in each organ system which is invisible to physical examination. The result is both a
further increase in venous pressures and increased organ compartment pressures, both of
which will reduce organ perfusion. The kidney is particularly sensitive to this. It is very rare to
be hypovolaemic and signifi cantly oedematous.

Oedema = fluid overload

So, hypervolaemia reduces organ perfusion by several mechanisms and thus causes organ
dysfunction. The kidneys and lungs are particularly susceptible to this although all organ
systems will be affected (see graphic below). There are many studies proving the link between
venous congestion and organ injury.

Manifestations of fluid overload The salt content of 0.9% sodium chloride

Key points

• Fluid overload causes significant harm

• Humans cannot excrete salty water easily so excess salty water causes fluid overload.
• Humans only need 1 mmol/kg/24h of sodium. More than this causes harm.
• Compound Sodium Lactate (CSL - also known as Hartmanns) and 0.9% sodium chloride are
therefore NOT maintenance fluids. They are resuscitation fluids only.
• 4% glucose 0.18% sodium chloride contains 31 mmol of sodium and chloride and 40g of
glucose per litre. It can also come with either 20 or 40 mmol potassium. Giving 2L of this over
24 hours (83 mls/h) therefore provides almost exactly the water and electrolyte requirements
of a 70kg person.

Shock

See this excellent presentation on the physiology of shock:

https://www.youtube.com/watch?time_continue=242&v=DVW9_zTuVWA
Stressed venous volume is the amount of venous blood above the outlet in the tank. The venous
blood below the outlet (unstressed) does not contribute to venous return. Stressed/unstressed
volume is determined by the amount of blood and size of the tank (which is governed by
venous tone via the sympathetic nervous system).

Shock is a result of inadequate organ perfusion.

It can be:

❖ Hypovolaemic (bleeding, dehydration)

❖ Vasodilatory (sepsis, pancreatitis, anaphylaxis, liver failure, neurogenic)
❖ Cardiogenic (heart failure of any cause)
❖ Obstructive (tamponade, PE)

If severe enough it will be manifested by low blood pressure.

The causes and treatments are very different. Hypovolaemia is a rare cause of shock outside of
trauma.

Hypovolaemia

Venous return is dependent on the pressure gradient between the veins (stressed venous
volume) and the right atrium (central venous pressure). The sympathetic nervous system will
activate venoconstriction in hypovolaemia to maintain venous return. Once this is overwhelmed,
venous return, stroke volume and blood pressure will fall.

There are only 2 causes of hypovolaemia - bleeding and extracellular fluid deficit:

Bleeding

This is usually obvious from the history and examination. The priority here is to stop the
bleeding. Aggressive fluid resuscitation while bleeding is uncontrolled will simply exacerbate
blood loss due to increased blood pressure and dilution of clotting factors. In such cases (and as
per NICE guidelines) fluid should only be used to resuscitate to, a level where a pulse can be
felt, or a systolic BP of 70-90 mmHg (so called permissive hypotension). The idea is to give the
minimum amount of fluid possible to prevent death while treating the cause of the bleeding.
Compound sodium lactate is preferred to 0.9% sodium chloride as its lower chloride levels
won’t cause an acidosis.
Blood and clotting factors are ideally reserved until the bleeding has been stopped at which
time the aim is to restore normovolaemia, blood pressure and clotting factors.

Fluid loss

This often causes confusion in clinicians. There is a plethora of different terms that are used
interchangeably. A consensus statement in 2019 has sought to clarify these terms. DOI:
10.1080/07853890.2019.1628352 https://bit.ly/2RvAiEF

Water is in 2 compartments in the body. The cells (intracellular fluid) and the extracellular fluid
(ECF). The ECF is subdivided into interstitial and intravascular fluid and the ECF moves between
these by filtering out of the vessels into the interstitium and returning to the circulation via the
lymphatics.

Hypertonic dehydration - water deficit causing hyperosmolality. Such a patient will have a high
sodium and a high haematocrit/haemoglobin. It results from inadequate water intake or
increased losses (sweating). Intravascular volume is preserved Intracellular volume is reduced.

Isotonic dehydration - water and salt loss causing a deficit of extracellular fluid with normal
osmolality. Large volume GI losses from vomiting, NG free drainage and diarrhoea cause such
fluid loss with relatively preserved sodium levels as GI fluid contains varying amounts of sodium
(see diagram below). The haematocrit should still be high though in the absence of other
reasons for derangement. Dehydration and fluid loss often co-exist (e.g. not drinking and
vomiting).

Hypovolaemia is caused by loss of blood or ECF and specifically describes intravascular volume
depletion.

Treatment is replacement of any water and electrolyte deficit. The history is key. How long has
the patient not been drinking for? How much diarrhoea and vomiting has there been? Suitable
fluid will be either 5% glucose, 4% glucose 0.18% sodium chloride or, in the case of large
volume GI losses, compound sodium lactate depending on the patients sodium levels and
severity of dehydration and hypovolaemia. The deficit should be replaced in addition to normal
daily fluid requirements. Caution needs to be exercised when correcting significantly deranged
sodium levels (see below).

Very large gastric losses from vomiting can cause a hypochloraemic alkalosis (such as is seen in
infants with pyloric stenosis). This is one of the very few indications to use 0.9% sodium chloride.
What about sepsis and pancreatitis?

Contrary to popular belief, sepsis and pancreatitis do not cause hypovolaemia. Significant
capillary leak will not occur at normal capillary pressures so intravascular blood volume will be
maintained. Such patients do not present with oedema. However, systemic inflammatory
response patients are more prone to capillary leak at high capillary pressures so any iatrogenic
fluid overload will cause more capillary leak than in a healthy person. Evidence shows only 10%
of a crystalloid bolus remains in the circulation an hour after giving it in sepsis. 90% will go into
the tissues.

Vasodilatory

In this type of shock the capacitance veins are unable to constrict to maintain stressed volume
and venous return. Administration of fluid will not cause much increase in stressed venous
volume (it will mostly be included in the unstressed volume) and so this will have limited effect
on cardiac output and blood pressure. Continued fluid resuscitation will lead to all the
consequences of fluid overload detailed above. Correct treatment here is the use of
vasoconstrictors (drugs like metaraminol, noradrenaline and terlipressin). These generally have
to be given in a High Dependency/Intensive Care unit.

As stated above, septic patients are not hypovolaemic (this includes any condition leading to a
systemic inflammatory response such as pancreatitis or major surgery). They are vasodilated and
over 50% have impaired cardiac function as a result of sepsis. If they have been ill for several
days then there may be an element of superimposed dehydration which will need correcting. In
these circumstances it may be appropriate to give a fluid challenge and assess the response
(see algorithm below). A maximum of 2L should be given after which time fluid administration
should stop and a referral to Intensive Care should be made.

Cardiogenic

This is failure of the circulation’s pump. Fluids are of no benefit and will cause even more harm
than in other patients. Pulmonary oedema and AKI will quickly develop or worsen with fluid
administration. Specialist referral is essential.

Obstructive

A small fluid challenge may be appropriate but urgent specialist referral is required.
Clinical signs in shock

Heart rate, blood pressure, urine output, peripheral perfusion, lactate, urea and creatinine etc
are non-specific features of the cause of shock. Tachycardia, low blood pressure, prolonged
capillary refill, high lactate and reduced urine output are all signs of hypovolaemia but they are
more commonly signs of conditions like a systemic inflammatory response (sepsis, pancreatitis)
or cardiac failure. Fluid will help in hypovolaemia but be of little use or detrimental in other
causes.

Key points

• Fluid resuscitation should only be given to those who are bleeding or fluid depleted.
• Bleeding - stop the bleeding and support the circulation with blood or compound sodium
lactate.
• Fluid deficit - Resuscitate with compound sodium lactate if signs of shock. If not shocked then
use compound sodium lactate, 4% glucose 0.18% sodium chloride or 5% glucose depending
on plasma sodium levels and the cause of dehydration. 0.9% sodium chloride should only be
used in hypochloraemic alkalosis from excessive vomiting.
• Sepsis and pancreatitis do not cause hypovolaemia.
• Clinical signs are important but non specific of the need for fluid.
• History is very important for determining fluid needs.

Prescribing

Enteral (oral or NG) fluid intake is always preferable to IV

IV fluids should be given to:

• Maintain water and electrolyte homeostasis if nil by mouth - maintenance fluid

• Treat hypovolaemia - resuscitation fluid

Prescribing should always take into account history, examination, U&Es, Hb and the
recorded fluid balance

Maintenance

Humans need:

• 25-30 ml/kg/24h water

• 1 mmol/kg/24h sodium, potassium and chloride
• 50-100 g/day glucose (1 L 5% glucose contains 50g) - this does not supply nutritional needs
but will prevent ketosis
4% glucose 0.18% sodium chloride contains 31 mmol of sodium and chloride and 40g of
glucose per litre. It can also come with either 20 or 40 mmol potassium. Giving 2L of this over
24 hours (83 mls/h) therefore provides almost exactly the water and electrolyte requirements of
a 70kg person.

Note:
Fluid overload causes significant harm
Humans cannot excrete salty water easily so excess salty water causes fluid overload.
Humans only need 1 mmol/kg/24h of sodium. More than this causes harm.
Compound sodium lactate and 0.9% sodium chloride are therefore NOT maintenance fluids.
They are resuscitation fluids only.
0.9% sodium chloride contains a high concentration of chloride which can cause an acidosis.

Resuscitation

Algorithms for IV fluid therapy in adults

Algorithm 1: Assessment

Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, assess whether the patient is hypovolaemic and needs fluid resuscitation
Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation include: systolic BP <100mmHg; heart rate
>90bpm; capillary refill >2s or peripheries cold to touch; respiratory rate >20 breaths per min; NEWS 5; 45o passive leg raising suggests fluid responsiveness.

Yes
No

Assess he pa ien s likel fl id and elec rolyte needs

Algorithm 2: Fluid Resuscitation
Initiate treatment
Identify cause of deficit and respond.
Give a fluid bolus of 500 ml of crystalloid
(containing sodium in the range of
130 154 mmol/l) over less than 15
minutes.
History: previous limited intake, thirst, abnormal losses, comorbidities.
Clinical examination: pulse, BP, capillary refill, JVP, oedema (peripheral/pulmonary), postural hypotension.
Clinical monitoring: NEWS, fluid balance charts, weight.
Laboratory assessments: FBC, urea, creatinine and electrolytes.
Yes Ensure nutrition and fluid needs are met
Can the patient meet their fluid and/or electrolyte needs orally or enterally? Also see Nutrition support in adults (NICE
clinical guideline 32).

No

Does the patient have complex fluid or Yes

Reassess the patient using the ABCDE electrolyte replacement or abnormal Algorithm 4: Replacement and Redistribution
approach distribution issues?
Does the patient still need fluid Look for existing deficits or excesses, ongoing
resuscitation? Seek expert help if unsure abnormal losses, abnormal distribution or other Existing fluid or Ongoing abnormal fluid or Redistribution and
complex issues. electrolyte deficits electrolyte losses other complex issues
or excesses Check ongoing losses and estimate Check for:
Check for: amounts. Check for: gross oedema
Yes No
No dehydration vomiting and NG tube loss severe sepsis
fluid overload biliary drainage loss hypernatraemia/
hyperkalaemia/ high/low volume ileal stoma hyponatraemia
Does the patient have hypokalaemia loss renal, liver and/or
signs of shock? Algorithm 3: Routine Maintenance diarrhoea/excess colostomy cardiac impairment.
Estimate deficits or loss post-operative fluid
excesses. ongoing blood loss, e.g. retention and
Yes No melaena redistribution
Give maintenance IV fluids
sweating/fever/dehydration malnourished and
Normal daily fluid and electrolyte requirements: refeeding issues
pancreatic/jejunal fistula/stoma
25 30 ml/kg/d water loss Seek expert help if
1 mmol/kg/day sodium, potassium*, chloride urinary loss, e.g. post AKI necessary and estimate
Yes
>2000 ml 50 100 g/day glucose (e.g. glucose 5% contains polyuria. requirements.
Seek expert help 5 g/100ml).
given?

No
Prescribe by adding to or subtracting from routine maintenance, adjusting for all
Reassess and monitor the patient other sources of fluid and electrolytes (oral, enteral and drug prescriptions)
Stop IV fluids when no longer needed.
Give a further fluid bolus of 250 500 ml of Nasogastric fluids or enteral feeding are preferable
crystalloid when maintenance needs are more than 3 days.
Monitor and reassess fluid and biochemical status by clinical and laboratory
monitoring

*Weight-based potassium prescriptions should be rounded to the nearest common fluids available (for example, a 67 kg person should have fluids containing 20 mmol and 40 mmol of potassium in a 24-hour period).
Potassium should not be added to intravenous fluid bags as this is dangerous.
In a en fl id he a in ad l in h i al , NICE clinical g ideline 174 (December 2013. Last update December 2016) © National Institute for Health and Care Excellence 2013. All rights reserved.

See NICE prescribing algorithm below.

The only causes of hypovolaemia are bleeding and dehydration

Bleeding

Stop the bleeding and support the circulation with blood or compound sodium lactate.
Dehydration

Water deficiency. High sodium and high haematocrit/Hb. If oral or NG route not possible, treat
with 5% glucose until sodium normalised. Caution with lowering Na levels too quickly if very
high (max reduction is 0.5mmol/h). Seek expert help.

Fluid loss

Sodium and water loss (GI losses - see section below). Normal sodium +/- high haematocrit/Hb.
Treat with compound sodium lactate or 4% glucose 0.18% sodium chloride, depending on
plasma sodium levels and the location in the GI tract losses are occurring from, until estimated
losses replaced.

Hypotension from other causes

Giving fluid resuscitation to treat shock from other causes than hypovolaemia will at best only be
of very limited and short term value and at worst cause significant harm. Always try and work out
the cause and direct your treatment at that. It is not always clear in an acute situation. It is
acceptable to give a fluid challenge or 250-500 mls and assess the response. Once a maximum
of 2L has been given a referral to ICU should be made and no more fluid given unless there is
obvious bleeding. See NICE prescribing algorithm below.

Prescribing algorithms

The below prescribing reminders are available as a double-sided credit card sized images which
can be ticked behind your ID badge.

Dr Ashley Miller Maintenance Fluid @icmteaching Dr Ashley Miller Resuscitation Fluid @icmteaching

Can the patient Consider fluid and Fluid overload Fluid deficit Causes: Clinical signs (may be present in sepsis, pancreatitis and heart
electrolyte needs Assess
meet their fluid failure which should not be treated with IV fluid unless fluid depleted)
• Positive fluid • Compatible history (not for hypo- • Bleeding
needs orally or • History • Tachycardia
Assess balance drinking, D&V etc)
enterally?
• Examination volaemia • Fluid deficit • Hypotension or postural hypotension
• Fluid balance • Peripheral oedema • Water loss: ↑Na, ↑Hb, ↑urea
Sepsis and pancreatitis do not cause • Oliguria
• U&Es, Hb If so no IV fluid • GI losses: →Na, ↑Hb, ↑urea
hypovolaemia but any associated • ↑ Lactate
If so no IV fluid • Weight chart ABCDE
(unless specific indication)
fluid depletion must be treated • Reduced peripheral perfusion

Prescribe 1.2 ml/kg/h 4% glucose 0.18% sodium chloride + 20 - 40 mmol K per L Bleeding Fluid deficit (with signs of shock)
(modify as • Stop the bleeding, expert help, consider blood • 250-500mls compound sodium lactate
below) 25-30 ml/kg/d water 1mmol/kg/d Na, K, Cl 50-100g/d glucose products & major haemorrhage protocol
Treat • Reassess (ABCDE)
• Bolus 250mls compound sodium lactate to
• Without signs of shock, see Maintenance
target central pulse / systolic BP 70-90 until
Ongoing abnormal fluid Na <135 or >145 Fluid Fluid deficit bleeding controlled
Modify or electrolyte losses:
K <3.5 or >5.5 overload • Water loss with ↑Na - 5%
(treat as for fluid deficit)
Complex fluid glucose Still shocked?
• Vomiting / NG loss Reassess Does the patient still need fluid resuscitation?
or electrolyte Point your camera • No IV fluid • GI losses with → Na - Give further 250 mls compound sodium
• Biliary drainage loss (ABCDE) Seek expert help if unsure
replacement at the QR code for • Consider Compound Sodium Lactate
• Stoma losses lactate over <15 mins and reassess (ABCDE)
issues or
• Diarrhoea management diuretics • Volume to replace deficit
losses?
• Polyuria (DI) • Usual maintenance thereafter
Any patient (suitable for escalation of care) who
Reassess Refer has had 2000 mls of resuscitation fluid and still Call ICU registrar on-call (bleep 845)
Stop IV fluid when no longer needed. Aim to switch to oral or enteral ASAP. has signs of shock
at least daily
Electrolyte compositions of common fluids

Glucose 4%
0.9% sodium Compound
Sodium 5% glucose
chloride Sodium Lactate
chloride 0.18%

Sodium
154 131 31 0
mmol

Chloride
154 111 31 0
mmol

Potassium
0/20/40 5 0/20/40 0/20/40
mmol

Glucose g 0 0 40 50

Uses specialist only resuscitation maintenance high sodium

Think

Drug
Which fluid? Why? Resuscitation or
maintenance? Fluid balance, U&Es?

Dose
How much? Resuscitation or maintenance?
Fluid balance, U&Es?

Duration
How long do they need it for? Aim is for oral
intake as soon as possible

De-escalation
Stop as soon as oral intake possible.
Special circumstances

Post-operative patients:

Aim should be to establish oral intake ASAP.

Maintenance fluids for those who are not drinking should be prescribed as normal (4% glucose
0.18% sodium chloride with 20-40 mmol K) if electrolytes are in the normal range.
The stress response to surgery activates ADH secretion and water retention making it normal for
patients to be oliguric for 24 hours or so and also predisposing to hyponatraemia.
It is therefore important not to give too much water (not >25-30 mls/kg in 24h) so that
hyponatraemia is avoided. This is especially true with elderly patients and those on drugs
causing hyponatraemia.
• Do not chase the urine output with fluid.
• Do however look for signs of fl uid loss such as bleeding, large NG losses (with ileus) etc.
• Do monitor urea and electrolytes daily and make adjustments as required.

GI losses

See the figure below from NICE for the electrolyte composition of GI fluids which can be lost.
As a general rule gastric losses include about half the sodium concentration that is in plasma
while lower GI losses have a similar sodium concentration to plasma.
In these cases higher concentrations of sodium may be needed in replacement fluids.
Compound sodium lactate alone or in combination with 4% glucose 0.18% sodium chloride can
be used in these instances with continual re-evaluation of fluid and electrolyte requirements.
Significant GI losses should be added to maintenance volumes administered.
Loss of large volumes of gastric contents can cause a hypochloraemic alkalosis. This is one of
the few indications for 0.9% sodium chloride to replace the deficit of sodium and chloride.
Electrolyte abnormalities

Significant electrolyte abnormalities should prompt expert review. Causes are varied and may
be complex. The cause should always be established to guide appropriate treatment.

Significant abnormalities that occur in hospital should prompt a critical incidence report.

The table below outlines causes and treatments. There is a Trust hyperkalaemia guideline with
more detailed information which can be found on the intranet.

Rapid correction in plasma sodium can be dangerous. Always seek expert guidance with
significant sodium abnormalities.

Hyponatraemia Hypernatraemia Hypokalaemia Hyperkalaemia

Na <135 Na >145 K+ <3.5 K+ >5.5

Establish and treat Water deficiency +/- Establish underlying MEDICAL EMERGENCY
underlying cause: sodium overdose cause: See Trust guideline
Na loss (diuretics, Inadequate intake
addisons, DKA) water Encourage oral intake of Loss (diuretics, D&V, Assess ABCDE
retention (liver, cardiac, water if possible steroids) Send VBG AND lab
renal failure, SIADH), Alkalosis sample to confirm
water overload (IVI, NG water if not drinking Check ECG
polydipsia, hypothyroid) and NG route possible Check ECG
LESS SEVERE (5.5-5.9)
Treatments include - IV 5% glucose if oral or MILD (3 - 3.4) Repeat in 6 h and then
stopping causative enteral route not Sando K 2 tablets TDS daily if stable.
drug, water restriction, possible or Review drugs (K sparing
frusemide or IV sodium Kay Cee L 25 mls TDS diuretics, ACEi, IVI)
chloride depending on Correct slowly to Check level in 3 days
cause. prevent complications SEVERE (>6)
MODERATE (2.5 - 2.9) Give 10ml 10% calcium
AVOID HYPOTONIC SEEK SENIOR ADVICE Sando K 2 tablets QDS chloride or 30mls 10%
FLUID or calcium gluconate IV
DO NOT USE FLUIDS Kay Cee L 25 mls QDS over 3-5 mins IV via
SEEK SENIOR ADVICE CONTAINING SODIUM Check level in 24h large vein
Give 10 units Actrapid
Na <125 SEEK EXPERT SEVERE (<2.5) IV in 50ml of 50%
ADVICE IV replacement using 40 glucose over 15-30
mmol KCL in fluids TDS minutes
Correct slowly to Check levels 12 hourly Give 10-20mg
prevent complications. nebulised salbutamol
Max increase 0.5mmol/ Check serum Mg level
h SEEK SENIOR ADVICE

If ➡GCS or seizures due

to hyponatraemia give
200mls of 2.7% NaCl
Image from https://doi.org/10.1080/07853890.2019.1628352

Liver failure

Expert management is required.

Chronic liver failure patients are often fluid overloaded with electrolyte abnormalities. Splancnic
vasodilatation, which is exacerbated when unwell, can cause low blood pressure. Terlipressin is
usually better than volume resuscitation in these circumstances but seek expert review.
GI bleeding can cause rapid and life-threatening hypovolaemia.

Renal failure

Expert management is required.

Pre-renal acute kidney injury (AKI) can result from any cause of shock (see physiology above).
An AKI is usually not due to hypovolaemia. Other causes of AKI include:
• Fluid overload (venous congestion) - see physiology above
• Systemic inflammatory response - Direct toxicity of inflammatory mediators. Venodilatation
causing reduced venous return and cardiac output. See physiology above.
• Heart failure (venous congestion)
• Renal obstruction

It is very important to establish the cause of an AKI rather than just make the assumption that
fluids will help. As previously stated, fluid resuscitating a normovolaemic patient will cause
increased venous pressures, reduce renal perfusion and worsen AKI.

A patient in established renal failure (anuric) cannot excrete water and electrolytes. Any
administered fluid can only be removed by dialysis/filtration.

Cardiac failure

Expert management is required.

Fluids should be avoided or used very cautiously. Usually it will be diuresis, not fluid, that is
required.

Sepsis / pancreatitis

Use the NICE algorithm for fluid above.

Sepsis and pancreatitis do not cause hypovolaemia. See physiology above.
If hypotension persists after 2L of fluid resuscitation then referral to ICU must made so the
patient can be treated with vasopressors and not receive harmful further fluid.

DKA

Follow the Trust guidelines for DKA management. Beware of hyperchloraemic acidosis from
0.9% sodium chloride.

Brain injured patients

Need expert management in ICU.

Hypotonic fluid must be avoided.

Burns

Need expert management in ICU.

Critical incident reporting

The following table shows the consequences of fluid mismanagement that NICE deem
reportable as critical incidents. Please remember that critical incident reporting is not to assign
blame but to encourage learning and good practice.

Consequence of fluid Time frame of

Identifying features
mismanagement identification

Patient fluid needs not met by oral, enteral or

IV intake
History, examination and investigation
Hypovolaemia Before or during fluid therapy
consistent with dehydration

Unrecognised bleeding

Features of pulmonary oedema on During or within 6 hours of IV

Pulmonary oedema
examination and imaging fluid therapy

Na <130 During or within 24h of IV

Hyponatraemia
No other likely cause identified fluid therapy

Na >155
IV fluid regimen included 0.9% sodium
Hypernatraemia chloride or Compound Sodium Lactate Any time whilst in hospital
Patients water requirements not met by oral,
enteral or IV intake

Pitting oedema in dependent areas

During or within 24h of IV
Peripheral oedema No other cause identified (eg cardiac failure,
fluid therapy
nephrotic syndrome)

K <3 likely to be due to IV fluids without

adequate K provision During or within 24h of IV
Hypokalaemia
No other obvious cause (eg K wasting fluid therapy
diuretics, refeeding syndrome)
Roles and responsibilities

Role Responsibility
• Training across the Trust
• Clinical governance
• Audit
• Review of IV fluid prescribing and
IV Fluid Lead Clinician patient outcomes
• To work with the IV fluid lead nurse and
departmental governance leads to
ensure good fluid management in the
Trust

• To maintain and assess ward based

practice
• To deliver point-of-care education
IV Fluid Lead Nurse
sessions
• To report back to and work with the IV
fluid lead clinician

• To assess fluid prescribing practice in

their speciality
• To ensure the reporting of fluid related
critical incidents
Departmental governance leads
• To include fluid management in M&M
discussions
• To report back to and work with the IV
fluid lead clinician

• To assess patient’s fluid requirements

• To prescribe safely
Prescribers • To re-assess appropriately
• To regularly take and review FBC and
U&E.

• To administer fluids as prescribed

• To update fluid balance charts
Nurse
• To weigh patients as per the hospital
policy.