Table 5 The four stages to check for appropriateness of IV fluid therapy.

1. Assessment

The patient’s fluid balance (via fluid chart with input and output) is assessed on admission in the hospital and on a day-by-day basis

The patient’s weight is assessed within the last 3 days of fluid prescription

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

The assessment of the patient’s fluid status (hypo/eu/hypervolemia) includes the use of clinical judgement, vital signs and fluid balance with urine output

Recent lab results with urea and electrolytes (within 24 h of fluid prescription)

If possible sodium balance should be reported

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 was made

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

 Fluid responsiveness is assessed with functional hemodynamics, passive leg raising test or end-expiratory occlusion test, or a combination

 Mean arterial pressure and cardiac output are monitored continuously via pulse contour analysis allowing assessment of beat-to-beat variations

 Patients who have received initial fluid resuscitation are reassessed within 30 min

 Care is upgraded in patients who have already been given > 2000 mL of crystalloids and still need fluid resuscitation after reassessment

 Patients who have not had > 2000 mL of crystalloids and who still need fluid resuscitation after reassessment receive 2–4 mL/kg 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/h) 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 hypokalemia (K > 5 mmol/L)

 The amount of fluid intake via other sources should be subtracted from the basic maintenance need of 1 ml/kg/h:

  Enteral or parenteral nutrition

  Fluid creep (see further)

C. Replacement and redistribution

 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)

D. Fluid creep

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

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

  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 or dose of fluid

 The IV fluid prescription is adapted to current electrolyte disorders and other sources of fluid intake

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