What IV fluids are recommended for a patient with ascites and potential underlying liver disease?

IV Fluid Selection in Patients with Ascites

In patients with ascites from cirrhosis, avoid normal saline for routine volume expansion—use albumin (20% or 25% solution) as the preferred colloid, and reserve crystalloids like Lactated Ringer's for specific situations where albumin is not indicated. 1

Primary Recommendation: Albumin Over Crystalloids

• Albumin (20% or 25% solution) is the fluid of choice for volume expansion in cirrhotic patients with ascites, particularly after large-volume paracentesis (>5 liters) at 8 g per liter removed 1, 2
• Normal saline should be avoided as routine IV fluid in these patients because it worsens salt retention and can exacerbate ascites 1
• The 2021 British Society of Gastroenterology guidelines explicitly recommend against normal saline in ascites management 1

When Albumin is Mandatory

• Post-paracentesis >5 liters: Albumin 8 g/L of ascites removed (e.g., 100 mL of 20% albumin per 3 liters) prevents post-paracentesis circulatory dysfunction, which reduces mortality by 36% 2, 3
• Spontaneous bacterial peritonitis (SBP): 1.5 g/kg albumin within 6 hours of diagnosis, followed by 1 g/kg on day 3, which reduces hepatorenal syndrome and mortality 1, 3
• Severe hyponatremia with renal dysfunction (Na <125 mmol/L with creatinine >150 μmol/L or rising): Volume expansion with albumin or colloids (gelofusine, haemaccel) is preferred over crystalloids 1

Limited Role for Crystalloid Solutions

• Lactated Ringer's or balanced crystalloids may be considered only in specific scenarios: acute hypovolemia without significant ascites, or when albumin is unavailable 4
• Avoid Lactated Ringer's in patients with severe metabolic alkalosis, lactic acidosis with decreased lactate clearance, severe hyperkalemia, or traumatic brain injury 4
• If crystalloids must be used for volume expansion in hyponatremia with renal impairment, normal saline (154 mmol/L sodium) or colloids containing equivalent sodium are acceptable despite worsening salt retention—the priority is preventing irreversible renal failure over managing ascites 1

Hyponatremia Management Algorithm

• Serum sodium 126-135 mmol/L: Continue diuretics, no water restriction, no IV fluids needed 1
• Serum sodium 121-125 mmol/L with normal creatinine: Stop or reduce diuretics cautiously, observe closely 1
• Serum sodium 121-125 mmol/L with elevated creatinine (>150 μmol/L or rising): Stop diuretics immediately and give volume expansion with albumin or colloid 1
• **Serum sodium <120 mmol/L**: Stop diuretics and provide volume expansion with albumin/colloid, but avoid increasing sodium by >12 mmol/L per 24 hours to prevent central pontine myelinolysis 1
• Severe symptomatic acute hyponatremia: Hypertonic saline (3%) may be used, but only for acute symptomatic cases with slow correction 1

Critical Pitfalls to Avoid

• Do not routinely restrict fluids unless severe hyponatremia (<125 mmol/L) with clinical hypervolemia exists—fluid restriction can worsen effective hypovolemia and increase ADH secretion 1
• Do not use normal saline for routine volume expansion in cirrhotic ascites—it contains 154 mmol/L sodium and will worsen fluid overload 1
• Do not use synthetic colloids (hydroxyethyl starch, dextran-70, polygeline) as they are inferior to albumin and cause higher rates of post-paracentesis circulatory dysfunction (34-38% vs 18.5%) 3
• Do not give albumin during paracentesis—infuse it after the procedure is completed 2, 3

Practical Approach for Common Scenarios

• Tense ascites requiring paracentesis: Drain completely in one session, then give albumin 8 g/L if >5 liters removed 2
• Refractory ascites: Discontinue diuretics, perform serial large-volume paracentesis with albumin, avoid IV crystalloids 5
• Hypovolemic shock during/after paracentesis: Use albumin 25% (hyperoncotic) which expands plasma volume 3-4 times the infused volume 6
• Routine maintenance fluids: Avoid IV fluids entirely—focus on sodium restriction (<5 g/day) and oral intake 3