IV Fluid Therapy Guidelines

General Principles

The American College of Surgeons recommends using balanced crystalloid solutions, such as Ringer's Lactate or Plasmalyte, as first-line therapy for most hospitalized patients requiring IV fluids, as they reduce major adverse kidney events and mortality while maintaining better acid-base balance 1, 2.
Balanced crystalloids should be the default choice for IV fluid therapy across most clinical scenarios, with electrolyte compositions closer to plasma and consistently demonstrating superior outcomes compared to normal saline 3, 4, 1, 2.

In hemorrhagic shock, use balanced crystalloids as first-line fluid therapy to reduce mortality and adverse renal events, and avoid using albumin as it provides no benefit and is more expensive 3, 4.
In acute brain injury, use isotonic crystalloids, such as 0.9% NaCl, Plasmalyte, or Isofundine, as first-line fluid therapy, and avoid hypotonic solutions, including Ringer's Lactate, due to increased mortality 7, 8.
In sepsis-induced hypoperfusion, administer at least 30 mL/kg of balanced crystalloid within the first 3 hours, and target mean arterial pressure of 65 mmHg in patients requiring vasopressors 1.
In perioperative fluid management, use balanced crystalloids as the primary intraoperative fluid, particularly in patients with end-stage renal disease or those undergoing major surgery, and target mildly positive fluid balance (+1-2 L) by end of surgery in ESRD patients to protect remaining kidney function 2, 6.

In pediatric patients (28 days to 18 years) requiring maintenance IV fluids, use isotonic balanced solutions with appropriate potassium chloride and dextrose (2.5%-5%) to prevent hypoglycemia, and monitor serum glucose hourly during acute resuscitation, then every 2-4 hours once stable 2.

Use dynamic variables, such as pulse pressure variation and stroke volume variation, rather than static variables, such as central venous pressure, to predict fluid responsiveness 1.
Normalize lactate levels as a resuscitation goal when elevated, and reassess frequently using heart rate, blood pressure, oxygen saturation, respiratory rate, temperature, and urine output 1.
Avoid fluid overload, as both inadequate and excessive IV fluid administration lead to poor outcomes, including increased infection risk and organ dysfunction, and use goal-directed therapy with frequent hemodynamic reassessment 1.