Skip to main content

Main menu

  • Home
  • Content
    • Current Issue
    • Ahead of Print
    • Past Issues
    • Supplements
    • Article Type
  • Specialty
    • Articles by Specialty
  • CME/MOC
    • Articles
    • Calendar
  • Info For
    • Manuscript Submission
    • Authors & Reviewers
    • Subscriptions
    • About CCJM
    • Contact Us
    • Media Kit
  • Conversations with Leaders
  • Conference Coverage
    • Kidney Week 2024
    • CHEST 2024
    • ACR Convergence 2023
    • Kidney Week 2023
    • ObesityWeek 2023
    • IDWeek 2023
    • CHEST 2023
    • MDS 2023
    • IAS 2023
    • ACP 2023
    • AAN 2023
    • ACC / WCC 2023
    • AAAAI Meeting 2023
    • ACR Convergence 2022
    • Kidney Week 2022
    • AIDS 2022
  • Other Publications
    • www.clevelandclinic.org

User menu

  • Register
  • Log in

Search

  • Advanced search
Cleveland Clinic Journal of Medicine
  • Other Publications
    • www.clevelandclinic.org
  • Register
  • Log in
Cleveland Clinic Journal of Medicine

Advanced Search

  • Home
  • Content
    • Current Issue
    • Ahead of Print
    • Past Issues
    • Supplements
    • Article Type
  • Specialty
    • Articles by Specialty
  • CME/MOC
    • Articles
    • Calendar
  • Info For
    • Manuscript Submission
    • Authors & Reviewers
    • Subscriptions
    • About CCJM
    • Contact Us
    • Media Kit
  • Conversations with Leaders
  • Conference Coverage
    • Kidney Week 2024
    • CHEST 2024
    • ACR Convergence 2023
    • Kidney Week 2023
    • ObesityWeek 2023
    • IDWeek 2023
    • CHEST 2023
    • MDS 2023
    • IAS 2023
    • ACP 2023
    • AAN 2023
    • ACC / WCC 2023
    • AAAAI Meeting 2023
    • ACR Convergence 2022
    • Kidney Week 2022
    • AIDS 2022
1-Minute Consult

Does my patient need maintenance fluids?

Jorge Sanchez, MD and Robert Lichtenberg, MD
Cleveland Clinic Journal of Medicine October 2019, 86 (10) 653-655; DOI: https://doi.org/10.3949/ccjm.86a.19018
Jorge Sanchez
Department of Internal Medicine, MacNeal Internal Medicine Resident Program, Berwyn, IL
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Robert Lichtenberg
Department of Internal Medicine, MacNeal Hospital, Berwyn, IL
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: [email protected]
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

My adult nonacutely ill patient, weighing 70 kg with a glomerular filtration rate (GFR) greater than 60 mL/min/1.73 m2, is admitted to the general medical service. She is to receive nothing by mouth for at least the next 24 hours for testing. Do I need to provide maintenance fluids intravenously?

The question seems like it should have an easy answer. However, there is no consensus either on the type of fluids or the need for them at all.

Mortiz and Ayus1 have described the role of maintenance intravenous (IV) fluids in acutely ill patients and made the case for isotonic saline (0.9% NaCl) to minimize the risk of hyponatremia, while acknowledging that it provides 7 to 10 g of sodium per day.

Recommendations for IV fluids for non-acutely ill hospitalized patients range from isotonic solutions such as 0.9% NaCl and lactated Ringer’s, to hypotonic fluids such as 5% dextrose in water (D5W) in 0.45% NaCl and D5W in 0.2% NaCl.2–5

The 2013 guidelines of the UK National Institute for Health and Care Excellence (NICE) recommend hypotonic fluids to provide 25 to 30 mL/kg/day of water with 1 mmol/kg/day of sodium. For a 70-kg patient (body surface area 1.7 m2), this would be 1,750 to 2,000 mL of water, with a maximum of 70 mEq/L of sodium (35 mEq/L).5 An option would be D5W in 0.2% NaCl, which has 34 mEq/L of sodium.

When choosing maintenance IV fluids, we need to consider the following questions:

  • What is my patient’s volume status?

  • What is the baseline serum sodium and renal function?

  • Are there comorbid conditions that may affect antidiuretic hormone (ADH) status such as physiologic stimulation from vol ume depletion, drugs, pathologic medical conditions, or syndrome of inappropriate ADH stimulation?

  • Will my patient be receiving strictly nothing by mouth?

  • Are there unusual fluid losses?

SCENARIO 1: ‘USUAL’ MAINTENANCE

If the patient is euvolemic, with a normal serum osmolality, a GFR more than 60 mL/ min/1.73 m2, no stimuli for ADH secretion, and no unusual fluid losses, “usual” maintenance would be expected. The usual volume for this patient can be estimated by the following formulas:

  • Maintenance volume: 2,550 mL (1,500 mL × 1.7 m2 body surface area)

  • Holliday-Segar method6: 2,500 mL (1,500 mL plus 20 mL/kg for every kilogram over 20 kg).

The usual sodium can be also estimated by the following formulas:

  • 2 g Na/day = 2,000 mg/day = 87 mEq/day

  • Holliday-Segar6: 3 mEq Na/100 mL and 2 mEq K/100 mL of maintenance fluid.

Maintenance IV fluids for our nonacutely ill adult patient could be:

  • NICE guideline5: D5W in 0.2% NaCl with 20 mEq KCl, to run at 75 mL/hour

  • Holliday-Segar method6: D5W in 0.2% NaCl with 20 mEq KCl, to run at 100 mL/ hour.

Twenty-four hours later, assuming no unusual fluid losses or stimulation of ADH secretion, our patient would weigh the same and would have no significant change in serum osmolality.

OTHER OPTIONS

What if I provide 0.9% NaCl instead?

Each 1 L of normal saline provides 154 mEq of sodium, equivalent to 3.5 g of sodium. Thus, for the 24 hours, with administration of 2 to 2.5 L, the patient would receive a sodium load of 7 to 8.75 g. The consequences of this can be debated, but for 24 hours, more than likely, nothing will happen or be noticeable. The kidneys have a wonderful ability to “dump” excess sodium ingested in the diet, as evidenced by the average Western diet with a sodium load in the range of 4 g per day.7,8

What if I provide 0.45% NaCl instead?

Each liter provides 50% of the sodium load of 0.9% NaCl. With the 24-hour administration of 2 to 2.5 L of D5W in 0.45% NaCl, the sodium load would be 3.5 to 4.8 g, and the kidneys would dump the excess sodium.

What if I provide ‘catch-up’ fluids after 24 hours, not maintenance fluids?

Assuming only usual losses and no unusual ADH stimulation except for the physiologic stimuli from volume depletion for 24 hours, our patient would lose 2 kg (1 L fluid loss = 1 kg weight loss) and 87 mEq of sodium. This is approximately 4.5% dehydration; thus, other than increased thirst, no physical findings of volume depletion would be clinically evident.

However, serum osmolality and sodium would increase. After 24 hours of nothing by mouth with usual fluid losses, there would be a rise in serum osmolality of 13.5 mOsm/L (a rise in sodium of 6 to 7 mEq/L), which would stimulate ADH in an attempt to minimize further urinary losses. There would be an intracellular volume loss of 1.3 L (Table 1). Clinically, just as with the administration of 0.9% sodium, these changes would not likely be of any clinical consequence in the first 24 hours.

View this table:
  • View inline
  • View popup
TABLE 1

Scenario 1: 24 hours without fluids

SCENARIO 2: IMPAIRED WATER EXCRETION, AND FLUIDS GIVEN

If the patient is euvolemic but has or is at risk for ADH stimulation,1,9 providing maintenance IV fluids according to the NICE or Holliday-Segar recommendations (a total of 2 L of 0.2% NaCl = 34 mEq Na/L = 68 mOsm/L) would result in an excess of free water, as an increase in ADH secretion impairs free water clearance. A potential scenario with impaired water excretion is shown in Table 2.

View this table:
  • View inline
  • View popup
TABLE 2

Scenario 2: Antidiuretic hormone stimulation and 2L of 0.2% NaCl in 24 hours

After 24 hours, the patient’s serum osmolality would drop by about 7 mOsm/L, and the serum sodium would decrease by 3 or 4 mEq. The consequence of the intracellular fluid shift would be seen by the expansion of the intracellular volume from 28 to 28.7 L.

If this patient were to have received 2 L of 0.9% NaCl (308 mOsm/L × 2 L = 616 Osm) as suggested by Moritz and Ayus,1 the result would be a serum osmolality of 284 mOsm/L, thus avoiding hyponatremia and intracellular fluid shifts.

THE BOTTOM LINE

Know your patient, answer the clinical questions noted above, and decide.

For a euvolemic patient with normal serum sodium, GFR greater than 60 mL/1.73 m2, and no ADH stimulation, for 24 hours it probably doesn’t matter that much, but a daily reassessment of the continued need for and type of intravenous fluids is critical.

For patients not meeting the criteria noted above such as a patient with systolic or diastolic heart failure, advanced or end-stage renal disease puts the patient at risk for early potential complications of either hyponatremia or sodi um overload. For these patients, maintenance intravenous fluids need to be chosen wisely. Daily weights, examinations, and laboratory testing will let you know if something is not right and will allow for early detection and treatment.

  • © 2019 The Cleveland Clinic Foundation. All Rights Reserved.

REFERENCES

  1. ↵
    1. Mortiz ML,
    2. Ayus JC
    . Maintenance intravenous fluids in acutely ill patients. N Engl J Med 2015; 373(14):1350–1360. doi: 10.1056/NEJMra1412877
    OpenUrlCrossRefPubMed
  2. ↵
    1. Feld LG,
    2. Neuspiel DR,
    3. Foster BA, et al
    ; Subcommittee on Fluid and Electrolyte Therapy. Clinical practice guideline: maintenance intravenous fluids in children. Pediatrics 2018; 142(6. doi: 10.1542/peds.2018-3083
    OpenUrlCrossRef
    1. Sterns RH
    . Maintenance and replacement fluid therapy in adults. www.uptodate.com/contents/maintenance-and-replacement-fluid-therapy-in-adults. Accessed August 21, 2019
    1. Shafiee MA,
    2. Bohn D,
    3. Hoorn EJ,
    4. Halperin ML
    . How to select optimal maintenance intravenous fluid therapy. QJM 2003; 96(8):601–610. doi: 10.1093/qjmed/hcg101
    OpenUrlCrossRefPubMed
  3. ↵
    National Institute for Health and Care Excellence (NICE). Intravenous fluid therapy in adults in hospital. www.nice.org.uk/guidance/cg174. Accessed August 21, 2019
  4. ↵
    1. Holliday MA,
    2. Segar WE
    . The maintenance need for water in parenteral fluid therapy. Pediatrics 1957; 19(5):823–832pmid: 13431307
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Appel LJ,
    2. Foti K
    . Sources of dietary sodium: implications for patients, physicians, and policy. Circulation 2017; 135(19):1784–1787. doi: 10.1161/CIRCULATIONAHA.117.027933
    OpenUrlFREE Full Text
  6. ↵
    1. Harnack LJ,
    2. Cogswell ME,
    3. Shikany JM, et al
    . Sources of sodium in US adults from 3 geographic regions. Circulation 2017; 135(19):1775–1783 doi: 10.1161/CIRCULATIONAHA.116.024446
    OpenUrlAbstract/FREE Full Text
  7. ↵
    1. Sterns RH
    . Pathophysiology and etiology of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). www.uptodate.com/contents/pathophysiology-and-etiology-of-the-syndrome-of-inappropriate-antidiuretic-hormone-secretion-siadh. Accessed August 21, 2019
PreviousNext
Back to top

In this issue

Cleveland Clinic Journal of Medicine: 86 (10)
Cleveland Clinic Journal of Medicine
Vol. 86, Issue 10
1 Oct 2019
  • Table of Contents
  • Table of Contents (PDF)
  • Index by author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Cleveland Clinic Journal of Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Does my patient need maintenance fluids?
(Your Name) has sent you a message from Cleveland Clinic Journal of Medicine
(Your Name) thought you would like to see the Cleveland Clinic Journal of Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Does my patient need maintenance fluids?
Jorge Sanchez, Robert Lichtenberg
Cleveland Clinic Journal of Medicine Oct 2019, 86 (10) 653-655; DOI: 10.3949/ccjm.86a.19018

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Does my patient need maintenance fluids?
Jorge Sanchez, Robert Lichtenberg
Cleveland Clinic Journal of Medicine Oct 2019, 86 (10) 653-655; DOI: 10.3949/ccjm.86a.19018
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Linkedin Share Button

Jump to section

  • Article
    • SCENARIO 1: ‘USUAL’ MAINTENANCE
    • OTHER OPTIONS
    • SCENARIO 2: IMPAIRED WATER EXCRETION, AND FLUIDS GIVEN
    • THE BOTTOM LINE
    • REFERENCES
  • Figures & Data
  • Info & Metrics
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • What diagnostic tests should be done after discovering clubbing in a patient without cardiopulmonary symptoms?
  • Does my adult patient need a measles vaccine?
  • Do I need to treat supine hypertension in my hospitalized patient?
Show more 1-Minute Consult

Similar Articles

Subjects

  • Hospital Medicine

Navigate

  • Current Issue
  • Past Issues
  • Supplements
  • Article Type
  • Specialty
  • CME/MOC Articles
  • CME/MOC Calendar
  • Media Kit

Authors & Reviewers

  • Manuscript Submission
  • Authors & Reviewers
  • Subscriptions
  • About CCJM
  • Contact Us
  • Cleveland Clinic Center for Continuing Education
  • Consult QD

Share your suggestions!

Copyright © 2025 The Cleveland Clinic Foundation. All rights reserved. The information provided is for educational purposes only. Use of this website is subject to the website terms of use and privacy policy. 

Powered by HighWire