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

From: Intravenous fluid therapy in the perioperative and critical care setting: Executive summary of the International Fluid Academy (IFA)

Stage of evaluation Audit standard
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