IV Fluid Selection for Hospital Admission

Primary Fluid Choice: Balanced Crystalloids

The American Society of Anesthesiologists recommends using isotonic balanced crystalloid solutions, such as Ringer's Lactate or Plasmalyte, without dextrose as the first-line choice for most hospitalized patients requiring IV fluids, as they reduce the risk of kidney injury and mortality compared to normal saline, while avoiding unnecessary hyperglycemia 1, 2, 3, 4
Balanced crystalloid solutions, such as Ringer's Lactate or Plasmalyte, are preferred over 0.9% normal saline because they reduce major adverse kidney events and maintain better acid-base balance, particularly when larger volumes (>5000 mL) are administered 1, 2, 3, 4
The SMART study of 15,802 ICU patients demonstrated reduced incidence of major adverse kidney events with balanced solutions compared to normal saline 2, 3
High-volume chloride-rich solutions (>5000 mL) are associated with increased mortality and postoperative hyperchloremia in critically ill patients 1, 3, 4
Balanced solutions consistently provide better acid-base balance than normal saline across all patient populations 1, 4

The American Academy of Pediatrics recommends that pediatric patients (28 days to 18 years) requiring maintenance IV fluids should receive isotonic solutions with appropriate potassium chloride AND dextrose (2.5%-5%) to prevent hypoglycemia 5
In cases of diabetic ketoacidosis, switch to D5 with 0.45-0.75% saline when serum glucose reaches 250 mg/dL to prevent hypoglycemia while continuing insulin therapy 6
Infants at risk for hypoglycemia should receive D10 normal saline to meet glucose requirements of 4-6 mg/kg/min 6
In cases of hypernatremic dehydration, use 5% dextrose alone (without sodium) for gradual correction to prevent worsening hypernatremia 6

The first-line choice for base crystalloid solution should be a balanced crystalloid (Ringer's Lactate or Plasmalyte) 1, 2, 4
Normal saline should be avoided as routine first-line and only used when balanced solutions are unavailable 1, 4
Colloids should not be used for routine resuscitation as they offer no mortality benefit over crystalloids and carry additional risks of renal impairment and coagulopathy 4

When dextrose-containing fluids are used, monitor serum glucose hourly during acute resuscitation, then every 2-4 hours once stable to prevent both hyperglycemia and hypoglycemia 6
In pediatric patients, monitor for cerebral edema during osmolality correction, particularly in those under 20 years 6