NHS

GUIDANCE FOR INTRAVENOUS

FLUID AND ELECTROLYTE
PRESCRIPTION IN ADULTS
Fluid prescriptions are very important. Prescribing
the wrong type or amount of fluid can do serious
harm. Assessment of fluid requirements needs care
and attention, with adjustment for the individual
patient. This is as important as safe drug
prescribing.
This document guides fluid and electrolyte
management in medical and surgical
ADULT patients.
Exclusions: Children: consult paediatrician or
paediatric resuscitation guidelines.
Diabetic patients: use diabetic fluid protocol for
maintenance.
Pregnant women: consult obstetrician.
Head injury patients: avoid fluids containing
dextrose.
Renal failure patients: consult senior doctor.
Produced by the Fluid Prescription Working Group.
2nd edition November 2012.
www.scottishintensivecare.org.uk/nutrition/guidelines.htm

Basic physiology of sick patients it is very easy to give

patients salt and water but very difficult to remove them.
Serum sodium may fall due to excess water load. Even
healthy patients take >12 hours to excrete the sodium load of
2 litres of 0.9%NaCl with a gain in weight of 1kg after 6 hours.
In sick patients with leaky capillaries this fluid
retention is worse and contributes to complications such
as ileus, nausea and vomiting, pressure sores, poor
mobility, pulmonary oedema, wound and anastomotic
breakdown.
Urine output naturally decreases after a traumatic insult
such as surgery due to increased sodium retention by the
kidney. High sodium-containing fluid regimens exacerbate the
problem.
Cellular dysfunction and potassium loss
result. Excess chloride leads to renal vasoconstriction
and increased sodium retention, worsening oedema.
Urine output is a poor guide to fluid requirements in
sick patients.
It is vital that sick patients receive THE RIGHT AMOUNT
OF THE RIGHT FLUID AT THE RIGHT TIME.
Maintenance fluid requirement: approx 30ml/kg/24hrs
of water.
Questions to ask before prescribing fluid:
1. Is my patient euvolaemic, hypovolaemic or
hypervolaemic?
2. Does my patient need IV fluid? Why?
3. How much?
4. What type(s) of fluid does my patient need?

1. Assess the patient

Euvolaemic: veins are well filled, extremities are warm,
blood pressure and heart rate are normal (depending on
other pathology).
Hypovolaemic:The patient may have cold hands and feet,
absent veins, hypotension, tachycardia, oliguria and confusion. History of fluid loss or low intake.
Hypervolaemic: Patient is oedematous, may have inspiratory crackles; history of poor urine output or fluid overload.
2. Does my patient need IV fluid?
NO: he may be drinking adequately, may be receiving
adequate fluid via NG feed or TPN, or may be receiving
large volumes with drugs or drug infusions (or a
combination of these). ALLOW PATIENTS TO DRINK IF
AT ALL POSSIBLE.
Hypervolaemic: may need fluid restriction or gentle
diuresis.
YES: not drinking, has lost, or is losing fluid
So WHY does the patient need fluid?
Maintenance fluid only patient does not have excess
losses above insensible loss. If no other intake he needs
approximately 30ml/kg/24hrs. He may only need part of
this if receiving other fluid. Patients having to fast for over
8-12 hours should be started on IV maintenance fluid.
Replacement of losses, either previous or current. If
losses are predicted it is best to replace these later rather
than give extra fluid in anticipation of losses which may not
occur. This fluid is in addition to maintenance fluid. Check
blood gases.
Resuscitation: The patient is hypovolaemic as a result of
dehydration, blood loss or sepsis and requires urgent
correction of intravascular depletion to correct the deficit

3. How much fluid does my patient need?

a. Obtain weight (estimate if required). Maintenance fluid
requirement approximately 30ml/kg/24hours. (Table 1).
b. Review recent U&Es, other electrolytes and Hb.
c. Recent events e.g. fasting, intake, losses, sepsis,
operations, fluid overload. Check fluid balance charts.
Calculate how much loss has to be replaced and work
out which type of fluid has been lost: e.g. GI secretions,
blood, inflammatory losses.
Note urine does not need to be replaced unless excessive
(diabetes insipidus, recovering renal failure). Post-op: high
urine output may be due to excess fluid;
low urine output is common and may be normal due to antidiuretic hormone release.
Assess fully before giving extra fluid.
4. What type of fluid does my patient need?
MAINTENANCE FLUID
IV fluid should be given via volumetric pump if a patient is
on fluids for over 6 hours or if the fluid contains
potassium. Always prescribe as ml/hr not x hourly
bags.
Never give maintenance fluids at more than 100ml/hour.
Weight kg
35-44
45-54
55-64
65-74
75
Table 1

Fluid Requirement in mls/day Rate in ml/hour

1200
50
1500
65
1800
75
2100
85
2400
100 (max)

Preferred maintenance fluids: 0.18%saline/4%dextrose

with or without added potassium (KCl 10/ 20 mmol) in
500ml. 1 litre bags are available. This fluid if given at
the correct rate (Table 1) provides all water and Na +
/K+ requirements until the patient can eat and drink or be
fed. Excess volumes of this fluid (or any) fluid may cause
hyponatraemia.
Alternatively 5% dextrose 500ml and 0.9% NaCl 500ml
may be used in a ratio of 2 bags of 5% dextrose to 1 bag
of 0.9% NaCl. Prescribe each bag with added potassium
(KCl 20mmol) if patient has normal or low potassium.
Patients with renal failure: Consult a senior doctor for
fluid advice. If the serum potassium is above 5mmol/l or
rising quickly do not give potassium containing fluids.
Electrolyte requirements
Sodium 1 mmol/kg/24hrs (approx. 1x500ml 0.9%NaCl)
Potassium 1 mmol/kg/24hrs (give KCl 20mmol in each
bag)
Calories: minimum of 400kcal/24hrs to help with
electrolyte handling and to help avoid insulin resistance.
Magnesium, calcium and phosphate may fall in sick
patients monitor and replace as required.
REPLACEMENT FLUID
Fluid losses may be due to diarrhoea, vomiting, fistulae,
drain output, bile leaks, high stoma output, ileus, blood
loss or excessive sweating. Inflammatory losses in the
tissues are hard to quantify and are common in pancreatitis, sepsis, burns and abdominal emergencies.
It is vital to replace high gastro-intestinal (GI) losses.
Patients may otherwise develop severe metabolic
derangement with acidosis or alkalosis and hypokalaemia. Hypochloraemia occurs with upper GI losses.

Urinary and insensible losses are covered by the maintenance

part of the prescription. In the recovery phase patients start to
pass more urine as they mobilise excess fluid.
Hyponatraemia is common: in the absence of large GI losses
causes are too much fluid, SIADH or chronic diuretic use.
Potassium replacement:
A potassium level in the normal range does not mean that there is
no total body potassium deficit. 20 mmol may be given in 500ml
0.9%NaCl at 125ml/hr. In critical care only give up to 40mmol in
100ml bags via a central line at 25ml/hr. Ensure IV cannulae work.
Potassium-containing fluids must be given via a pump. Give KayCee-L or Sando-K orally.
Estimate replacement fluid/electrolyte requirements (see table
below) by adding up all the losses over the previous 24 hours
and give this volume as Hartmanns solution or PlasmaLyte 148
(PL148). Use 0.9% NaCl with KCl for upper GI or bile loss.
Otherwise avoid it as it causes fluid retention.

Content Na+
K+
mmol/l mmol/l
Fluid
Gastric
50
15
content

Normal
Cl Bic
mmol/l mmol/l volume/
24hr
2-3
140
0-15
litres
0.5-1
100
38
litre

145

Small
bowel
content

140

11

70-130 var

Ileostomy

50

25

Colostomy

60

15

40

Diarrhoea

30- 30-70
140

20-80

Bile

Table 2

var
0.5 litre
0.1-0.2
litre
Abnrml

RESUSCITATION FLUID
For severe dehydration, sepsis or haemorrhage leading to
hypovolaemia and hypotension. For urgent resuscitation
use Hartmanns, PlasmaLyte 148 or colloid (gelatin/
albumin). Hartmanns and PL148 are balanced
electrolyte solutions and are better handled by the body
than 0.9%NaCl. See Fluid Challenge Algorithm below.
Priorities: Stop the bleeding: consider surgery/endoscopy.
Treat sepsis. CALL FOR HELP!
For severe blood loss initially use colloid or Hartmanns/
PL148 until blood/clotting factors arrive. Use
O Negative blood for torrential bleeding. Severely septic
patients with circulatory collapse may need inotropic
support in a critical care area. Their blood pressure may
not respond to large volumes of fluid; excess volumes may
be detrimental.
Electrolyte contents for common fluids (mmol per litre)
Osm = Osmolality
Fluid/Content
0.9%NaCI
0.18%saline
4%dextrose
0.45%saline
5%dextrose
Gelofusine
Hartmanns
PlasmaLyte
148
5%dextrose

Na K
154 0
30 0
77

CI Mg
154 0
30 0
77

154 0 154 0
131 5 111 0
140 5 98 1.5
0

Ca
0
0

Lactate
0
0

Osm.
308
284

406

0
2
0

0
274
29
278
Acetate27 297

190kcal/l

278

IN SUMMARY: assess, why, how much, which?

Take your time; consult senior if you are unsure.
Patients on IV fluids need regular blood tests.
Patients should be allowed food and drink ASAP

Fluid Challenge Algorithm

Hypovolaemia: low BP, tachycardia, low CVP/JVP,
oliguria, reduced skin turgor, poor tissue perfusion,
capillary refill time >4sec. Note patients with epidurals
may need vasoconstriction rather than fluid but must
be assessed for other causes of hypotension.

Is there a concern regarding fluid challenge

e.g. severe LV dysfunction/cardiogenic shock?

YES

NO
Give 250ml IV fluid
challenge with
colloid or Hartmanns
over 2-5 mins

YES

Are there continued signs

of hypovolaemia with low
likelihood of fluid
overload?

NO
Adequate response?

YES
Decide on
continued fluid
prescription and
management

NO

NO

Have you reached

2000ml limit?

YES
Patient has complex
pathology seek senior/
critical care opinion
urgently

Plasma-Lyte 148 is another balanced crystalloid and may be

used instead of Hartmanns when available.
References: Southampton Fluid Guidance 2009
British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical
Patients http://www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdf