Intravenous fluid therapy in adults in hospital

This guideline covers the general principles for managing intravenous (IV) fluid therapy in hospital inpatients aged 16 and over with a range of conditions. It aims to help prescribers understand the optimal amount and composition of IV fluids to be administered and the best rate at which to give them, to improve fluid prescribing and outcomes among people in hospital. It does not cover pregnant women, and those with severe liver or renal disease, diabetes or burns.

# Introduction 
This guideline contains recommendations about general principles for managing intravenous (IV) fluids, and applies to a range of conditions and different settings. It does not include recommendations relating to specific conditions.
Many adult hospital inpatients need intravenous (IV) fluid therapy to prevent or correct problems with their fluid and/or electrolyte status. Deciding on the optimal amount and composition of IV fluids to be administered and the best rate at which to give them can be a difficult and complex task, and decisions must be based on careful assessment of the patient's individual needs.
Errors in prescribing IV fluids and electrolytes are particularly likely in emergency departments, acute admission units, and general medical and surgical wards rather than in operating theatres and critical care units. Surveys have shown that many staff who prescribe IV fluids know neither the likely fluid and electrolyte needs of individual patients, nor the specific composition of the many choices of IV fluids available to them. Standards of recording and monitoring IV fluid and electrolyte therapy may also be poor in these settings. IV fluid management in hospital is often delegated to the most junior medical staff who frequently lack the relevant experience and may have received little or no specific training on the subject.
The National Confidential Enquiry into Perioperative Deaths report in 1999 highlighted that a significant number of hospitalised patients were dying as a result of infusion of too much or too little fluid. The report recommended that fluid prescribing should be given the same status as drug prescribing. Although mismanagement of fluid therapy is rarely reported as being responsible for patient harm, it is likely that as many as 1 in 5 patients on IV fluids and electrolytes suffer complications or morbidity due to their inappropriate administration.
There is also considerable debate about the best IV fluids to use (particularly for more seriously ill or injured patients), resulting in wide variation in clinical practice. Many reasons underlie the ongoing debate, but most revolve around difficulties in interpretation of both trial evidence and clinical experience, including the following factors:
Many accepted practices of IV fluid prescribing were developed for historical reasons rather than through clinical trials.
Trials cannot easily be included in meta-analyses because they examine varied outcome measures in heterogeneous groups, comparing not only different types of fluid with different electrolyte content, but also different volumes and rates of administration and, in some cases, the additional use of inotropes or vasopressors.
Most trials have been undertaken in operating theatres and critical care units rather than admission units or general and elderly care settings.
Trials claiming to examine best early therapy for fluid resuscitation have actually evaluated therapy choices made after initial fluid resuscitation, with patients already in critical care or operating theatres.
Many trials inferring best therapy for fluid resuscitation after acute fluid loss have actually examined situations of hypovolaemia induced by anaesthesia.
There is a clear need for guidance on IV fluid therapy for general areas of hospital practice, covering both the prescription and monitoring of IV fluid and electrolyte therapy, and the training and educational needs of all hospital staff involved in IV fluid management.
The aim of this NICE guideline is to help prescribers understand the:
physiological principles that underpin fluid prescribing
pathophysiological changes that affect fluid balance in disease states
indications for IV fluid therapy
reasons for the choice of the various fluids available and
principles of assessing fluid balance.
In developing the guideline, it was necessary to limit the scope by excluding patient groups with more specialised fluid prescribing needs. It is important to emphasise that the recommendations do not apply to patients under 16 years, pregnant women, and those with severe liver or renal disease, diabetes or burns. They also do not apply to patients needing inotropes and those on intensive monitoring, and so they have less relevance to intensive care settings and patients during surgical anaesthesia. Patients with traumatic brain injury (including patients needing neurosurgery) are also excluded. The scope of the guideline does not cover the practical aspects of administration (as opposed to the prescription) of IV fluids.
It is hoped that this guideline will lead to better fluid prescribing in hospitalised patients, reduce morbidity and mortality, and lead to better patient outcomes.
Strategies for further research into the subject have also been proposed.
The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.# Patient-centred care
This guideline offers best practice advice on the care of people over 16 years who are in hospital receiving intravenous fluid therapy.
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England  all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. Patients should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
NICE has produced guidance on the components of good patient experience in adult NHS services. All healthcare professionals should follow the recommendations in patient experience in adult NHS services.# Recommendations
The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

# Terms used in this guideline
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 Acutely ill patients in hospital (NICE clinical guideline 50).

# Principles and protocols for intravenous fluid therapy
The assessment and management of patients' fluid and electrolyte needs is fundamental to good patient care.
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.
Skilled and competent healthcare professionals should prescribe and administer IV fluids, and assess and monitor patients receiving IV fluids (see recommendations 1.6.11.6.3).
When prescribing IV fluids, remember the 5 Rs: Resuscitation, Routine maintenance, Replacement, Redistribution and Reassessment.
Offer IV fluid therapy as part of a protocol (see 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
Download the PDF here.
Include the following information in IV fluid prescriptions:
The type of fluid to be administered.
The rate and volume of fluid to be administered.
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.
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.
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).

# Assessment and monitoring

## Initial assessment
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.
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 Diagram of ongoing losses), and any comorbidities, including patients who are malnourished and at risk of refeeding syndrome (see 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
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 , 2011).
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  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.
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 acidbase status. Consider less frequent monitoring for patients who are stable.
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 Consequences of fluid mismanagement to be reported as critical incidents).
If patients are transferred to a different location, reassess their fluid status and IV fluid management plan on arrival in the new setting.

# Resuscitation
If patients need IV fluid resuscitation, use crystalloids that contain sodium in the range 130154 mmol/l, with a bolus of 500 ml over less than 15 minutes. (For more information, see the Composition of commonly used crystalloids table.)
Do not use tetrastarch for fluid resuscitation.
Consider human albumin solution 45% for fluid resuscitation only in patients with severe sepsis.

# Routine maintenance
If patients need IV fluids for routine maintenance alone, restrict the initial prescription to:
30 ml/kg/day of water and
approximately 1 mmol/kg/day of potassium, sodium and chloride and
approximately 50100 g/day of glucose to limit starvation ketosis. (This quantity will not address patients' nutritional needs; see Nutrition support in adults .) For more information see IV fluid prescription for routine maintenance over a 24-hour period.
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 BMI is more than 40 kg/m2.
Consider prescribing less fluid (for example, 2025 ml/kg/day fluid) for patients who:
are older or frail
have renal impairment or cardiac failure
are malnourished and at risk of refeeding syndrome (see Nutrition support in adults ).
When prescribing for routine maintenance alone, consider using 2530 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.
Consider delivering IV fluids for routine maintenance during daytime hours to promote sleep and wellbeing.

# Replacement and redistribution
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 Diagram of ongoing losses) or abnormal distribution.
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 Nutrition support in adults ).

# Training and education
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.
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.
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
Download the PDF here.
Source: Copyright  National Clinical Guideline Centre

## 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 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 Xray
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
Source: This table was drafted based on the consensus decision of the members of the Guideline Development Group. 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 intravenous fluid bags as this is dangerous.

## IV fluid prescription (by body weight) for routine maintenance over a 24hour period
Body weight
Water
Sodium, chloride, potassium
Body weight
Water
Sodium, chloride, potassium
kg
30 ml/kg/day
approx. 1 mmol/kg/day of each
kg
30ml/kg/day
approx. 1 mmol/kg/day of each
Add 50100 grams/day glucose (e.g. glucose 5% contains 5g/100ml).
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 intravenous fluid bags as this is dangerous.
Source: This table was drafted based on the consensus decision of the members of the Guideline Development Group.

# More information
You can also see this guideline in the NICE pathways on intravenous fluid therapy in hospital and sepsis.
To find out what NICE has said on topics related to this guideline, see our web page on hospitals.
See also the guideline committee's discussion and the evidence reviews (in the full guideline), and information about how the guideline was developed, including details of the committee.
  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 3090 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.
 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 intravenous fluid bags as this is dangerous.# Research recommendations
The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group's full set of research recommendations is detailed in the full guideline.

# Assessment and monitoring
What is the incidence of complications during, and as a consequence of, IV fluid therapy?

## Why this is important
This is almost certainly under-reported in the ward setting with significant implications for patients, predominantly morbidity through to mortality. It is probable that complications of fluid therapy are frequent and may be associated with increased clinical needs, such as critical care and, on occasion, may necessitate fluid resuscitation. Lack of a set of clearly defined features of the complications of fluid mismanagement compounds the problem. It is important to define these features and then undertake an observational study in a hospital setting to determine the epidemiology of these complications. Such a study would highlight the prevalence of fluid related complications and inform the development of preventive measures.