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Intravenous fluid therapy in adult inpatients
Paul Frost1 2
Intravenous fluid management is a common medical task, • Stress response: during the catabolic phase of this
and safe unambiguous fluid prescribing is a required response potassium is lost, sodium and water are
training outcome for junior doctors.1 Despite this, errors retained, and oliguria ensues. After surgery it is
• Link to this article online in intravenous fluid management are common and have therefore important to differentiate oliguria caused
for CPD/CME credits been attributed to inadequate training and knowledge.2 by the stress response (harmless) from that caused by
1 Poor fluid management can result in serious morbidity, acute kidney injury.
Critical Care Directorate, University
Hospital of Wales, Cardiff such as pulmonary oedema and dangerous hyponatrae- • Inflammatory conditions (for example, sepsis
CF14 4XW, UK mia as a result of excessive fluids and acute kidney injury or after trauma or surgery) and other medical
2
Institute of Medical Education, as a result of under-resuscitation.2 3 conditions (such as diabetes, hyperglycaemia, and
School of Medicine, Cardiff
University, Cardiff CF14 4XN hypervolaemia): these degrade the endothelial
Correspondence to: P Frost How best to do it glycocalyx and reduce its barrier function. Thus
Frostp2@cf.ac.uk There is a lack of high quality evidence, such as that from infused colloids may leak from the intravascular
Cite this as: BMJ 2015;350:g7620 randomised controlled trials, to guide intravenous fluid space into the interstitial fluid compartment reducing
doi: 10.1136/bmj.g7620
management.4 Safe intravenous fluid prescribing requires their volume expanding effect and contributing to
This series aims to help junior the integration of relevant clinical skills, such as the assess- interstitial oedema.5
doctors in their daily tasks. To ment of fluid balance, with an understanding of fluid physi- • Malnutrition: this can lead to sodium and water overload
suggest a topic, please email us at
ology under normal and pathological conditions and the and depletion of potassium, phosphate, calcium, and
practice@bmj.com.
properties of commonly available intravenous fluids. magnesium. In malnourished patients intravenous
thebmj.com glucose may precipitate pulmonary oedema and cardiac
Previous articles in this Water movement between the plasma and interstitial spaces arrhythmia (refeeding syndrome).6
series The capillary endothelium is lined by the glycocalyx, a • Drug treatment: many drugs can disturb fluid and
ЖЖWhen and how to network of proteoglycans and glycoproteins separating electrolyte balance; common examples include
the plasma from the subglycocalyx space. Fluid move- loop diuretics (hypovolaemia and hypokalaemia),
treat patients who refuse
ment across the capillary is determined by the trans corticosteroids and non-steroidal anti-inflammatory
treatment
endothelial pressure difference and the colloid osmotic drugs (fluid retention).
(BMJ 2014;348:g2043)
pressure difference between the plasma and the subglyco- • Organ dysfunction: in heart failure and cirrhosis
ЖЖCaring for a dying calyx space. As a result, most fluid that is filtered from the neurohumoral adaptations lead to an expanded
patient in hospital plasma through non-fenestrated capillaries returns to the extracellular fluid compartment, peripheral oedema,
(BMJ 2013;346:f2174) circulation through the interstitial lymphatics as lymph.5 ascites, and vulnerability to circulatory overload with
ЖЖEarly management of intravenous fluids. Neurosurgery or traumatic brain
acutely ill ward patients Water movement between the interstitial and intracellular injury may injure the hypothalamus and pituitary
(BMJ 2012;345:e5677) spaces gland, leading to diabetes insipidus, the syndrome of
ЖЖOrgan donation This is mainly determined by osmotic forces. Water bal- inappropriate antidiuretic hormone secretion (SIADH),
(BMJ 2010;341:c6009) ance is regulated by the antidiuretic hormone-thirst feed- or cerebral salt wasting. Organ failure can make fluid
ЖЖMotivational back mechanism, which is influenced by osmoreceptors prescribing more challenging. Thorough clinical
interviewing and baroreceptors. assessment, focusing on the detection of hypovolaemia,
(BMJ 2010;340:c1900) and senior clinical review will be needed.
Fluid balance in disease and injury Table 1 describes the daily fluid balance for a 70 kg
Normal fluid and electrolyte balance (table 1) can be radi- man under normal conditions and box 1 lists normal
cally altered by disease and injury, owing to non-specific maintenance requirements.
metabolic responses to stress, inflammation, malnutrition,
medical treatment, and organ dysfunction. For instance: Clinical assessment of fluid balance
The patient’s fluid status can usually be determined by
THE BOTTOM LINE a comprehensive history and examination supported by
laboratory testing. Key history, some of which may need
• Fluid balance can usually be determined by history (intake, losses, current to be obtained from relatives or carers, includes estimates
illness, and treatment) and examination (skin, neurological, cardiorespiratory,
of fluid intake (enteral and parenteral routes) and losses
and abdominal) supported by tests (urea and electrolytes, creatinine, lactate,
(such as blood, urine, gastrointestinal, and insensible).
and haematocrit)
Also consider the effects of the presenting illness, comor-
• The prescription of intravenous fluids can be made simpler by junior bidity, and medical treatment on fluid balance. Focus
doctors routinely considering the 5Rs: Resuscitation, Routine maintenance,
clinical examination on the skin and on neurological,
Redistribution, Replacement, and Reassessment
cardiorespiratory, and abdominal systems, as outlined
• Senior clinical review and occasionally invasive haemodynamic monitoring in box 2. The specificity and sensitivity of symptoms and
may be needed for patients with complex fluid balance problems, such as
signs indicative of volume status are improved if consid-
those secondary to renal, liver, and cardiac impairment
ered together rather than individually (box 2).
Fig 1 | Body fluid compartment Fluid status can sometimes be difficult to ascertain even mia requires measurement of urinary osmolality and
volumes and theoretical with careful assessment sodium concentration.9 In hypovolaemic hyponatraemia
distribution of intravenous For instance, hypovolaemia is possible in patients with (for example, secondary to diarrhoea and vomiting), the
fluids in healthy people
heart failure who have been over-treated with diuret- expected findings would be a low (<30 mmol/L) urinary
ics. Moreover, hypovolaemia can coexist with oedema or sodium and urinary osmolality greater than 100 mOsm/
ascites—for example, after acute haemorrhage in a patient kg. Urinary osmolality and urinary sodium are unreliable
with cirrhosis or during the recovery phase of acute ill- in the presence of renal failure, after diuretics, or after the
nesses, such as pancreatitis and sepsis. Such patients will administration of intravenous fluid.
require senior review or even invasive haemodynamic moni-
toring in the intensive care unit to assess their fluid respon- Properties of common intravenous fluids
siveness before fluid is given.7 In more straightforward Intravenous fluids can be classified as colloids or crystalloids.
cases, improved tachycardia and increased blood pressure
after a fluid bolus (500 mL of crystalloid given over 15 min- Colloids
utes) provides additional evidence of the presence of hypo- Colloids are large molecular weight substances typically
volaemia, although these patients still need senior review. dissolved in crystalloid solutions such as isotonic saline.
They can be classified into two major groups, the semisyn-
Review of input-output charts and trends in daily weights thetics (hydroxyethyl starches, gelatins, and dextrans) and
This can help determine fluid balance, but polyuria does plasma derivatives (such as albumin) (table 2).10 Colloids
not always exclude hypovolaemia (for example, with diu- do not easily cross the capillary membrane, and this theo-
retic therapy or diabetic ketoacidosis), and oliguria may retical intravascular persistence explains their extensive
be a physiological response to surgery (case scenario 1).8 use in resuscitation (fig 1). Although some studies show
more intravascular repletion with colloids than with crys-
Box 1 | Normal Laboratory tests talloids,11 the effect is less than expected owing to capil-
maintenance Increases in urea, creatinine, lactate, haematocrit, and lary leak, which occurs in acute illness. Also, relative to
requirements
haemoglobin (in the absence of blood loss) can occur with crystalloids, semisynthetic colloids are expensive and are
Water: 25-30 mL/kg/day dehydration but are not diagnostic. associated with adverse reactions such as renal failure,
Sodium, potassium, and coagulopathy, and anaphylaxis. Currently, there is little
chloride: up to 1 mmol/
Serum sodium evidence to support the use of semisynthetic colloids for
kg/day
Both hypernatraemia and hyponatraemia can occur with volume resuscitation, and their use in critically ill patients
Glucose: 50-100 g/day
hypovolaemia, and tracking down the cause of hyponatrae- is likely to be harmful.12 Hydroxyethyl starches have been
Redistribution Reassessment
Maintenance fluids may need to be adjusted to take into Careful monitoring is needed to minimise the risks of adverse
account the internal redistribution of fluid (third space events such as fluid overload, hypovolaemia, and electrolyte
losses) that can occur in cardiac, renal, and liver impair- disturbances. Do not prescribe fluids for more than 24 hours
ment—for example, ascites and oedema. In general, main- and assess fluid status at least daily, if not more often.