Implementation of the Guideline Description of Implementation Strategy The National Institute for Health and Care Excellence (NICE) has developed tools to help organizations implement this guidance. These are available on the NICE Web site External Web Site Policy (see also the “Availability of Companion Documents” field). Key Priorities for Implementation The following recommendations have been identified as priorities for implementation. Principles and Protocols for Intravenous Fluid Therapy When prescribing intravenous (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 in the full version of the guideline document [see the “Availability of Companion Documents” field]): 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. 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. Assessment and Monitoring 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” in the original guideline document), and any comorbidities, including patients who are malnourished and at risk of refeeding syndrome. 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: National Early Warning Score (NEWS) Fluid balance charts Weight Laboratory investigations should include current status and trends in: Full blood count Urea, creatinine and electrolytes 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 hyponatremia 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. 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” in the original guideline document).
