9/3/2020 Choosing between colloids and crystalloids for IV infusion | Nursing Times

CRITICAL CARE

REVIEW
Choosing between colloids and crystalloids for IV infusion
20 NOVEMBER, 2017

Intravenous fluid therapy is sometimes needed to restore homoeostasis and

prevent organ failure. This overview of intravenous fluid use is accompanied by a
self-assessment questionnaire so you can test your knowledge after reading it

Abstract

Hypovolaemia resulting from illness or trauma can precipitate imbalances in

homoeostasis due to the loss of circulating fluid volume. By
addressing hypovolaemia, homoeostasis can be restored, preventing
hypoperfusion and subsequent organ dysfunction. Administering intravenous
fluids can replace any lost circulating volume. The National Institute for Health
and Care Excellence outlines five ‘Rs’ of fluid therapy: resuscitation, routine
maintenance, replacement, redistribution and reassessment. This article
provides an overview of fluid therapy, covering the NICE guidance and clarifying
the differences between crystalloids and colloids, and when to use them.

Citation: Smith L (2017) Choosing between colloids and crystalloids for IV

infusion. Nursing Times [online]; 113: 12, 20-23.

Author: Lisa Smith is senior lecturer in emergency and urgent care at the
University of Cumbria.

This article has been double-blind peer reviewed

Scroll down to read the article or download a print-friendly PDF here
Assess your knowledge and gain CPD evidence by taking the Nursing Times Self-assessment test

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Introduction

To maintain its finely tuned homoeostasis, the human adult body needs an average
daily fluid intake of 2.5-3 litres (Moore and Cunningham, 2017). It also requires a
constant balance in the levels of nutrients, oxygen and water to preserve a stable
internal environment (Moini, 2016). This balance can be easily altered by illness or
injury, resulting in a loss of one or all of these elements. This can lead to
dehydration, hypoperfusion leading to reduced oxygen uptake, and organ
dysfunction, so redressing the imbalance is essential.

A reduction in oral fluid intake, the redistribution of fluid in the vascular spaces and
a decreased circulating volume need to be managed. Intravenous fluid therapy is
one way of managing reduced fluid intake by reducing its effects and replacing lost
fluids.

Recognising the signs and symptoms of fluid loss is necessary to identify the need
for fluid administration. Knowledge of when to administer IV fluids, what type of
fluid to administer, and why they are all essential. The National Institute for Health
and Care Excellence’s 2017 guidance on IV fluid therapy in adults in hospital
stresses the need for health professionals to understand the physiology of fluid and
electrolyte balance. It also outlines five ‘Rs’ of fluid administration (Box 1).
However, there are many fluid replacement products available and it is not always
clear which one should be used.

This article provides an overview of the NICE guidance, highlighting what it means
for health professionals administering IV fluids. It also sheds light on the
differences between crystalloid and colloid solutions, and gives practical guidance
on when each one should be used.

Box 1. Five ‘Rs’ of intravenous fluid administration

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Resuscitation
Routine maintenance
Replacement
Redistribution
Reassessment

Source: National Institute for Health and Care Excellence (2017)

Physiology

For effective tissue and organ perfusion, maintenance of finely balanced levels of
oxygen, fluid and electrolytes (homoeostasis) is essential. Fluid volumes need to be
distributed into the intracellular and extracellular spaces (the latter being further
divided into the interstitial and intravascular compartments). The movement of
fluid between these spaces is continual. This enables cells to receive their necessary
supply of electrolytes such as sodium, potassium and carbon. Along with oxygen,
these are fundamental for cell performance (Peate and Nair, 2016).

Homoeostasis is easily affected by any insult to the body, be it from illness, injury,
trauma or medication. This imbalance can quickly lead to worsening illness and/or
impede recovery. Hypovolaemia will reduce the circulating fluid volumes, resulting
in reduced electrolyte and oxygen supply to the cells. A large reduction in fluid
volume can result in hypovolaemic shock. Patients who go into hypovolaemic shock
need fluid resuscitation to maintain their cardiac output and organ perfusion.

NICE guidance

NICE’s 2017 guidance on IV fluid therapy indicates that the assessment of patients
should include:

Physical examination;
Observation of vital signs over time;
Clinical presentation.

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It also provides a set of parameters that may indicate that a patient needs fluid
resuscitation (Box 2).

Box 2. Parameters for fluid resuscitation

Systolic blood pressure: <100mmHg

Heart rate: >90 beats per minute
Capillary refill: >2 seconds or peripheries cool to touch
Respiratory rate: >20 breaths per minute
NEWS: ≥5

NEWS = National Early Warning Score

Source: National Institute for Health and Care Excellence (2017)

The parameters highlight the importance of assessing patients’ fluid and

electrolyte balance. This involves ascertaining their history of fluid intake and any
complaints of thirst. Consideration should also be given to the likelihood of
insensible fluid loss – for example, from altered bowel function such as diarrhoea,
or injuries such as burns. Comorbidities such as diabetes and cardiovascular disease
can also lead to fluid and electrolyte imbalances.

The monitoring of vital signs, along with the assessment of jugular venous pressure
and observation for possible oedema and postural hypotension, can help identify
abnormalities in patients’ fluid and electrolyte balance. The National Early Warning
Score (NEWS) and fluid balance and weight charts are essential tools. Additional
tests such as full blood count and urea and electrolytes can confirm the need for IV
fluid therapy (NICE, 2017).

The ‘5Rs’ of fluid resuscitation

Resuscitation

To ascertain the fluid requirements of patients who are acutely ill, an accurate
assessment is needed and should include the ABCDE – airway, breathing,
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circulation, disability, exposure – approach (Frost, 2015). It is also important to

investigate the cause of any potential fluid loss. Finding and treating that cause,
along with the administration of fluid therapy, is essential to rule out refractory
fluid loss. If not addressed, this persistent loss of circulating volume could lead to:

The need for further fluid resuscitation;

Increased volumes of fluid requirements;
In severe cases, debilitating illness or death.

NICE (2017) recommends a bolus of 500ml of crystalloid solution (containing

sodium in the range of 130-154mmol/L) over less than 15 minutes in patients
requiring fluid resuscitation; this should be avoided for those who have any
evidence of pulmonary oedema as a result of cardiac failure (Frost, 2015). This
initial fluid resuscitation should be followed by a reassessment. If further fluid
resuscitation is required, then fluid boluses of 250-500ml should be given. Patients
needing continuous boluses of up to 2L will need further medical review.

Routine maintenance

Routine maintenance fluids are needed in patients who are at ongoing risk of fluid
loss. Reasons for this could be poor fluid intake, recent surgery, bowel dysfunction
and other comorbidities. Clinical examination, investigations, vital signs monitoring
(including fluid balance and weight measurements) can all help to determine a
patient’s need for routine maintenance fluids.

Replacement

Ongoing assessment of patients’ fluid balance is paramount. Assessment should

focus on:

Ensuring adequate hydration;

Ensuring electrolyte balance;
Checking for any potential fluid overload.

When ensuring normal electrolyte parameters are met, it is particularly important

to consider the potassium levels. Alterations in potassium – either hypokalaemia or

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hyperkalaemia – can affect patients’ cardiac performance causing arrhythmias,

heart failure and/or cardiac arrest. If continued fluid loss is suspected, this should
be checked and losses monitored.

Redistribution

Redistribution of fluid can occur in critical illness. Fluid is lost from the circulatory
volume and moves into the tissues; this is called ‘third space loss’ (Frost, 2015).
This may be seen in patients with cardiac failure, renal failure or sepsis, and
oedema may be present. To manage these patients effectively, increased
monitoring, further assessment and investigations are needed. In some cases,
specialist intervention, such as the monitoring of central venous pressure, kidney
function tests or high dependency care, may be required.

Reassessment

Regular reassessment of patients’ fluid therapy needs is essential. In those who

require ongoing fluid therapy for three or more days, the enteral routes of
administration should be considered (NICE, 2017). Enteral routes reduce the need
for IV access and, in doing so, reduce the risks of ongoing IV therapy, such as
catheter-related infections.

Types of fluids
Crystalloids

Crystalloid solutions are isotonic plasma volume expanders that contain

electrolytes. They can increase the circulatory volume without altering the chemical
balance in the vascular spaces. This is due to their isotonic properties, meaning
their components are close to those of blood circulating in the body. Crystalloid
solutions are mainly used to increase the intravascular volume when it is reduced.
This reduction could be caused by haemorrhage, dehydration or loss of fluid during
surgery.

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The most frequently used crystalloid fluid is sodium chloride 0.9%, more commonly
known as normal saline 0.9%. Other crystalloid solutions are compound sodium
lactate solutions (Ringer’s lactate solution, Hartmann’s solution) and glucose
solutions (see ‘Preparations containing glucose’ below). Some crystalloid
preparations containing additives such as potassium or glucose are used in specific
circumstances, for example, in hypokalaemia and hypoglycaemia (Joint Formulary
Committee, 2017).

Crystalloid solutions such as sodium chloride 0.9%, Ringer’s lactate and

Hartmann’s solutions need to be administrated in larger volumes than colloid
solutions. As two-thirds of the infused volume will move into the tissues, only the
remaining third will stay in the intravascular space (NICE, 2017), leaving a
diminished circulating volume in need of further fluid administration. This
increased volume can cause unwanted side-effects such as oedema (NICE, 2017).

Excessive amounts of infused sodium chloride 0.9% can produce hyperchloraemic

acidosis due to its high chloride content, leading to renal dysfunction, resulting in a
reduced glomerular filtration rate (NICE, 2017; Clarke and Malecki-Ketchell, 2016;
Myburgh and Mythen, 2013). To reduce this risk, compound sodium lactate
solutions (Ringer’s lactate/Hartmann’s solutions) can be used (Joint Formulary
Committee, 2017; NICE, 2017).

Crystalloid preparations containing glucose

Normal saline with the addition of 5% glucose is often used as a maintenance fluid.
The main function of normal saline is to replace lost water, as it distributes the
fluid throughout the body – thereby increasing total body water – but does not
restore intravascular volume. The loss of water without loss of electrolytes is rare,
but can be seen in patients with diabetes insipidus and hypercalcaemia. The

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additional glucose acts as a source of energy for patients who are unable to take
oral foods and fluids (Joint Formulary Committee, 2017).

Hyponatraemia is a side-effect of the excessive use of 5% glucose. This is

counteracted by using mixed solutions, such as 0.18% or 0.45% sodium chloride in
4% glucose, or normal saline and 5% glucose (Frost, 2015).

Colloids

Colloids are gelatinous solutions that maintain a high osmotic pressure in the
blood. Particles in the colloids are too large to pass semi-permeable membranes
such as capillary membranes, so colloids stay in the intravascular spaces longer
than crystalloids. Examples of colloids are albumin, dextran, hydroxyethyl starch (or
hetastarch), Haemaccel and Gelofusine.

Caution should be used when administering hetastarch: exacerbated by the

haemodilution effects of fluid administration, it can negatively affect platelet
count, which can have a temporary negative effect on clotting times and
coagulation (Marx and Schuerholz, 2010). Hypertension and tachycardia, cardiac
failure, and pulmonary and peripheral oedema are all potential side-effects of the
excessive administration of albumin, dextran or hetastarch (Frost, 2015; Marx and
Schuerholz, 2010).

Which fluid to administer?

Crystalloids and colloids are plasma volume expanders used to increase a depleted
circulating volume. Over the years they have been used separately or together to
manage haemodynamic instability. Both are suitable in fluid resuscitation,
hypovolaemia, trauma, sepsis and burns, and in the pre-, post- and peri-operative
period. On occasion, they are used together (Frost, 2015).

Colloids carry an increased risk of anaphylaxis, are more expensive (Frost, 2015) and
come with an added complication for vegetarian or vegan patients, as some
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preparations contain gelatin (Joint Formulary Committee, 2017). However, colloid

solutions are less likely to cause oedema than crystalloid solutions. Crystalloids are
less expensive, carry little or no risk of anaphylaxis, and pose no problem for
vegetarian or vegan patients. However, evidence on any potential harmful effects of
crystalloids is inconclusive. Table 1 summarises the main characteristics of
crysalloid and colloid solutions.

What the literature says

The question of which plasma volume expander to use has long been controversial,
resulting in several studies and systematic reviews. In recent years, numerous
research studies have been performed in different clinical situations to compare
crystalloids and colloids and look at their advantages and disadvantages (Skytte
Larsson et al, 2015; Jabaley and Dudaryk, 2014; Yates et al, 2014; Burdett et al,
2012).

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Jabaley and Dudaryk (2014) published a study that compared the effects of
crystalloids and colloids in trauma patients who needed fluid resuscitation; as
haemorrhage is the second most common cause of death from trauma, the need for
haemodynamic stability and the maintenance of tissue and organ perfusion is
essential. The study had limitations, including small sample size, funding and
reporting bias, and the results were inconclusive.

Yates et al (2014) studied post-operative patients who were administered goal-

directed fluid therapy. Their study demonstrated that colloids had no benefit over
crystalloids in patients who had had colorectal surgery and confirmed that using
crystalloids was just as effective.

Skytte Larsson et al (2015) compared the effect of colloids and crystalloids on renal
perfusion, filtration and oxygenation after cardiac surgery. Maintenance of oxygen
delivery and renal perfusion are particularly important in the post-operative period
to exclude the risk of acute kidney injury. Skytte Larsson et al concluded that there
was no difference in effectiveness between colloid and crystalloid solutions in
ensuring adequate oxygen perfusion to the kidneys.

Smorenberg and Groeneveld (2015) studied the effects of fluid therapy on 42 septic
and non-septic patients who had been assessed as hypovolaemic. Their study
compared the urine output of those receiving crystalloid and colloid solutions and
determined that patients receiving crystalloids had higher output volumes than
those receiving colloids.

Perel et al (2013) performed a Cochrane systematic review of 78 randomised

controlled trials comparing colloids and crystalloids as plasma volume expanders in
patients who were critically ill. They concluded that colloids did not prove more

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effective than crystalloids in reducing the risk of death in patients with trauma or
burns and in patients post-operatively.

Orbegozo Cortés et al (2014) published a structured review on crystalloid solutions.

It included 28 studies that had investigated the physiological effects of crystalloid
solutions in several different clinical situations. The review concluded that
crystalloid solutions can have negative effects on electrolyte balance, coagulation
and liver and kidney function. It found that normal saline increased blood loss and
the need for blood transfusion, and that Ringer’s lactate solution increased serum
lactate levels. However, overall the studies were inconclusive as to whether the
changes brought about by crystalloid solutions made any difference to patients’
morbidity and mortality. This lack of definitive conclusions was due to the fact that
the 28 studies has been performed in different clinical settings.

Making use of these studies is problematic because they were conducted across
diverse clinical environments using different research methods, with alternative
hypotheses and, therefore, also with potentially different outcomes. One size does
not fit all, meaning the answer may not be the same for all clinical environments:
colloids may be better suited to some clinical situations and crystalloids may be
better in others.

Implications for practice

To safely administer IV fluids, nurses and midwives need to ensure that:

The patient is getting the right type of fluid to meet their clinical need;
The patient is adequately assessed before, during and after IV therapy;
IV therapy is working for the patient and, if this is not the case, oral or enteral fluids are considered as an alternative;
Fluid balance and weight charts are completed and reviewed;
Regular blood samples are taken, checked and reviewed.

Managers of staff administrating IV fluids need to ensure that:

Staff receive up-to-date education and training, including on the ‘5Rs’ of fluid therapy;
Staff know what they are giving to patients and why;

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Fluid therapy is delivered in accordance with the best use of resources.

Nurses and midwives administering IV fluids should be aware of the variations

between the different fluid types as well as any potential complications. They also
have a duty of care to understand the effects, side-effects, precautions and
contraindications (Nursing and Midwifery Council, 2015) of each. As with any
medication, patients undergoing infusion therapy should be closely monitored to
avoid fluid and electrolyte imbalances. This may mean weighing them daily, as this
is a reliable method of monitoring fluid status (NICE, 2017).

Key points

The loss of circulating fluid volume can lead to imbalances in homoeostasis

Recognising, assessing and monitoring patients’ need for fluid therapy is crucial
The ‘5Rs’ of intravenous fluid administration are: resuscitation, routine maintenance, replacement, redistribution and reassessment
Crystalloids and colloids, both plasma volume expanders, are used to increase depleted circulating volumes
To administer intravenous fluids, health professionals must understand what crystalloids and colloids do and when to use them

Test your knowledge with Nursing Times Self-assessment after reading this article. If you score 80% or more, you will
receive a personalised certificate that you can download and store in your NT Portfolio as CPD or revalidation evidence.
Take the Nursing Times Self-assessment for this article

Burdett E et al (2012) Perioperative buffered versus non-buffered fluid administration for surgery in adults.
Cochrane Database of Systematic Reviews; 12: CD004089.

Clarke D, Malecki-Ketchell A (2016) Nursing the Acutely Ill Adult: Priorities in Assessment and Management.
London: Palgrave.

Frost P (2015) Intravenous fluid therapy in adult inpatients. British Medical Journal; 350: g7620.

Jabaley C, Dudaryk R (2014) Fluid resuscitation for trauma patients: crystalloids versus colloids. Current Anesthesiology Reports; 4: 3, 216-224.

Joint Formulary Committee (2017) British National Formulary 72. London: BMJ Group and Pharmaceutical Press.

Marx G, Schuerholz T (2010) Fluid-induced coagulopathy: does the type of fluid make a difference? Critical Care; 14: 1, 118.

Moini J (2016) Anatomy and Physiology for Health Professionals. Burlington, MA: Jones and Bartlett Learning.

Moore T, Cunningham S (2017) Clinical Skills for Nursing Practice. Abingdon: Routledge.

Myburgh JA, Mythen MG (2013) Resuscitation fluids. The New England Journal of Medicine; 369: 13, 1243.

National Institute for Health and Care Excellence (2017) Intravenous Fluid Therapy in Adults in Hospital.

Nursing and Midwifery Council (2015) Standards for Medicines Management.

Orbegozo Cortés D et al (2014) Isotonic crystalloid solutions: a structured review of the literature. British Journal of Anaesthesia; 112: 6, 968-981.

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9/3/2020 Choosing between colloids and crystalloids for IV infusion | Nursing Times
Peate I, Nair M (2016) Fundamentals of Anatomy and Physiology for Nursing and Healthcare Students. Chichester: Wiley Blackwell.

Perel P et al (2013) Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews; 2:
CD000567.

Pryke S (2004) Advantages and disadvantages of colloid and crystalloid fluids. Nursing Times; 100: 10, 32-33.

Skytte Larsson J et al (2015) Effects of acute plasma volume expansion on renal perfusion, filtration, and oxygenation after cardiac surgery: a
randomized study on crystalloid vs colloid. British Journal of Anaesthesia; 115: 5, 736-742.

Smorenberg A, Groeneveld AB (2015) Diuretic response to colloid and crystalloid fluid loading in critically ill patients. Journal of Nephrology; 28: 1,
89-95.

Yates DR et al (2014) Crystalloid or colloid for goal-directed fluid therapy in colorectal surgery. British Journal of Anaesthesia; 112: 2, 281-289.
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