What are the guidelines for intravenous (IV) fluid administration in adults?

From the Guidelines

Adult IV fluid guidelines typically recommend starting with isotonic crystalloids like 0.9% normal saline or lactated Ringer's solution at a maintenance rate of 30-35 mL/kg/day for most patients, with boluses of 500-1000 mL of crystalloid administered over 15-30 minutes for acute resuscitation in hypovolemic patients, as recommended by the most recent guidelines 1.

Key Considerations

• For acute resuscitation in hypovolemic patients, the goal is to restore blood volume and improve microvascular blood flow, with crystalloid solutions being the first choice due to their tolerability and cost-effectiveness 1.
• Maintenance fluids can be calculated using the 4-2-1 rule, adjusting for the patient's weight, with electrolyte content adjusted based on serum levels, particularly sodium, potassium, and glucose 1.
• Patients with heart failure, kidney disease, or liver disease require careful fluid management to prevent fluid overload, with regular monitoring of vital signs, urine output, electrolytes, and fluid balance being essential 1.

Clinical Scenarios

• In patients with sepsis, early identification and prompt administration of intravenous fluids are crucial, with the goal of restoring mean arterial pressure to 65 mmHg, as advocated by the Surviving Sepsis Campaign 1.
• In patients with abdominal sepsis, overly aggressive fluid resuscitation may increase intra-abdominal pressure and worsen the inflammatory response, highlighting the need for careful fluid management and monitoring of clinical endpoints such as mean arterial pressure, skin color, and capillary refill 1.

Choice of Fluids

• Crystalloids are generally recommended for most routine cases, with colloids being considered in specific clinical situations, such as significant blood loss or hypoalbuminemia 1.
• The choice of fluid should be guided by the patient's underlying condition, with consideration of factors such as electrolyte balance, fluid overload risk, and the need for volume expansion 1.

From the Research

Guidelines for IV Fluid Administration

• The European Society of Intensive Care Medicine provides conditional recommendations for using crystalloids rather than albumin in critically ill patients in general, in patients with sepsis, in patients with acute respiratory failure, and in patients in the perioperative period and patients at risk for bleeding 2.
• The guideline also provides conditional recommendations for using balanced crystalloids rather than isotonic saline in critically ill patients in general, in patients with sepsis, and in patients with kidney injury 2.
• The use of balanced crystalloids, such as lactated Ringer's solution or Plasma-Lyte A, may improve outcomes for patients with sepsis compared to saline (0.9% sodium chloride) 3.
• Balanced crystalloid solutions have a sodium, potassium, and chloride content closer to that of extracellular fluid and have fewer adverse effects on acid-base balance compared to saline 4.

Fluid Choice

• The choice of fluid depends on the patient's condition, with crystalloids being recommended for volume expansion in most cases 2.
• Albumin is conditionally recommended for use in patients with cirrhosis, while isotonic saline is conditionally recommended for use in patients with traumatic brain injury 2.
• Balanced crystalloids are preferred in some patient populations, such as those with sepsis or kidney injury 2, 3.

Administration Considerations

• The management of intravenous fluids is challenging due to the dynamic fluid requirements of critically ill patients 5.
• Nurses play a vital role in monitoring the safety and efficacy of intravenous fluid therapy and in selecting the optimal patient-specific selection and dose of fluid for administration 5.
• The use of intravenous fluids can have significant effects on human physiology, and the properties of various intravenous fluids must be understood to provide optimal care 5, 6.