Can 0.9% saline be used instead of 5% dextrose in water for intra‑operative intravenous fluid in surgical patients?

Can Saline Be Used Instead of Dextrose Water for Intraoperative IV Fluids?

Yes, 0.9% saline can be used instead of 5% dextrose in water for intraoperative IV fluids in surgical patients, but buffered crystalloid solutions (like Ringer's lactate or Plasma-Lyte) are actually preferred over both options for most surgical cases. 1

The Hierarchy of Fluid Choice for Surgery

First Choice: Buffered Crystalloids

The 2024 International Multidisciplinary Perioperative Quality Initiative guidelines strongly recommend buffered crystalloid solutions over 0.9% saline for perioperative fluid management 1. This recommendation is based on substantial evidence showing that:

• Large volumes of 0.9% saline cause hyperchloremic acidosis, renal vasoconstriction, and acute kidney injury (AKI) 1
• A propensity-matched study of 22,851 noncardiac surgery patients found hyperchloremia in ~20% of patients receiving saline, which was associated with increased 30-day mortality 1
• A registry study of >30,000 patients undergoing major abdominal surgery showed fewer complications with buffered crystalloids compared to 0.9% saline 1
• The SALT trial and a large trial of 15,802 critically ill patients both demonstrated that buffered crystalloids were associated with lower risk of major adverse kidney events (MAKE) compared to 0.9% saline 1

The Dose-Response Relationship

Critical caveat: Two recent large RCTs (19,136 patients total) found no difference in postoperative complications between saline and buffered solutions, BUT these patients only received small amounts of study fluid 1. This suggests a dose-response relationship where the harm from 0.9% saline becomes apparent with larger volumes (typically >3L) 2.

Why NOT Dextrose Water for Intraoperative Use?

Dextrose Causes Hyperglycemia

5% dextrose in water or saline causes significant hyperglycemia during surgery, even in non-diabetic patients 3:

• A randomized trial showed that just 500 mL of 5% dextrose in 0.9% saline caused plasma glucose to spike to 11.1 mmol/L (200 mg/dL) 15 minutes after infusion
• 72% of patients receiving dextrose saline had glucose >10 mmol/L 3
• Patients receiving lactated Ringer's or normal saline remained normoglycemic throughout 3

Dextrose Is Not Needed to Prevent Hypoglycemia

Despite average fasting times of almost 13 hours, none of the surgical patients developed preoperative hypoglycemia when given non-dextrose crystalloids 3. This debunks the common rationale for using dextrose-containing fluids intraoperatively.

Mixed Evidence on PONV

The evidence on dextrose and postoperative nausea/vomiting (PONV) is contradictory:

• One 2025 study found dextrose reduced early PONV but increased late PONV (at 24 hours) and led to greater opioid and antiemetic requirements 4
• Another 2025 study suggested divided doses of dextrose (preop and intraop) reduced PONV 5
• However, the hyperglycemia risk outweighs any potential antiemetic benefit for routine intraoperative use

Practical Algorithm for Intraoperative Fluid Selection

For Most Surgical Cases:

1. Use buffered crystalloids (Ringer's lactate, Plasma-Lyte, Hartmann's solution) as first-line intraoperative fluid 1
2. Avoid 0.9% saline unless the patient has:
   • Metabolic alkalosis
   • Hyponatremia requiring correction
   • Hypochloremia

Volume Considerations:

• Small volumes (<1L): The difference between saline and buffered crystalloids is less clinically significant 1
• Moderate to large volumes (>1L): Buffered crystalloids clearly superior to prevent hyperchloremic acidosis and kidney injury 1
• Very large volumes (>3L): Consider adding colloids (albumin) to avoid crystalloid-related complications 1

When to Use Dextrose:

Reserve dextrose-containing fluids for specific indications, NOT routine intraoperative use:

• Postoperative maintenance fluids before oral intake resumes 6
• Pediatric patients (who have greater hypoglycemia risk) 6
• Patients with documented hypoglycemia
• Preoperative fasting periods in children (should not exceed 1 hour for clear fluids) 6

Special Population: Kidney Transplant

For kidney transplant recipients specifically, there is a strong recommendation for buffered crystalloids over 0.9% saline (strong recommendation, high-quality evidence) to reduce delayed graft function 1.

Common Pitfalls to Avoid

1. Don't use dextrose water routinely intraoperatively - it causes unnecessary hyperglycemia without preventing hypoglycemia 3
2. Don't assume small volumes don't matter - even 500 mL of dextrose saline causes significant glucose elevation 3
3. Don't use large volumes of 0.9% saline - the risk of hyperchloremic acidosis and AKI increases with volume 1
4. Don't forget to monitor - if forced to use saline in large volumes, monitor chloride levels and acid-base status 1