What is the most appropriate intravenous fluid to administer to a patient fasting in preparation for stoma closure?

Most Appropriate Intravenous Fluid for Patients Fasting Before Stoma Closure

Balanced crystalloid solutions such as Ringer's lactate are the most appropriate intravenous fluids to administer to patients fasting in preparation for stoma closure. 1

Rationale for Using Ringer's Lactate

Ringer's lactate (also called lactated Ringer's solution) is preferred for the following reasons:

• In the early post-operative phase after bowel surgery, the main goal is to assure hemodynamic stability by providing water and electrolytes through balanced electrolyte solutions such as Ringer's lactate 1
• ESPEN guidelines specifically recommend "intravenous normal saline or a balanced electrolyte solution such as Hartman or Ringer solution, 1–4 l/day, depending upon intestinal losses" 1
• Balanced crystalloid solutions help avoid the hyperchloremic metabolic acidosis that can occur with normal saline, especially when used in larger volumes

Fluid Management Algorithm for Fasting Stoma Closure Patients

1. Initial Assessment:

   • Evaluate hydration status
   • Check baseline electrolytes, particularly sodium, potassium, and magnesium
   • Assess urine output (aim for at least 800-1000 ml/day)

2. Fluid Selection:

   • First choice: Ringer's lactate solution
   • Alternative: Balanced electrolyte solutions like Hartmann's solution
   • Avoid: Excessive use of normal saline (0.9% NaCl) due to risk of hyperchloremic metabolic acidosis

3. Dosing Guidelines:

   • Administer 1-4 L/day depending on stomal/stool losses 1
   • Adjust rate based on hemodynamic parameters and urine output
   • Target urine sodium concentration >20 mmol/L 1

4. Monitoring:

   • Maintain good hydration status with urine volume ≥800-1000 ml/day
   • Monitor serum electrolytes, particularly sodium, potassium, and magnesium
   • Watch for signs of fluid overload (edema, respiratory distress)

Special Considerations

Electrolyte Management

• Pay special attention to sodium, potassium, and magnesium balance 1
• Hypokalemia is often secondary to sodium depletion with secondary hyperaldosteronism
• Magnesium deficiency can cause dysfunction of potassium transport systems and increase renal potassium excretion

Common Pitfalls to Avoid

1. Excessive fluid administration: Can cause edema due to high circulating aldosterone levels in these patients
2. Inadequate monitoring: Failure to track urine output and electrolytes can lead to missed dehydration or electrolyte imbalances
3. Using dextrose-containing solutions: Not routinely required for elective surgical patients and may cause transient hyperglycemia even in non-diabetic patients
4. Relying solely on normal saline: May lead to hyperchloremic metabolic acidosis with prolonged use

Resuming Oral Intake

After stoma closure, when oral intake is resumed:

• Restrict oral hypotonic fluids (tea, coffee, juices) which cause sodium loss from the gut 1
• Consider oral glucose-saline replacement solutions with sodium concentration ≥90 mmol/L for patients with high stoma outputs 1

Ringer's lactate has been shown to be safe and effective for perioperative fluid management, with research showing no significant increase in circulating lactate concentrations when administered at standard rates 2.