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” in the original guideline document) 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 Hyponatremia or hypernatremia Renal, liver and/or cardiac impairment Post-operative fluid retention and redistribution Malnourished and refeeding issues 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, recognizing, 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” is available in the full version of the original guideline document. Consequences of Fluid Mismanagement to Be Reported as Critical Incidents Consequence of Fluid Mismanagement Identifying Features Time Frame of Identification Hypovolemia 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 X-ray During IV fluid therapy or within 6 hours of stopping IV fluids Hyponatremia Serum sodium less than 130 mmol/l No other likely cause of hyponatremia identified During IV fluid therapy or within 24 hours of stopping IV fluids Hypernatremia 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 hypernatremia 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 Hyperkaliemia 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 Hypokalemia 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 This table was drafted based on the consensus decision of the members of the Guideline Development Group. See the original guideline document for the table ‘IV Fluid Prescription (by body weight) for Routine Maintenance Over a 24-hour Period’. Clinical Algorithm(s) An algorithm titled “Algorithms for IV Fluid Therapy” is provided in the full version of the original guideline document. In addition, a NICE pathway on intravenous fluid therapy in adults in hospital is available from the National Institute for Health and Care Excellence (NICE) Web site External Web Site Policy. Scope Disease/Condition(s) Any condition requiring intravenous (IV) fluids Guideline Category Evaluation Management Treatment Clinical Specialty Cardiology Endocrinology Geriatrics Internal Medicine Nursing Nutrition Pulmonary Medicine Surgery Intended Users Advanced Practice Nurses Hospitals Nurses Physician Assistants Physicians Guideline Objective(s). To provide guidance on intravenous (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 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 Principles of assessing fluid balance. Note: The scope of the guideline does not cover the practical aspects of administration (as opposed to the prescription) of IV fluids. Target Population Adult hospital in patients who require intravenous (IV) fluid therapy to prevent or correct problems with their fluid and/or electrolyte status Note: 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 anesthesia. Patients with traumatic brain injury (including patients needing neurosurgery) are also excluded.
