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FLUIDS & ELECTROLYTES

GUIDELINES - ADULT

PRESCRIBING INTRAVENOUS FLUIDS and ELECTROLYTES for ADULT patients (4th Edition)
Reviewed by Queensland Health Safe Medication Management Unit, Fluid and Electrolyte Guidelines Working Party,
September 2010, Next review: end of 2012

1. Assess current fluid status

Is the patient dry, wet or just right?

Review fluid balance charts, urine output and daily weight
Review clinical symptoms and signs of fluid deficit or overload
Fluid deficit
Estimate degree from history and signs including: thirst, dry mucous membranes, tachycardia, and low urine output. Postural or
supine hypotension plus flat neck veins with or without other evidence of shock indicate intravascular hypovolaemia.
First correct intravascular hypovolaemia: Institute rapid replacement with fluids such as 0.9% sodium chloride or Compound
Sodium Lactate, or appropriate colloids such as Albumin 4% or succinylated Gelatin. Blood and blood products may be indicated.
Seek assistance from a Senior Medical Officer. It may be necessary to contact ICU or Emergency Department.
Replace estimated extracellular deficit: Correct with an appropriate replacement fluid, based on type of fluid lost and current
tonicity (plasma sodium concentration). Compound Sodium Lactate may be appropriate. If serum sodium is low, avoid 5% glucose
or glucose saline combinations. Administer half required volume over 8 hours and the second half over 16 hours. If poor cardiac
reserve reduce rate to half over 12 hours and second half over 24 hours. Frequently reassess during this process.
Fluid Overload
Signs include: increased daily weight, raised JVP, peripheral oedema (consider hypoalbuminaemia) and pulmonary oedema.
Management: Minimise sodium and fluid given. Consider diuretic.

2. Assess ongoing fluid losses

Estimate ongoing volume losses including vomiting, diarrhoea, nasogastric drainage and other losses (e.g. with ileus). These should
be added to the volume given daily. The type of fluid to use depends on the source of loss.

3. Assess maintenance requirements

Requirements in unstressed, well individuals differ from sick hospital patients. A well, unstressed 70 kg adult, who is NBM,
euvolaemic, not septic or post-surgical, with normal cardiac and renal function and no additional fluid losses would have needs met by
0.3% sodium chloride and 3.3% glucose containing 40 mmol/L of potassium at 80 mL/hr (1L 12hrly).
Typical daily healthy ADULT needs
Sodium
Potassium
Fluid

Weight based (lean body weight)

2 mmol/kg
1 mmol/kg
30-35mL/kg

For Average Adult

140 mmol
70 mmol
2L

Remember to consider all sources of fluid administration, including TPN, NG feeds, and drug infusions.
Post-operative or sick patients or those with co-morbidities, including neurosurgical patients, require a modifed regime.

4. Modify in the following situations

If you are not experienced with management of any of these patients, please seek advice
Conditions where ADH levels are elevated
Patients (especially young women) with nausea, emesis, pain and stress tend to retain water and develop hypotonicity. The postoperative period is high risk. Fluids with a higher sodium concentration administered in reduced volumes are indicated (for example
day 1 post-op: 0.9% sodium chloride with 20 mmol/L potassium at 40-50 mL/hr may be appropriate in a euvolaemic patient).
Smaller patients (weight less than 50kg)
Proportional reductions are indicated.
Reduced left ventricular function
Patients are at increased risk of fluid overload. Reduce volume given and monitor fluid status more frequently.
Reduced renal function
Patients may be at increased risk of fluid overload and hyperkalaemia.
If oliguric, do not use maintenance potassium. If hypovolaemic, correct any fluid deficit as above. If euvolaemic, limit the volume
given to approximately: urine vol + other losses + 500mL per day.
Medications that increase potassium (e.g. ACE inhibitors and Angiotensin II antagonists, spironolactone and eplerenone)
Patients are at increased risk of hyperkalaemia. Monitor potassium levels frequently.
Septic patients
Have variably increased fluid requirements. Vasopressor support in ICU may be required.
Obese
Estimate fluid requirements and electrolyte doses based on lean body weight (see medication dose calculators
http://medicationdosingcalculators.health.qld.gov.au). Adjustment of weight for morbid obesity is complex.
Malnourished patients and extended duration of therapy
Often experience complex and resistant electrolyte disturbances.
Specific fluid requirements
Patients on dialysis, with burns, transplants, acute neurological conditions (such as meningitis, encephalitis and stroke), diabetic
ketoacidosis or hyperosmolar hyperglycaemic state have very specific fluid requirements. Seek advice.
Some properties of common fluids (adapted from table 1 in the GIFTSUP guidelines)
Type of Fluid
Sodium mmol/L
Potassium mmol/L
Chloride mmol/L
Sodium chloride 0.9% *
154
0
154
Compound Sodium Lactate
129
5
109
0.3% sodium chloride & 3.3% glucose *
51
0
51
5% glucose
0
0
0

Glucose g/L
0
0
33
50

v4.00 - 04/2011

* Available as pre-mix with 20mmol or 40mmol/L of potassium.

5. When to review

Unstable patients need to be reviewed at least every 2-4 hours. All patients should be reassessed at least daily.
Consider slowing the rate of fluid infusion overnight in patients at risk of overload.
Switch to an enteral route (oral, NG, PEG etc) as soon as possible to minimise iatrogenic complications.
Please direct any feedback / comments on these guidelines to Safe Medication Management Unit (07) 31316525

See Prescribing Guidelines for Electrolytes over page

FLUIDS & ELECTROLYTES

GUIDELINES - ADULT

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Electrolyte disturbances that are difficult to correct often indicate significant pathology please seek advice.
Unit specific protocols for electrolyte disturbances take precedence over these guidelines.
HYPOKALAEMIA (mild 3.1 - 3.5mmol/L, moderate 2.5 - 3.0mmol/L, severe less than 2.5mmol/L)
The total body deficit of potassium correlates poorly with plasma potassium because most potassium is intracellular.
Low plasma potassium is a serious problem: Plasma levels less than 3.5mmol/L may result in dysrhythmias.
Moderate and severe hypokalaemia should be treated with IV and (where possible) oral supplementation. These patients usually
require at least an extra 60-80mmol potassium above maintenance requirements in next 24 hours (i.e. 100 -140mmol in total);
repeat plasma levels 4-6 hours after commencing treatment.
All potassium containing infusions must be given via an infusion pump or burette.
Maximum CONCENTRATION = 40mmol/L in sodium chloride 0.9% peripherally to prevent phlebitis.
EXCEPTION: isotonic, premixed potassium chloride 10mmol/100mL minibags (commercially premade, ready to use) can
be given peripherally. Note: Minibags MUST be given via an infusion pump.
If maximum concentrations are exceeded administration through a large vein with high blood flow (e.g. CVC, venous access
port, PICC) is required.
Maximum RATE:
With burette = 10mmol/hr.
With infusion pump = 20mmol/hr.
If maximum rate (above) exceeded, cardiac monitoring and administration through a large vein is recommended.
Mild hypokalaemia may be treated with oral supplementation alone, provided the oral route is available. For example:
Potassium Chloride effervescent Tablets (e.g. Chlorvescent) - 12 tablets twice daily (14mmol potassium per tablet).
OR
Potassium Chloride slow release tablets 600mg (e.g. Span K or Slow K or Duro K) - 2 tablets twice daily (8mmol potassium
per tablet).
OR
Potassium chloride 10% oral solution - (20mmol potassium per 15mL).
If resistant to treatment, check magnesium and replace if necessary; check for medications which may decrease plasma
potassium, e.g. salbutamol, and ensure that potassium containing maintenance fluid is administered as necessary.
HYPOMAGNESAEMIA (less than 0.7mmol/L, severe less than 0.4mmol/L)
Severe or symptomatic hypomagnesaemia (tremors, weakness, cardiac arrhythmias, convulsions) should be corrected with
intravenous magnesium sulphate.
Magnesium sulphate 5mL ampoules contain 2.47g magnesium sulphate equivalent to 10mmol magnesium. 10-20mmol
magnesium, as magnesium sulphate, can be administered in 100mL 0.9% sodium chloride over 1-2 hours. NB: in emergency
situations, magnesium can be given more rapidly.
Mild or asymptomatic hypomagnesaemia can be treated with oral magnesium supplements, Magmin.
MagMin tablets contain 500mg magnesium aspartate equivalent to 1.54mmol magnesium. Begin with 1-2 magnesium
aspartate (MagMin) tablets twice daily and increase dose if tolerated; diarrhoea is a common side effect.
HYPONATRAEMIA (less than 135mmol/L, severe less than 120mmol/L)
Management of hyponatraemia requires careful assessment of fluid status and biochemical indices including plasma glucose and
osmolality, and urinary sodium and osmolality.
If hypovolaemic, correction of the intravascular deficit with 0.9% sodium chloride is appropriate.
If euvolaemic or hypervolaemic, consider drugs (e.g. SSRIs, diuretics, antiepileptics) or conditions associated with inappropriate
ADH secretion, or conditions with reduced effective circulating volume (e.g. cirrhosis, cardiac failure). Manage with fluid restriction.
Symptomatic hyponatraemia (e.g. drowsiness, headache, fitting) is an emergency and should be managed in an intensive care
setting. Hypertonic saline and airway access may be indicated.
Seek senior advice, especially in severe (less than 120 mmol/L) or symptomatic hyponatraemia.
In general, increase plasma sodium by no more than 10mmol/L/day, to prevent permanent neurological injury from osmotic
demyelination. 0.9% sodium chloride (not hypertonic saline) is the normal mainstay of IV therapy.
HYPOPHOSPHATAEMIA (less than 0.7mmol/L, severe less than 0.4mmol/L)
Phosphate does not normally need replacement until less than 0.6mmol/L except if: alcoholism, alcohol withdrawal, malnutrition, refeeding syndrome, receiving TPN, renal phosphate wasting, recovery from diabetic ketoacidosis or respiratory failure.
Consider IV replacement if plasma phosphate less than 0.4mmol/L.
Sodium phosphate and potassium phosphate (Low-K Phos) contains 13.4mmol of phosphate in a 20mL ampoule. If phosphate
is less than 0.3mmol/L then 2 ampoules of Low-K Phos are often needed in the first 24 hours. This can be added to 100250mL
0.9% sodium chloride and given over 6-8 hours.
Oral effervescent phosphate is available, Phosphate Sandoz, and contains 16.1mmol phosphate per 500mg tablet. May need to
divide daily dose throughout the day. Diarrhoea is a common side effect.
HYPOCALCAEMIA (less than 2.15mmol/L, severe less than 2mmol/L CORRECTED or less than 0.9mmol/L IONISED)
REMEMBER: Plasma calcium (even corrected for albumin) is an unreliable measure of functional (ionised) calcium.
Hypocalcaemia often reflects severe body fluid and electrolyte disturbances.
If the patient is symptomatic (e.g. seizures, tetany, positive Chvosteks / Trousseaus) or at high risk of developing symptomatic
hypocalcaemia (e.g. post-parathyroidectomy), use IV replacement.
Calcium gluconate 10% is the preferred form of IV replacement and contains 2.25mmol of calcium in 10mL. It can be added to
100mL of 0.9% sodium chloride and infused over 30 minutes, preferably into a large vein.
Calcium chloride 10% contains 6.8mmol calcium in 10mL. It is very irritating and should be given via a central line.
DO NOT co-infuse or mix calcium with phosphate containing preparations.
For oral replacement, use effervescent calcium tablets (Sandocal) or calcium carbonate tablets (Caltrate). Give away from food.
Active Ingredient per tablet:
Sandocal - 1g elemental calcium providing approx 25mmol calcium.
Caltrate - 600mg elemental calcium providing approx 15mmol calcium.
If resistant to treatment, exclude hypomagnesaemia.
Electrolyte solutions are incompatible with blood products, other medications and often each other.
Seek advice before mixing together in an infusion or giving simultaneously via the same IV line.