Table 3 Four stages of monitoring the appropriateness of fluid prescription at the bedside. Adapted with permission from [43]

1. Assessment

• The patient’s fluid balance is assessed on admission in the hospital

• Daily as well as the cumulative fluid balance is calculated

• The patient’s fluid and electrolyte needs are assessed as part of every ward review

• The assessment includes the use of an appropriate clinical parameter for evaluation of the fluid balance

• Patient’s body weight is measured

• Body composition and volume excess are accessed with bio-electrical impedance analysis

• Signs and symptoms for fluid accumulation are daily screened

• Hemodynamic monitoring is performed

• Recent laboratory result with urea and electrolytes (within 24 h of fluid prescription)

• Urine analysis

2. Indication

A. Resuscitation

• For patients in need of fluid resuscitation:

∘ The cause of the fluid deficit is identified

∘ An assessment of shock or hypoperfusion is made

∘ A fluid bolus of 4 mL/kg of crystalloids is given

• Patients who have received initial fluid resuscitation are reassessed

∘ Dynamic assessment of volemia parameters before AND after fluid bolus (e.g., CVP, fluid responsiveness, PPV, SVV, passive leg raising test)

• Care is upgraded in patients who have already been given > 2000 ml or 30 ml/kg (whichever comes first) of crystalloids and still need fluid resuscitation after reassessment

• Patients who have not had > 30 mL/kg of crystalloids and who still need fluid resuscitation after reassessment receive 250–500 mL of crystalloids and have a further reassessment

B. Maintenance

• If patients need IV fluids for routine maintenance alone, the initial prescription is restricted to:

∘ 25–30 mL/kg/day (1 mL/kg/hr) of water and

∘ Approximately 1 mmol/kg/day of potassium (K⁺) and

∘ Approximately 1–1.5 mmol/kg/day of sodium (Na⁺) and

∘ Approximately 1 mmol/kg/day of chloride and

∘ Approximately 50–100 g/day (1–1.5 g/kg/day) of glucose to limit starvation ketosis

• Definition of inappropriateness in case of electrolyte disturbances

∘ Solutions not containing adequate amount of sodium in case of hyponatremia (Na < 135 mmol/L)

∘ Solutions not containing adequate amount of potassium in case of hypokalemia (K < 3.5 mmol/L)

∘ Solutions containing too much sodium in case of hypernatremia (Na > 145 mmol/L)

∘ Solutions containing too much potassium in case of hyperkalemia (K > 5 mmol/L)

C. Replacement, redistribution and creep

• If patients have ongoing abnormal losses or a complex redistribution problem, the fluid therapy is adjusted for all other sources of fluid and electrolyte losses (e.g., normal saline may be indicated in patients with metabolic alkalosis due to gastro-intestinal losses)

• All sources of fluids administered need to be detailed: crystalloids, colloids, blood products, enteral and parenteral nutritional products, intravenous medication and oral intake (water, tea, soup, etc.)

• Precise data on the concentrated electrolytes added to these fluids or administered separately need to be documented

• Fluid creep is defined as the sum of the volumes of these electrolytes, the small volumes to keep venous lines open (saline or glucose 5%) and the total volume used as a vehicle for medication

3. Prescription

• The following information is included in the IV fluid prescription:

∘ The type of fluid

∘ The rate of fluid infusion

∘ The volume of fluid

• The estimated duration of fluid administration

• The IV fluid prescription is adapted to current electrolyte disorders

4. Management

• Patients have an IV fluid management plan, including a fluid and electrolyte prescription over the next 24 h

• The prescription for a maintenance IV fluid only changes after a clinical exam, a change in dietary intake or evaluation of laboratory results