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Intravenous fluid therapy in adults in hospital overview

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Intravenous fluid therapy in adults in hospital HAI

About

What is covered

Many adult hospital inpatients need IV fluid therapy to prevent or correct problems with their fluid and/or electrolyte status. Deciding on the optimal amount and composition of IV fluids to be administered and the best rate at which to give them can be a difficult and complex task, and decisions must be based on careful assessment of the patient's individual needs.
Errors in prescribing IV fluids and electrolytes are particularly likely in emergency departments, acute admission units, and general medical and surgical wards. Surveys have shown that many staff who prescribe IV fluids know neither the likely fluid and electrolyte needs of individual patients, nor the specific composition of the many choices of IV fluids available to them. Standards of recording and monitoring IV fluid and electrolyte therapy may also be poor in these settings. IV fluid management in hospital is often delegated to the most junior medical staff who frequently lack the relevant experience and may have received little or no specific training on the subject.
There is a clear need for guidance on IV fluid therapy for general areas of hospital practice, covering both the prescription and monitoring of IV fluid and electrolyte therapy, and the training and educational needs of all hospital staff involved in IV fluid management.
The aim is to help prescribers understand the:
  • physiological principles that underpin fluid prescribing
  • pathophysiological changes that affect fluid balance in disease states
  • indications for IV fluid therapy
  • reasons for the choice of the various fluids available and
  • principles of assessing fluid balance.
It is hoped that the pathway will lead to better fluid prescribing in hospitalised patients, reduce morbidity and mortality, and lead to better patient outcomes.
The pathway contains recommendations about general principles for managing IV fluids, and applies to a range of conditions and different settings. It does not include recommendations relating to specific conditions.

Updates

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on intravenous fluid therapy for adults in hospital.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

27 January 2014 Minor maintenance updates

Short Text

Intravenous fluid therapy in adults in hospital

What is covered

Many adult hospital inpatients need IV fluid therapy to prevent or correct problems with their fluid and/or electrolyte status. Deciding on the optimal amount and composition of IV fluids to be administered and the best rate at which to give them can be a difficult and complex task, and decisions must be based on careful assessment of the patient's individual needs.
Errors in prescribing IV fluids and electrolytes are particularly likely in emergency departments, acute admission units, and general medical and surgical wards. Surveys have shown that many staff who prescribe IV fluids know neither the likely fluid and electrolyte needs of individual patients, nor the specific composition of the many choices of IV fluids available to them. Standards of recording and monitoring IV fluid and electrolyte therapy may also be poor in these settings. IV fluid management in hospital is often delegated to the most junior medical staff who frequently lack the relevant experience and may have received little or no specific training on the subject.
There is a clear need for guidance on IV fluid therapy for general areas of hospital practice, covering both the prescription and monitoring of IV fluid and electrolyte therapy, and the training and educational needs of all hospital staff involved in IV fluid management.
The aim is to help prescribers understand the:
  • physiological principles that underpin fluid prescribing
  • pathophysiological changes that affect fluid balance in disease states
  • indications for IV fluid therapy
  • reasons for the choice of the various fluids available and
  • principles of assessing fluid balance.
It is hoped that the pathway will lead to better fluid prescribing in hospitalised patients, reduce morbidity and mortality, and lead to better patient outcomes.
The pathway contains recommendations about general principles for managing IV fluids, and applies to a range of conditions and different settings. It does not include recommendations relating to specific conditions.

Sources

The NICE guidance that was used to create the pathway.
Intravenous fluid therapy in adults in hospital. NICE clinical guideline 174 (2013)

Quality standards

Quality statements

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Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on intravenous fluid therapy for adults in hospital.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

27 January 2014 Minor maintenance updates

Supporting information

Consequences of fluid mismanagement to be reported as critical incidents

Consequence of fluid mismanagement
Identifying features
Time frame of identification
Hypovolaemia
Patient's fluid needs not met by oral, enteral or IV intake and
Before and during IV fluid therapy
* Features of dehydration on clinical examination
* Low urine output or concentrated urine
* Biochemical indicators, such as more than 50% increase in urea or creatinine with no other identifiable cause
Pulmonary oedema (breathlessness during infusion)
No other obvious cause identified (for example, pneumonia, pulmonary embolus or asthma)
During IV fluid therapy or within 6 hours of stopping IV fluids
Features of pulmonary oedema on clinical examination
Features of pulmonary oedema on X-ray
Hyponatraemia
Serum sodium less than 130 mmol/l
During IV fluid therapy or within 24 hours of stopping IV fluids
No other likely cause of hyponatraemia identified
Hypernatraemia
Serum sodium 155 mmol/l or more
During IV fluid therapy or within 24 hours of stopping IV fluids
Baseline sodium normal or low
IV fluid regimen included 0.9% sodium chloride
No other likely cause of hypernatraemia identified
Peripheral oedema
Pitting oedema in extremities and/or lumbar sacral area
During IV fluid therapy or within 24 hours of stopping IV fluids
No other obvious cause identified (for example, nephrotic syndrome or known cardiac failure)
Hyperkalaemia
Serum potassium more than 5.5 mmol/l
During IV fluid therapy or within 24 hours of stopping IV fluids
No other obvious cause identified
Hypokalaemia
Serum potassium less than 3.0 mmol/l likely to be due to infusion of fluids without adequate potassium provision
During IV fluid therapy or within 24 hours of stopping IV fluids
No other obvious cause (for example, potassium-wasting diuretics, refeeding syndrome)

IV fluid prescription (by body weight) for routine maintenance over a 24-hour period

Body weight
Water
Sodium, chloride, potassium
Body weight
Water
Sodium, chloride, potassium
kg
25–30 ml/kg/day
approx. 1 mmol/kg/day of each
kg
25–30ml/kg/day
approx. 1 mmol/kg/day of each
40
1000–1200
40
71
1775–2130
71
41
1025–1230
41
72
1800–2160
72
42
1050–1260
42
73
1825–2190
73
43
1075–1290
43
74
1850–2220
74
44
1100–1320
44
75
1875–2250
75
45
1125–1350
45
76
1900–2280
76
46
1150–1380
46
77
1925–2310
77
47
1175–1410
47
78
1950–2340
78
48
1200–1440
48
79
1975–2370
79
49
1225–1470
49
80
2000–2400
80
50
1250–1500
50
81
2025–2430
81
51
1275–1530
51
82
2050–2460
82
52
1300–1560
52
83
2075–2490
83
53
1325–1590
53
84
2100–2520
84
54
1350–1620
54
85
2125–2550
85
55
1375–1650
55
86
2150–2580
86
56
1400–1680
56
87
2175–2610
87
57
1425–1710
57
88
2200–2640
88
58
1450–1740
58
89
2225–2670
89
59
1475–1770
59
90
2250–2700
90
60
1500–1800
60
91
2275–2730
91
61
1525–1830
61
92
2300–2760
92
62
1550–1860
62
93
2325–2790
93
63
1575–1890
63
94
2350–2820
94
64
1600–1920
64
95
2375–2850
95
65
1625–1950
65
96
2400–2880
96
66
1650–1980
66
97
2425–2910
97
67
1675–2010
67
98
2450–2940
98
68
1700–2040
68
99
2475–2970
99
69
1725–2070
69
100
2500–3000
100
70
1750–2100
70
>100
2500–3000
100
Add 50–100 grams/day glucose (e.g. glucose 5% contains 5 g/100 ml).
For special considerations refer to the recommendations for routine maintenance.

Glossary

Airway, Breathing, Circulation, Disability, Exposure
body mass index
intravenous
National Early Warning Score
Passive leg raising is a bedside method to assess fluid responsiveness in a patient. It is best undertaken with the patient initially semi-recumbent and then tilting the entire bed through 45°. Alternatively it can be done by lying the patient flat and passively raising their legs to greater than 45°. If, at 30–90 seconds, the patient shows signs of haemodynamic improvement, it indicates that volume replacement may be required. If the condition of the patient deteriorates, in particular breathlessness, it indicates that the patient may be fluid overloaded.
A healthcare professional who has core competencies to diagnose and manage acute illness. These competencies can be delivered by a variety of models at a local level, such as a critical care outreach team, a hospital-at-night team or a specialist trainee in an acute medical or surgical specialty.

Paths in this pathway

Pathway created: December 2013 Last updated: January 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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