IV Fluid Selection for Hospital Admission
For most hospitalized patients requiring IV fluids, use isotonic balanced crystalloid solutions (such as Ringer's Lactate or Plasmalyte) without dextrose as your first-line choice, as they reduce the risk of kidney injury and mortality compared to normal saline, while avoiding unnecessary hyperglycemia. 1
Primary Fluid Choice: Balanced Crystalloids
Balanced crystalloid solutions (Ringer's Lactate or Plasmalyte) are preferred over 0.9% normal saline because they reduce major adverse kidney events and maintain better acid-base balance, particularly when larger volumes (>5000 mL) are administered. 1
The SMART study of 15,802 ICU patients demonstrated reduced incidence of major adverse kidney events (MAKE 30: death, two-fold increase in serum creatinine, or renal replacement therapy within 30 days) with balanced solutions compared to normal saline. 1
High-volume chloride-rich solutions (>5000 mL) are associated with increased mortality and postoperative hyperchloremia in critically ill patients. 1
Balanced solutions consistently provide better acid-base balance than normal saline across all patient populations. 1
When to Add Dextrose (D5)
Most adult patients do NOT require dextrose-containing fluids initially. The decision to add dextrose depends on specific clinical scenarios:
DO NOT use dextrose-containing fluids for:
Routine volume resuscitation or maintenance in adults - A study of 50 non-diabetic surgical patients showed that 500 mL of D5 normal saline caused significant hyperglycemia (plasma glucose 11.1 mmol/L) in 72% of patients, while those receiving non-dextrose crystalloids remained normoglycemic despite fasting times of 13 hours. 2
Initial fluid resuscitation in most hospitalized adults - Dextrose is unnecessary to prevent hypoglycemia in fasting adults and causes transient but significant hyperglycemia even in non-diabetic patients. 2
DO use dextrose-containing fluids for:
Pediatric patients (28 days to 18 years) requiring maintenance IV fluids should receive isotonic solutions with appropriate potassium chloride AND dextrose (2.5%-5%) to prevent hypoglycemia. 1
Diabetic ketoacidosis (DKA) - Switch to D5 with 0.45-0.75% saline when serum glucose reaches 250 mg/dL to prevent hypoglycemia while continuing insulin therapy. 3
Infants at risk for hypoglycemia - Use D10 normal saline to meet glucose requirements of 4-6 mg/kg/min in infants dependent on IV fluids. 3
Hypernatremic dehydration - Use 5% dextrose alone (without sodium) for gradual correction to prevent worsening hypernatremia. 3
Medication diluent - D5 solutions serve as vehicles for specific medications like vasopressors, ranitidine, or quinine, though glucose content must be considered in diabetic patients. 4, 5
Practical Algorithm for Fluid Selection
Step 1: Determine if dextrose is needed
- Adult, non-diabetic, routine admission? → No dextrose needed 2
- Pediatric patient (28 days-18 years)? → Yes, add dextrose 2.5-5% 1
- DKA with glucose <250 mg/dL? → Yes, switch to D5 3
- Infant at hypoglycemia risk? → Yes, use D10 3
- Hypernatremia? → Yes, use D5 alone (no sodium) 3
Step 2: Choose base crystalloid solution
- First-line: Balanced crystalloid (Ringer's Lactate or Plasmalyte) 1
- Avoid: Normal saline as routine first-line (use only when balanced solutions unavailable) 1
- Never use: Hypertonic saline (3% or 7.5%) for routine resuscitation 1
Step 3: Avoid colloids in most situations
- Do not use hydroxyethyl starch solutions - they increase renal failure risk and hemorrhagic complications. 1
- Do not routinely use albumin for volume resuscitation - no mortality benefit and significantly more expensive than crystalloids. 1
Critical Monitoring Considerations
When dextrose-containing fluids ARE used:
Monitor serum glucose hourly during acute resuscitation, then every 2-4 hours once stable to prevent both hyperglycemia and hypoglycemia. 3
Be aware that 50% dextrose is hypertonic and may cause phlebitis, thrombosis, hyperosmolar syndrome, and fluid overload - it should only be used via central venous access after suitable dilution. 6
In pediatric patients, monitor for cerebral edema during osmolality correction, particularly in those under 20 years. 3
Common Pitfalls to Avoid
Do not assume fasting adults need dextrose - even after 13 hours of fasting, non-diabetic adults remain normoglycemic without dextrose supplementation. 2
Do not use normal saline as default - the outdated practice of routine normal saline administration increases hyperchloremic metabolic acidosis and kidney injury risk. 1, 7
Do not give large volumes of any single fluid without reassessment - both inadequate and excessive fluid administration lead to poor outcomes including increased infection risk and organ dysfunction. 8
Do not use colloids for routine resuscitation - they offer no mortality benefit over crystalloids and carry additional risks of renal impairment and coagulopathy. 1, 8