Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Principles and protocols for intravenous fluid therapy

The assessment and management of patients' fluid and electrolyte needs is fundamental to good patient care.

1.1.1 Assess and manage patients' fluid and electrolyte needs as part of every ward review. Provide intravenous (IV) fluid therapy only for patients whose needs cannot be met by oral or enteral routes, and stop as soon as possible.

1.1.2 Skilled and competent healthcare professionals should prescribe and administer IV fluids, and assess and monitor patients receiving IV fluids (see the recommendations in the section on training and education).

1.1.3 When prescribing IV fluids, remember the 5 Rs: Resuscitation, Routine maintenance, Replacement, Redistribution and Reassessment.

1.1.4 Offer IV fluid therapy as part of a protocol (see the algorithms for IV fluid therapy):

  • Assess patients' fluid and electrolyte needs following algorithm 1: assessment.

  • If patients need IV fluids for fluid resuscitation, follow algorithm 2: fluid resuscitation.

  • If patients need IV fluids for routine maintenance, follow algorithm 3: routine maintenance.

  • If patients need IV fluids to address existing deficits or excesses, ongoing abnormal losses or abnormal fluid distribution, follow algorithm 4: replacement and redistribution.

Algorithms for IV fluid therapy

See the downloadable PDF version of the algorithm poster set.

Algorithms for IV fluid therapy

1.1.5 Include the following information in IV fluid prescriptions:

  • the type of fluid to be administered

  • the rate and volume of fluid to be administered.

1.1.6 Patients should have an IV fluid management plan, which should include details of:

  • the fluid and electrolyte prescription over the next 24 hours

  • the assessment and monitoring plan.

    Initially, the IV fluid management plan should be reviewed by an expert daily. IV fluid management plans for patients on longer-term IV fluid therapy whose condition is stable may be reviewed less frequently.

1.1.7 When prescribing IV fluids and electrolytes, take into account all other sources of fluid and electrolyte intake, including any oral or enteral intake, and intake from drugs, IV nutrition, blood and blood products.

1.1.8 Patients have a valuable contribution to make to their fluid balance. If a patient needs IV fluids, explain the decision, and discuss the signs and symptoms they need to look out for if their fluid balance needs adjusting. If possible or when asked, provide written information (for example, NICE's information for the public), and involve the patient's family members or carers (as appropriate).

1.2 Assessment and monitoring

Initial assessment

1.2.1 Assess whether the patient is hypovolaemic. Indicators that a patient may need urgent fluid resuscitation include:

  • systolic blood pressure is less than 100 mmHg

  • heart rate is more than 90 beats per minute

  • capillary refill time is more than 2 seconds, or peripheries are cold to touch

  • respiratory rate is more than 20 breaths per minute

  • National Early Warning Score (NEWS) is 5 or more

  • passive leg raising suggests fluid responsiveness.

    Passive leg raising is a bedside method to assess fluid responsiveness in a patient. It is best undertaken with the patient initially semi-recumbent and then tilting the entire bed through 45°. Alternatively, it can be done by lying the patient flat and passively raising their legs to greater than 45°. If, at 30 to 90 seconds, the patient shows signs of haemodynamic improvement, it indicates that volume replacement may be required. If the condition of the patient deteriorates, in particular breathlessness, it indicates that the patient may be fluid overloaded.

1.2.2 Assess the patient's likely fluid and electrolyte needs from their history, clinical examination, current medications, clinical monitoring and laboratory investigations:

  • History should include any previous limited intake, thirst, the quantity and composition of abnormal losses (see the diagram of ongoing losses), and any comorbidities, including patients who are malnourished and at risk of refeeding syndrome (see the NICE guideline on nutrition support in adults).

  • Clinical examination should include an assessment of the patient's fluid status, including:

    • pulse, blood pressure, capillary refill and jugular venous pressure

    • presence of pulmonary or peripheral oedema

    • presence of postural hypotension.

  • Clinical monitoring should include current status and trends in:

    • NEWS

    • fluid balance charts

    • weight.

  • Laboratory investigations should include current status and trends in:

    • full blood count

    • urea, creatinine and electrolytes.

Reassessment

1.2.3 If patients are receiving IV fluids for resuscitation, reassess the patient using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure), monitor their respiratory rate, pulse, blood pressure and perfusion continuously, and measure their venous lactate levels and/or arterial pH and base excess according to guidance on advanced life support (Resuscitation Council UK, 2011).

1.2.4 All patients continuing to receive IV fluids need regular monitoring. This should initially include at least daily reassessments of clinical fluid status, laboratory values (urea, creatinine and electrolytes) and fluid balance charts, along with weight measurement twice weekly. Be aware that:

  • Patients receiving IV fluid therapy to address replacement or redistribution problems may need more frequent monitoring.

  • Additional monitoring of urinary sodium may be helpful in patients with high-volume gastrointestinal losses. (Reduced urinary sodium excretion [less than 30 mmol/l] may indicate total body sodium depletion even if plasma sodium levels are normal. Urinary sodium may also indicate the cause of hyponatraemia, and guide the achievement of a negative sodium balance in patients with oedema. However, urinary sodium values may be misleading in the presence of renal impairment or diuretic therapy.)

  • Patients on longer-term IV fluid therapy whose condition is stable may be monitored less frequently, although decisions to reduce monitoring frequency should be detailed in their IV fluid management plan.

1.2.5 If patients have received IV fluids containing chloride concentrations greater than 120 mmol/l (for example, sodium chloride 0.9%), monitor their serum chloride concentration daily. If patients develop hyperchloraemia or acidaemia, reassess their IV fluid prescription and assess their acid–base status. Consider less frequent monitoring for patients who are stable.

1.2.6 Clear incidents of fluid mismanagement (for example, unnecessarily prolonged dehydration or inadvertent fluid overload due to IV fluid therapy) should be reported through standard critical incident reporting to encourage improved training and practice (see the table on consequences of fluid mismanagement to be reported as critical incidents).

1.2.7 If patients are transferred to a different location, reassess their fluid status and IV fluid management plan on arrival in the new setting.

1.3 Resuscitation

1.3.1 If patients need IV fluid resuscitation, use crystalloids that contain sodium in the range 130 to 154 mmol/l, with a bolus of 500 ml over less than 15 minutes. (For more information, see the table on composition of commonly used crystalloids on the guideline's tools and resources page.)

1.3.2 Do not use tetrastarch for fluid resuscitation.

1.3.3 Consider human albumin solution 4% to 5% for fluid resuscitation only in patients with severe sepsis.

1.4 Routine maintenance

1.4.1 If patients need IV fluids for routine maintenance alone, restrict the initial prescription to:

  • 25 to 30 ml/kg/day of water and

  • approximately 1 mmol/kg/day of potassium, sodium and chloride and

  • approximately 50 to 100 g/day of glucose to limit starvation ketosis. (This quantity will not address patients' nutritional needs; see the NICE guideline on nutrition support in adults.)

    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 IV fluid bags as this is dangerous. For more information, see the table on IV fluid prescription for routine maintenance over a 24-hour period.

1.4.2 For patients who are obese, adjust the IV fluid prescription to their ideal body weight. Use lower range volumes per kg (patients rarely need more than a total of 3 litres of fluid per day) and seek expert help if their body mass index (BMI) is more than 40 kg/m2.

1.4.3 Consider prescribing less fluid (for example, 20 to 25 ml/kg/day fluid) for patients who:

1.4.4 When prescribing for routine maintenance alone, consider using 25 to 30 ml/kg/day sodium chloride 0.18% in 4% glucose with 27 mmol/l potassium on day 1 (there are other regimens to achieve this). Prescribing more than 2.5 litres per day increases the risk of hyponatraemia. These are initial prescriptions and further prescriptions should be guided by 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 IV fluid bags as this is dangerous.

1.4.5 Consider delivering IV fluids for routine maintenance during daytime hours to promote sleep and wellbeing.

1.5 Replacement and redistribution

1.5.1 Adjust the IV prescription (add to or subtract from maintenance needs) to account for existing fluid and/or electrolyte deficits or excesses, ongoing losses (see the diagram of ongoing losses) or abnormal distribution.

1.5.2 Seek expert help if patients have a complex fluid and/or electrolyte redistribution issue or imbalance, or significant comorbidity, for example:

  • gross oedema

  • severe sepsis

  • hyponatraemia or hypernatraemia

  • renal, liver and/or cardiac impairment

  • post-operative fluid retention and redistribution

  • malnourished and refeeding issues (see the NICE guideline on nutrition support in adults).

1.6 Training and education

1.6.1 Hospitals should establish systems to ensure that all healthcare professionals involved in prescribing and delivering IV fluid therapy are trained on the principles covered in this guideline, and are then formally assessed and reassessed at regular intervals to demonstrate competence in:

  • understanding the physiology of fluid and electrolyte balance in patients with normal physiology and during illness

  • assessing patients' fluid and electrolyte needs (the 5 Rs: Resuscitation, Routine maintenance, Replacement, Redistribution and Reassessment)

  • assessing the risks, benefits and harms of IV fluids

  • prescribing and administering IV fluids

  • monitoring the patient response

  • evaluating and documenting changes and

  • taking appropriate action as required.

1.6.2 Healthcare professionals should receive training and education about, and be competent in, recognising, assessing and preventing consequences of mismanaged IV fluid therapy, including:

  • pulmonary oedema

  • peripheral oedema

  • volume depletion and shock.

1.6.3 Hospitals should have an IV fluids lead, responsible for training, clinical governance, audit and review of IV fluid prescribing and patient outcomes.

Diagram of ongoing losses

See the downloadable PDF version of the diagram of ongoing losses.

Source: Copyright – National Clinical Guideline Centre

Table 1 Consequences of fluid mismanagement to be reported as critical incidents

Consequence of fluid mismanagement

Identifying features

Time frame of identification

Hypovolaemia

Patient's fluid needs not met by oral, enteral or intravenous (IV) intake and:

  • Features of dehydration on clinical examination

  • Low urine output or concentrated urine

  • Biochemical indicators, such as more than 50% increase in urea or creatinine with no other identifiable cause

Before and during IV fluid therapy

Pulmonary oedema

(breathlessness during infusion)

  • No other obvious cause identified (for example, pneumonia, pulmonary embolus or asthma)

  • Features of pulmonary oedema on clinical examination

  • Features of pulmonary oedema on X ray

During IV fluid therapy or within 6 hours of stopping IV fluids

Hyponatraemia

  • Serum sodium less than 130 mmol/l

  • No other likely cause of hyponatraemia identified

During IV fluid therapy or within 24 hours of stopping IV fluids

Hypernatraemia

  • Serum sodium 155 mmol/l or more

  • Baseline sodium normal or low

  • IV fluid regimen included 0.9% sodium chloride

  • No other likely cause of hypernatraemia identified

During IV fluid therapy or within 24 hours of stopping IV fluids

Peripheral oedema

  • Pitting oedema in extremities and/or lumbar sacral area

  • No other obvious cause identified (for example, nephrotic syndrome or known cardiac failure)

During IV fluid therapy or within 24 hours of stopping IV fluids

Hyperkalaemia

  • Serum potassium more than 5.5 mmol/l

  • No other obvious cause identified

During IV fluid therapy or within 24 hours of stopping IV fluids

Hypokalaemia

  • Serum potassium less than 3.0 mmol/l likely to be due to infusion of fluids without adequate potassium provision

  • No other obvious cause (for example, potassium-wasting diuretics, refeeding syndrome)

During IV fluid therapy or within 24 hours of stopping IV fluids

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 IV fluid bags as this is dangerous.

Source: Table 1 was drafted based on the consensus decision of the members of the guideline development group.

Table 2 IV fluid prescription (by body weight) for routine maintenance over a 24‑hour period

Body weight (in kg)

Water (25 to 30 ml/kg/day)

Sodium, chloride, potassium (approximately 1 mmol/kg/day of each)

40

1000 to 1200

40

41

1025 to 1230

41

42

1050 to 1260

42

43

1075 to 1290

43

44

1100 to 1320

44

45

1125 to 1350

45

46

1150 to 1380

46

47

1175 to 1410

47

48

1200 to 1440

48

49

1225 to 1470

49

50

1250 to 1500

50

51

1275 to 1530

51

52

1300 to 1560

52

53

1325 to 1590

53

54

1350 to 1620

54

55

1375 to 1650

55

56

1400 to 1680

56

57

1425 to 1710

57

58

1450 to 1740

58

59

1475 to 1770

59

60

1500 to 1800

60

61

1525 to 1830

61

62

1550 to 1860

62

63

1575 to 1890

63

64

1600 to 1920

64

65

1625 to 1950

65

66

1650 to 1980

66

67

1675 to 2010

67

68

1700 to 2040

68

69

1725 to 2070

69

70

1750–2100

70

71

1775 to 2130

71

72

1800 to 2160

72

73

1825 to 2190

73

74

1850 to 2220

74

75

1875 to 2250

75

76

1900 to 2280

76

77

1925 to 2310

77

78

1950 to 2340

78

79

1975 to 2370

79

80

2000 to 2400

80

81

2025 to 2430

81

82

2050 to 2460

82

83

2075 to 2490

83

84

2100 to 2520

84

85

2125 to 2550

85

86

2150 to 2580

86

87

2175 to 2610

87

88

2200 to 2640

88

89

2225 to 2670

89

90

2250 to 2700

90

91

2275 to 2730

91

92

2300 to 2760

92

93

2325 to 2790

93

94

2350 to 2820

94

95

2375 to 2850

95

96

2400 to 2880

96

97

2425 to 2910

97

98

2450 to 2940

98

99

2475 to 2970

99

100

2500 to 3000

100

>100

2500 to 3000

100

Add 50 to 100 grams/day glucose (for example, glucose 5% contains 5 g/100 ml).

For special considerations, refer to the recommendations for routine maintenance.

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 IV fluid bags as this is dangerous.

Source: Table 2 was drafted based on the consensus decision of the members of the guideline development group.

Terms used in this guideline

Expert

In this guideline, the term 'expert' refers to a healthcare professional who has core competencies to diagnose and manage acute illness. These competencies can be delivered by a variety of models at a local level, such as a critical care outreach team, a hospital-at-night team or a specialist trainee in an acute medical or surgical specialty. For more information, see the NICE guideline on acutely ill patients in hospital.

  • National Institute for Health and Care Excellence (NICE)