What is the recommended approach for ordering intravenous (IV) fluids?

How to Order Intravenous Fluids

Use balanced crystalloid solutions (Ringer's Lactate or Plasmalyte) as your default first-line IV fluid for nearly all hospitalized patients requiring fluid therapy, as they reduce major adverse kidney events and mortality compared to normal saline. 1

Fluid Selection by Clinical Scenario

Standard Resuscitation and Most Clinical Situations

• Order balanced crystalloids (Ringer's Lactate or Plasmalyte) as first-line therapy for the majority of patients requiring IV fluids, including those in the ICU, perioperative settings, and general medical wards 1, 2
• These solutions have electrolyte compositions closer to plasma and consistently demonstrate superior outcomes compared to normal saline 1
• Balanced crystalloids maintain better acid-base balance and reduce the risk of hyperchloremic metabolic acidosis that occurs with large volumes of normal saline 3, 4

Hemorrhagic Shock

• Use balanced crystalloids as first-line fluid therapy rather than 0.9% NaCl to reduce mortality and adverse renal events 3
• Do NOT use colloid solutions (hydroxyethyl starches, gelatins, or albumin) as they provide no mortality benefit and increase risks of renal failure and coagulopathy 3
• Avoid albumin specifically—it offers no benefit over crystalloids and is significantly more expensive 3, 1
• The potentially deleterious effects on renal function and survival of high-volume chloride-rich solutions (>5000 mL) should orient treatment choices toward balanced solutions 3

Sepsis-Induced Hypoperfusion

• Administer at least 30 mL/kg of balanced crystalloid within the first 3 hours of recognition 1, 2
• Target mean arterial pressure of 65 mmHg in patients requiring vasopressors 1, 2
• Normalize lactate levels as a resuscitation goal when elevated 1, 2

Acute Brain Injury (Important Exception)

• Use isotonic crystalloids such as 0.9% NaCl, Plasmalyte, or Isofundine as first-line fluid therapy 1
• Avoid hypotonic solutions, including Ringer's Lactate, due to increased mortality in this specific population 1
• Consider hypertonic saline bolus only in traumatic brain injury with focal neurological signs due to its osmotic effect 3, 2

Perioperative Fluid Management

• Use balanced crystalloids as the primary intraoperative fluid, particularly in patients with end-stage renal disease or those undergoing major surgery 1
• Target mildly positive fluid balance (+1-2 L) by end of surgery in ESRD patients to protect remaining kidney function 1

Dosing Strategy

Initial Bolus Administration

• Administer 250-1000 mL rapid boluses for adults, reassessing hemodynamic response after each bolus 5
• Continue fluid boluses based on hemodynamic response rather than a fixed total volume 5
• For the typical 70 kg patient, doses of more than 1500 mL per day (approximately 20 mL/kg) are usually not required, though higher doses may be necessary in postoperative and trauma patients with severe blood loss 6

Monitoring and Reassessment

• Use dynamic variables (pulse pressure variation, stroke volume variation) rather than static variables (central venous pressure) to predict fluid responsiveness 1, 2
• Reassess frequently using heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, and urine output 1, 2
• Monitor for myoglobinuria in patients with muscle injury or rhabdomyolysis, which may require aggressive volume expansion 5

Fluids to Absolutely Avoid

Never Use These Solutions

• Hydroxyethyl starches: Significantly increase risks of renal failure, coagulopathy, and hemorrhage without mortality benefit 3, 5
• Hypertonic saline solutions (3% or 7.5%): Provide no mortality benefit as first-line treatment 3, 5
• Albumin for routine resuscitation: No mortality benefit and not cost-effective 3, 1, 5

Critical Pitfalls to Avoid

Fluid Overload

• Stop or reduce fluid administration when signs of adequate tissue perfusion return or when pulmonary edema develops 2, 5
• Both inadequate and excessive IV fluid administration lead to poor outcomes, including increased infection risk and organ dysfunction 1, 7
• Use goal-directed therapy with frequent hemodynamic reassessment to prevent fluid overload 1, 2

Monitoring Errors

• Do not rely solely on central venous pressure for guiding fluid therapy, as it poorly predicts fluid responsiveness 2, 5
• Do not wait for hemodynamic worsening before initiating fluid resuscitation 2

High-Volume Chloride Administration

• When large volumes (>5000 mL) are anticipated, balanced crystalloids are particularly important to avoid hyperchloremic metabolic acidosis and associated renal dysfunction 3
• Observational studies show increased mortality in patients with postoperative hyperchloremia following high-volume chloride-rich solution administration 3

Vasopressor Integration

• Start norepinephrine if hypotension persists despite adequate fluid resuscitation, targeting mean arterial pressure ≥65 mmHg 5
• Norepinephrine is the first-choice vasopressor; add epinephrine if an additional agent is needed 5