This document provides guidelines for intravenous fluid therapy for surgical patients. It discusses: 1. The consensus process used to develop the guidelines, which involved meetings between 2006-2008 of medical associations to establish recommendations. 2. Types of intravenous fluids that can be used, including crystalloids like Ringer's lactate and normal saline, as well as colloids and blood products. 3. Recommendations for pre-operative, intra-operative, and post-operative fluid management of surgical patients based on factors like fluid deficits, ongoing losses, and monitoring of volume status and hemodynamics.

1. Guidelines on Intravenous
Fluid
Therapy for Surgical
Patients
DR OMAR HASSAN
SURGICAL SHO
ST LUKES HOSPITAL

2.  The Consensus Process For IV fluids Administration:
 In October 2006 the Association of Surgeons of UK and Ireland,
BAPEN Medical, the Intensive Care Society, the Association for
Clinical Biochemistry and the Renal Association nominated core
members for a steering committee who came together to try to
establish consensus for good perioperative fluid prescribtion for
surgical patients.
 A national meeting was held in March 2007, The steering
committee then drafted an initial document which was
circulated to all delegates.
 A penultimate draft was produced and revised & at a final
meeting of the steering committee in March 2008 a series of
recommendations was set.

3. CRYSTALLOIDS
1-RINGER LACTATE : indicated in replacement and resuscitation,
balanced salt solutions,used post surgery,burns &hypovolumic shock.
2-NORMAL SALINE :indicated in cases of suspected hypochloraemia
e.g. from vomiting or gastric drainage,not for resusitation ,risk of
Hyperchloraemia.
3-DEXTROSE(10%,5%,5%NS,%0.18NS) sources of free water for
maintenance, used with caution as excessive amounts may cause
dangerous hyponatraemia,not appropriate for resuscitation or
replacement therapy except in conditions of significant free water
deficit e.g. Diabetes Insipidus.

4. COLLOIDS:
 Colloids contain larger insoluble molecules, such as gelatin &
HexaStarch preserve a high colloid osmotic pressure in the blood.
 More expensive & less commonly used than crystalloids.
BLOOD BASED PRODUCTS:
 any component of blood which is collected from a donor for blood
transfusion.
 life-saving in some situations, such as massive blood loss due to GIT
Bleeding , trauma & Anaemia or can be used to replace blood lost
during surgery.
 modern medical practice commonly uses only components of the
blood, such as fresh frozen plasma ,Platelets or packed cells .

5. ADULT DAILY FLUD&ELECTROLYTE REQUIREMENT:
 Sodium 70-120 mmol/day.
 Potassium 40-80 mmol/day.
 Chloride 110-150 mmol/day.
 (1.5-2.5) liters of water by the oral, enteral or parenteral route
(or a combination of routes).
 Careful monitoring should be undertaken using clinical
examination, fluid balance charts, and regular weighing when
possible.

6. *Preoperative fluid management:
 oral fluids should not be withheld for more than two hours prior
to the induction of anesthesia ,in patients without disorders of
gastric emptying undergoing elective surgery clear non particulate.
 preoperative administration of carbohydrate rich beverages 2-3 h
before induction of anesthesia may improve patient well being
and facilitate recovery from surgery. It should be considered in
the routine preoperative preparation for elective surgery.
 Routine use of preoperative mechanical bowel preparation is not
beneficial and may complicate intra and postoperative
management of fluid and electrolyte balance. Its use should
therefore be avoided whenever possible.

7.  fluid and electrolyte derangements commonly occur where
mechanical bowel preparation is used, and should be corrected by
simultaneous intravenous fluid therapy with Hartmann’s or Ringer-
Lactate/acetate type solutions.
 Excessive losses from gastric aspiration/vomiting should be treated
preoperatively with an appropriate crystalloid solution which
includes an appropriate potassium supplement.
 Losses from diarrhea/ileostomy/small bowel
fistula/ileus/obstruction should be replaced volume for volume
with Hartmann’s or Ringer-Lactate/acetate type solutions.

8.  “Saline depletion,” for example due to excessive diuretic
exposure, is best managed with a balanced electrolyte solution
such as Hartmann's.
 In high risk surgical patients preoperative treatment with
intravenous fluid and inotropes should be aimed at achieving
predetermined goals for cardiac output and oxygen delivery as this
may improve survival.
 When direct flow measurements are not possible, hypovolaemia will
be diagnosed clinically on the basis of pulse, peripheral perfusion
and capillary refill, venous (JVP/CVP) pressure and Glasgow Coma
Scale together with acid-base and lactate measurements. A low
urine output can be misleading and needs to be interpreted in the
context of the patient’s cardiovascular parameters above.

9.  Hypovolemia due predominantly to blood loss should be treated
with either a balanced crystalloid solution or a suitable colloid until
packed red cells are available. Hypovolemic due to severe
inflammation such as infection, peritonitis, pancreatitis or burns
should be treated with either a suitable colloid or a balanced
crystalloid.
 In either clinical scenario, care must be taken to administer
sufficient balanced crystalloid and colloid to normalize
hemodynamic parameters and minimize overload. The ability of
critically ill patients to excrete excess sodium and water is
compromised, placing them at risk of severe interstitial edema. The
administration of large volumes of colloid without sufficient free
water (e.g. 5% dextrose) may precipitate a hyper oncotic state.

10.  When the diagnosis of hypovolemic is in doubt and the central
venous pressure is not raised, the response to a bolus infusion of
200 ml of a suitable colloid or crystalloid should be tested. The
response should be assessed using the patient’s cardiac output and
stroke volume measured by flow-based technology if available.
 Alternatively, the clinical response may be monitored by
measurement/estimation of the pulse, capillary refill, CVP and
blood pressure before and 15 minutes after receiving the infusion.
This procedure should be repeated until there is no further increase
in stroke volume and improvement in the clinical parameters.

11. Intra operative fluid management
 In patients undergoing some forms of orthopedic and abdominal
surgery, intra-operative treatment with intravenous fluid to
achieve an optimal value of stroke volume should be used where
possible as this may reduce postoperative complication rates and
duration of hospital stay.
 Patients undergoing non -elective major abdominal or orthopedic
surgery should receive intravenous fluid to achieve an optimal
value of stroke volume during and for the first eight hours after
surgery. This may be supplemented by a low dose Dopexamine
infusion.

12.  Details of fluids administered must be clearly recorded and easily
accessible.
 When patients leave theatre for the ward, HDU or ICU their volume
status should be assessed. The volume and type of fluids given
preoperatively should be reviewed and compared with fluid losses
in theatre including urine and insensible losses.
 In patients who are Euvolaemic and haemodynamically stable a
return to oral fluid administration should be achieved as soon as
possible.

13. Post Operative Fluid Management
 In patients requiring continuing IV maintenance fluids, these
should be sodium poor and of low enough volume until the
patient has returned their sodium and fluid balance over the
perioperative period to zero. When this has been achieved the
IV fluid volume and content should be those required for daily
maintenance and replacement of any on-going additional losses.
 The hemodynamic and fluid status of those patients who fail to
excrete their perioperative sodium load, and especially whose
urine sodium concentration is <20mmol/L, should be reviewed.
 In high risk patients undergoing major abdominal surgery,
postoperative treatment with intravenous fluid and low dose
Dopexamine should be considered, in order to achieve a
predetermined value for systemic oxygen delivery, as this may
reduce postoperative complication rates and duration of hospital
stay.

14.  Thus while the pattern of change in heart rate, arterial pressure
and central venous pressure remain helpful markers of the
effects of fluid administration on vascular filling they are
influenced by other factors and do not have a linear relationship
with cardiac output or tissue perfusion.
 Frank-Starling relationship between cardiac filling pressure and
stroke volume, the latter more reliably reflects vascular filling
and hence fluid requirement.
 Surgical patients should be nutritionally screened, and NICE
guidelines for perioperative nutritional support adhered to.
Care should be taken to mitigate risks of the refeeding
syndrome(metabolic disturbances that occur as a result of
reinstitution of nutrition to patients who are nutritionally
depleted patients) .

15. Fluid management in acute kidney injury (AKI):
 Higher molecular weight hydroxyethyl starch(hetastarch and
pentastarch MW ≥ 200 kDa) Balanced electrolyte solutions
containing potassium can be used cautiously in patients with AKI
closely monitored on HDU or ICU in preference to 0.9% saline. If
free water is required 5% dextrose or dextrose saline should be
used. Patients developing hyperkalemia or progressive AKI should
be switched to non potassium containing crystalloid solutions such
as 0.45% saline or 4%/0.18 dextrose/saline.
 Based on current evidence, higher molecular weight starch
containing fluids (hetastarch and pentastarch MW ≥ 200 kDa)
should be avoided in patients with severe sepsis due to an
increased risk of AKI, it should be avoided in brain-dead kidney
donors due to reports of osmotic-nephrosis-like lesions.

16. Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, assess whether the patient is hypovolaemic and needs fluid resuscitation
Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation include: systolic BP <100mmHg; heart rate
>90bpm; capillary refill >2s or peripheries cold to touch; respiratory rate >20 breaths per min; NEWS ≥5; 45o passive leg raising suggests fluid responsiveness.
Assess the patient’s likely fluid and electrolyte needs
History: previous limited intake, thirst, abnormal losses, comorbidities.
Clinical examination: pulse, BP, capillary refill, JVP, oedema (peripheral/pulmonary), postural hypotension.
Clinical monitoring: NEWS, fluid balance charts, weight.
Laboratory assessments: FBC, urea, creatinine and electrolytes.
Can the patient meet their fluid and/or electrolyte needs orally or enterally?
Does the patient have complex fluid or
electrolyte replacement or abnormal
distribution issues?
Look for existing deficits or excesses, ongoing
abnormal losses, abnormal distribution or other
complex issues.
Algorithm 2: Fluid Resuscitation
Initiate treatment
Identify cause of deficit and respond.
Give a fluid bolus of 500 ml of crystalloid
(containing sodium in the range of
130–154 mmol/l) over 15 minutes.
Reassess the patient using the ABCDE
approach
Does the patient still need fluid
resuscitation? Seek expert help if unsure
Ongoing abnormal fluid or
electrolyte losses
Check ongoing losses and estimate
amounts. Check for:
vomiting and NG tube loss
biliary drainage loss
high/low volume ileal stoma
loss
diarrhoea/excess colostomy
loss
ongoing blood loss, e.g.
melaena
sweating/fever/dehydration
pancreatic/jejunal fistula/stoma
loss
urinary loss, e.g. post AKI
polyuria.
Algorithm 3: Routine Maintenance
Give maintenance IV fluids
Normal daily fluid and electrolyte requirements:
25–30 ml/kg/d water
1 mmol/kg/day sodium, potassium, chloride
50–100 g/day glucose (e.g. glucose 5% contains
5 g/100ml).
Reassess and monitor the patient
Stop IV fluids when no longer needed.
Nasogastric fluids or enteral feeding are preferable
when maintenance needs are more than 3 days.
Existing fluid or
electrolyte deficits
or excesses
Check for:
dehydration
fluid overload
hyperkalaemia/
hypokalaemia
Estimate deficits or
excesses.
Redistribution and
other complex issues
Check for:
gross oedema
severe sepsis
hypernatraemia/
hyponatraemia
renal, liver and/or
cardiac impairment.
post-operative fluid
retention and
redistribution
malnourished and
refeeding issues
Seek expert help if
necessary and estimate
requirements.
>2000 ml
given? Seek expert help
Give a further fluid bolus of 250–500 ml of
crystalloid
Algorithm 4: Replacement and Redistribution
No
Yes
No
Yes
No
Ensure nutrition and fluid needs are met
Also see Nutrition support in adults (NICE
clinical guideline 32).
Yes
Yes
Prescribe by adding to or subtracting from routine maintenance, adjusting for all
other sources of fluid and electrolytes (oral, enteral and drug prescriptions)
Yes
Monitor and reassess fluid and biochemical status by clinical and laboratory
monitoring
Yes
No
No
No
Does the patient have
signs of shock?
Algorithm 1: Assessment
Algorithms for IV fluid therapy in adults
‘Intraenous fluid therapy in adults in hospital’, NICE clinical guideline 174 (December 2013) © National Institute for Health and Care Excellence 2013. All rights reserved.

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