QuestionPrescription
QuestionComment
Why would Plasmalyte not be correct?
17315
User
subscriber
May
QuestionComment
i gave 250 ml saline over 15 mins, would this be wrong? i just thought due to his older age and slightly lower eGFR? :/
40022
QuestionComment
250ml fluid challenge is usually given in patients with heart failure as you don't want to overload them with too much fluid - not sure if this info is on BNF 
40159
User
subscriber
Afia
User
subscriber
Vaccine Ketone
QuestionComment
Why is 0.9% NaCl over 10m incorrect? Does it have to be 15m?
61008
QuestionComment
in the actual PSA it has to be 10 because guidelines say <15m 
61703
User
subscriber
Epidermis Benign
User
subscriber
R.H
Concept
Chapter
# Summary

Intravenous (IV) fluid resuscitation describes when fluids are given to help restore the circulating volume and improve tissue perfusion. It is often required in patients who are hypovolaemic, for example due to infection, haemorrhage or other fluid losses e.g. severe vomiting and diarrhoea. Crystalloid fluids are first-line (e.g. 0.9% sodium chloride or Hartmann's) and NICE recommends giving an initial 500 ml bolus over less than 15 minutes. Regular reassessment is important, and although repeated fluid boluses can be given if the patient has signs of shock or has received over 2 litres of fluid expert help should be sought. Complications of IV fluid resuscitation include fluid overload and electrolyte imbalance. 

# Definition

IV fluids are given in two main situations: maintenance fluids (where the patient's normal requirements are met plus replacement of abnormal fluid and electrolyte losses) and fluid resuscitation.

NICE guidelines give an algorithm of how patients' fluid and electrolyte needs should be assessed and prescribed. 

Indicators that a patient may need fluid resuscitation include:

- Systolic blood pressure < 100 mmHg
- Heart rate > 90
- Respiratory rate > 20
- National Early Warning Score (NEWS) of 5 or more
- Cold peripheries
- Capillary refill time > 2 seconds

NICE suggests doing a passive leg raise test to assess fluid responsiveness. This involves lying the patient flat with their legs raised to greater than 45 degrees for 30-90 seconds. If this leads to haemodynamic improvement (e.g. a rise in blood pressure), this indicates fluid responsiveness i.e. fluid resuscitation is likely to be of benefit. 

# Investigations

Prior to prescribing fluid resuscitation, patients need an assessment of their fluid and electrolyte needs

This involves taking into account:

- History (e.g. recent fluid intake, thirst, abnormal fluid losses and comorbidities)
- Examination (observations, capillary refill, jugular venous pressure, signs of pulmonary or peripheral oedema, postural hypotension)
- Fluid balance charts 
- Weight
- Full blood count (e.g. to assess for anaemia due to bleeding)
- U&Es for renal function and electrolytes
- Lactate levels and/or pH
- Serum chloride in patients receiving high chloride IV fluids (e.g. normal saline) 

# Management

- Identifying and treating the cause of hypovolaemia is key (e.g. gastrointestinal bleeding, sepsis)
- Patients should be prescribed a 500ml bolus of a crystalloid (e.g. normal saline or Hartmann's) over less than 15 minutes initially
- In some cases (e.g. frail elderly patients) a smaller volume of fluid such as 250ml may be given
- They should then be reassessed using an A-E approach and if required further 250-500ml boluses should be given, to a maximum of 2 litres 
- After 2 litres have been given, or if the patient has signs of shock, expert help should be sought (e.g. intensive care in case inotropic support is required)
- NICE recommend that in patients with severe sepsis only, human albumin solution 4-5% may be considered for fluid resuscitation
- In patients who are hypovolaemic due to haemorrhage, replacement with blood products is preferrable

# Complications

- Hyperchloremic acidosis due to excess administration of normal saline
- Fluid overload with pulmonary and/or peripheral oedema
- Electrolyte imbalance (e.g. hypokalaemia) if fluids are insufficiently tailored to the patient's requirements 
- Dilutional anaemia

# References

[NICE - Intravenous fluid therapy in adults in hospital](https://www.nice.org.uk/guidance/cg174/)

[RCP Ten Top Tips for Intravenous Fluid Administration](https://www.bapen.org.uk/images/pdfs/rcp-ten-top-tips/intravenous-fluid-administration.pdf)
172
2694
Intravenous fluid resuscitation
Topic
13
Neurosurgery
# Drug choice feedback

This patient requires urgent fluid resuscitation as part of the management for his wound sepsis. Crystalloid fluids such as 0.9% sodium chloride or Hartmann's solution are first-line in such cases.

# Dose/Route/Frequency/Duration feedback

500mL is the standard dose used for a fluid bolus ('fluid challenge') in resuscitation. Vital observations such as heart rate and blood pressure are monitored after each dose to see if a further bolus is required. Fluids can only be given intravenously; this route of administration also ensures the fastest response to be seen in the patient. A duration of 15 minutes or less for every 500mL is acceptable.
6758
PrescriptionAnswer
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500 mL
PrescribeAnswerData
sodium chloride 0.9% solution
PrescribeAnswerData
15m
PrescribeAnswerData
once only (STAT)
PrescribeAnswerData
intravenous (IV)
PrescriptionAnswer
PrescribeAnswerData
500 mL
PrescribeAnswerData
sodium chloride 0.9% solution
PrescribeAnswerData
15m
PrescribeAnswerData
once only (STAT)
PrescribeAnswerData
intravenous (IV)
PrescriptionAnswer
PrescribeAnswerData
500 mL
PrescribeAnswerData
sodium chloride 0.9% solution
PrescribeAnswerData
10m
PrescribeAnswerData
once only (STAT)
PrescribeAnswerData
intravenous (IV)
PrescriptionAnswer
PrescribeAnswerData
500 mL
PrescribeAnswerData
Hartmann's solution (Na+ 131/K+ 5/Ca2+ 2/HCO3- 29/Cl- 111 mmol/L)
PrescribeAnswerData
15m
PrescribeAnswerData
once only (STAT)
PrescribeAnswerData
intravenous (IV)
Case Presentation: A 68-year-old gentleman admitted to the general ward for observation after a right hemicolectomy 7 days ago is being treated for sepsis. He is found to be drowsy and confused.




## PH


Colorectal cancer, Hyperlipidaemia, Gout


## DH


Atorvastatin 40mg PO ON, Allopurinol 300mg PO OD


## On examination


Appears delirious and not oriented to time and place. Peripheries warm, CRT 3s. HS I + II + 0, chest clear.


Temperature 38.9°C, HR 96, RR 27, BP 95/65, O2 95% RA, GCS 13, Weight 75kg


## Investigations


FBC: Hb 148, WCC 15.5, Plts 420


U&Es: Na<sup>+</sup> 141, K<sup>+</sup> 4.3, Cl<sup>-</sup> 98, Ur 9.2, Cr 110, eGFR 61mL/min/1.73m<sup>2</sup>


BM: 6.7mmol/L (normal rnage 3.5-5.5 mmol/L)


# Prescribing Request


Write a prescription for one fluid that is most appropriate for treating his current condition