Guidance on sparing of intravenous fluid use - updated
22 August 2024
The following advice to anaesthetists is provided by the Chair of ANZCA’s Safety and Quality Committee, Associate Professor Joanna Sutherland in response to a widespread shortage of intravenous fluids.
This guidance is produced to aid anaesthetists and their perioperative teams in minimising perioperative IV fluid use by avoiding potentially low-benefit fluid therapy situations, especially in an environment of limited supply.
It follows the ANZCA Safety Alert that was posted on 26 July. Australian health ministers issued a joint statement on 16 August that indicated that shortages of IV fluids, while easing, are expected to continue through 2024.
ANZCA recognises that anaesthetists have a clear understanding of their patients’ fluid requirements and so although many of these points may seem obvious or “second nature”, it is hoped that they can aid patient preparation and perioperative decision making in a systematic way. Further, ANZCA guidance is a principal source for advice from regulatory authorities.
This guidance is primarily intended to apply to elective adult patients and is dependent upon individual clinical circumstances. Anaesthetists are encouraged to demonstrate leadership and work with management to implement appropriate local and evidence-based solutions to manage risk and conserve resources for patients with the highest need.
Depending on the nature and volume of surgery performed, ANZCA recommends consideration of a local emergency IV fluid reserve – for institutions performing major surgery and/or obstetric procedures we suggest this should be a minimum of 5L of sodium based crystalloid solutions.
Preoperative
- Provide access to clear oral liquids up to two hours prior to surgery according to the guidance provided in PG07 Appendix 1.
- Fasting guidelines (PG07) continue to be free clear fluids between 6 and 2 hours before a procedure.
- Emerging evidence supports “SipTilSend” as a means of reducing unnecessarily prolonged preoperative liquid fasting, and implementation based on locally developed protocols is strongly encouraged.
- Importantly “SipTilSend” is supervised limited intake of fluid within 2 hours of surgery; up to 200 ml/hr in adults. All patients should continue to receive assessment of aspiration risk as part of their routine anaesthetic assessment and the anaesthetic planned accordingly.
- Any “SipTIlSend” policy should be introduced involve education and discussion with the wider multidisciplinary team including nursing and surgical colleagues (see example from NHS Scotland).
Anaesthesia preparation
Consider the need for “routine” IV infusions. Fluids may not be needed for cases such as:
- Routine upper GI endoscopy.
- Minor cases of short duration where blood loss is not expected and a rapid return to oral intake is likely.
- Elective colonoscopy. High quality evidence (Leslie et al., 2006, Leslie et al., 2016) suggests that routine use of IV fluids may not be necessary, although clinician judgement is always paramount
Consider the type of IV fluid
- In most cases perioperative Hartmann’s solution, Normal Saline and Plasmalyte are interchangeable.
- Anaesthetists will be aware of the risk of hyperchloraemic metabolic acidosis with the infusion of high volumes of Normal Saline.
- Ensure staff understand that dextrose containing solutions are hypotonic and cannot replace sodium containing solutions for rehydration or maintenance, or with infusion of certain medications, for example, syntocinon (also refer to Product Information or Australian Injectable Drugs Handbook for drug compatibilities).
- Anaesthetists will be aware that dextrose infusions in patients with diabetes may cause hyperglycaemia.
Exceptions – fluids should be considered as high value for patients who
- Have pre-existing renal impairment.
- Have recently been taking SGLT-2 inhibitors.
- Are having major or prolonged surgery.
- The RELIEF trial demonstrated that fluid restriction in major elective abdominal surgery resulted in more renal impairment and wound infection compared with moderate liberal IV fluids.
Anaesthesia and postoperative
- Use of direct bolus doses and small flush fluids rather than a carrier fluid, where appropriate
- Use of syringe drivers where appropriate rather than free-running IV bags.
- Use of rate controlled IV infusion pumps may help provide controlled low-rate fluids when needed and avoid unintended fluid boluses. This should be balanced against the need to have a free running IV set for rapid fluid infusion if needed.
- Early resumption of oral fluids and oral medications as soon as appropriate (in line with surgical requirements)
- Patients having major surgery, and any patient with pre-existing chronic kidney disease, will need regular (daily) monitoring of renal function.
- Recommended transfusion triggers for blood products remain unchanged.