Should intravenous (IV) fluids be given to a stroke patient who is nil per os (NPO)?

From the Guidelines

Intravenous (IV) fluids should be administered to stroke patients who are nil by mouth (NPO) to maintain euvolemia and prevent dehydration, which can worsen neurological outcomes. The recommended approach is to provide isotonic crystalloid solutions such as 0.9% normal saline at maintenance rates (typically 30 mL per kilogram of body weight) adjusted based on the patient's weight, age, and clinical condition, as suggested by 1. Hydration status should be monitored through regular assessment of vital signs, urine output, skin turgor, and laboratory values including electrolytes and renal function. IV fluids help prevent dehydration which could worsen neurological outcomes by compromising cerebral perfusion and increasing blood viscosity. They also provide a route for medication administration. However, fluid management must be carefully balanced to avoid overhydration, which could worsen cerebral edema, as noted in 1. Some key points to consider when administering IV fluids to stroke patients include:

• Maintaining euvolemia is desirable, as hypovolemia may predispose to hypoperfusion and exacerbate the ischemic brain injury, while hypervolemia may exacerbate ischemic brain edema and increase stress on the myocardium, as stated in 1.
• Isotonic solutions such as 0.9% saline are more evenly distributed into the extracellular spaces (interstitial and intravascular) and may be better for patients with acute ischemic stroke, as suggested by 1.
• The duration of IV fluid therapy should continue until the patient can safely resume oral intake or until alternative feeding methods such as nasogastric or percutaneous endoscopic gastrostomy (PEG) feeding are established, typically within 24-48 hours of admission if prolonged dysphagia is anticipated. Additionally, it is essential to consider the patient's blood pressure, as hypertension is present in the majority of patients with stroke, and blood pressure should be kept < 185/110 mmHg in patients with acute ischaemic stroke who are candidates for, or who have received, intravenous thrombolysis, as recommended by 1.

From the Research

Administration of IV Fluids to Stroke Patients

• The decision to administer IV fluids to a stroke patient who is nil by mouth (NBM) depends on various factors, including the patient's hydration status, cerebral edema, and risk of respiratory infections 2, 3.
• Studies have shown that dehydration can worsen outcomes in stroke patients, and rehydration therapies may be beneficial 2.
• However, the use of IV fluids, particularly hypertonic saline, requires careful consideration of the patient's serum sodium and chloride concentrations to avoid adverse events 4.
• In patients with acute ischemic stroke, a bolus of normal saline can increase cerebral blood flow, but the clinical significance of this effect is unclear 5.

Risks and Benefits of IV Fluids in NBM Stroke Patients

• NBM tube-fed stroke patients are at higher risk of developing respiratory infections, which can be mitigated with stringent oral care and measures to prevent reflux 3.
• The use of IV fluids in NBM stroke patients may help to maintain hydration and prevent dehydration, but it is essential to weigh the potential benefits against the risks of respiratory infections and other complications.
• The absence of a gag reflex and severe neurologic deficits on admission can predict prolonged dysphagia and poor outcomes in acute stroke patients, highlighting the need for careful assessment and management of these patients 6.

Considerations for IV Fluid Administration

• The choice of IV fluid, dosage, and administration method should be individualized based on the patient's specific needs and medical condition 4, 5.
• Close monitoring of the patient's vital signs, serum electrolytes, and cerebral edema is crucial to minimize the risks associated with IV fluid administration 4, 2.
• Further research is needed to determine the optimal IV fluid management strategy for NBM stroke patients, taking into account the complexities of cerebral edema, dehydration, and respiratory infections 2, 3.