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This open access book, published by Springer under the Open Access CC BY 4.0 Licence in collaboration with the International Fluid Academy (IFA, www.fluidacademy.org), explores rationalized intravenous fluid therapy for critically ill patients. Despite being commonly prescribed in inpatient settings, intravenous fluids are often administered without evidence-based guidelines, neglecting essential considerations such as the fact they are drugs, that need proper dosing, duration, indications, contraindications, side effects, and de-escalation. This book fills this knowledge gap.

Each chapter starts with a clinical vignette and a related question, followed by a concise summary abstract, key learning points, main text, and a conclusion that addresses the clinical question and provides relevant take-home messages. Additionally, every chapter includes an IFA commentary referencing the latest literature and evidence. The book begins with an introductory chapter that provides definitions and terminology, followed by four sections.

The first section covers the fundamentals of intravenous fluid therapy, including fluid compartments in sick patients, fluid bolus dynamics, heart-lung interactions, fluid challenge, fluid responsiveness, arterial blood gas analysis based on traditional and Stewart concepts, and electrolyte physiology relevant to clinical issues. The second section discusses commercially available intravenous fluids, while the third section focuses on fluid therapy in specific clinical situations. The final section introduces the concepts of fluid stewardship and appropriate fluid prescription.

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An Introduction to Fluid Stewardship - A Belgian perspective

Summary text accompanying the keynote lecture on the 7 D's of fluid therapy during opening ceremony of the 12th International Fluid Academy Day (IFAD) and 9th Benelux Emergency Medicine Symposium (BEMS) held at ULB Erasme auditoria (building W) in Anderlecht/Brussels on Saturday Nov 26th.

Introduction to Fluid Stewardship (IFAD 2022)

On 1 January 2019, the number of approved beds in Belgium was 52,565 of which 34,962 were acute beds, 13,608 were chronic and 3,995 were psychiatric beds. The distribution of the number of beds per province is shown below.

Figure 1. The distribution of the number of approved beds per province (2017)

Analysis of national data on consumption of proprietary medicinal products shows that intravenous (IV) infusion fluids were administered for a total of 14,296,864 litres in 2017. A particularly large proportion of 5,325,440 L of intravenous fluid was given to the patient for administration of other medications (antibiotics, sedation, painkillers, etc..) consisting of 4,262,270 L for medication and 1,063,169 L as dilution solution. This is called fluid creep (1). Maintenance fluids are glucose-containing IV(1) fluids and resuscitation fluids include physiological saline (NaCl 0.9%) or a balanced crystalloid solution (PlasmaLyte®, Hartmann, Ringer acetate) or colloids.

Grand Total (L)	14.296.864
Fluid Creep	5.325.440	37,2%
Maintenance	3.015.042	21,1%
Resuscitation	5.194.293	36,3%
Nutrition	553.750	3,9%

Figure 2 below shows the evolution of the total consumption of IV infusion fluids in Belgium from 2008 to 2017 with a subdivision according to the indication/type of fluid administration (maintenance, resuscitation, medication, nutrition, dilution). In recent years, we have mainly seen an increase in fluid creep. The volume of resuscitation fluids also appears to have increased after the publication of the "large" fluid trials (CHEST and 4S) in the New England Journal of Medicine. These studies showed adverse effects (mainly on kidney function) when using a certain type of colloids, namely hydroxy-ethyl starches. Following the publication of the EMEA PRAC decision, these fluids were banned in the intensive care unit and replaced by crystalloids (NaCl 0.9% and/or balanced/buffered solutions). Since some believe that larger amounts of crystalloids have to be administered to achieve the same effect on hemodynamics and volume expansion, we also see the total consumption increase over the years.

Figure 2. Evolution of total consumption of IV infusion fluids in Belgium from 2008 to 2017 with subdivision by type/indication of fluid

In 2017, there were 1,821,646 classic hospital admissions with a total of 8,379,571.6 acute bed occupying days (average of 4.6 days) and 12,751,522 total bed occupying days (combined average stay acute and chronic of 7 days). The total amount per province is shown on the heat map below (Fig . 3). This more or less corresponds to the number of approved beds (Fig. 1.)

Figure 3. Heat map of total intravenous fluid consumption (in ml) in 2017 per province

Put into perspective, this gives an average of 7.15 liters of IV infusion fluid per stay and 0.99L per bed occupying day. Compared to the international guidelines (NICE, GIFTASUP), this is a very high national consumption (2). (2)The evolution of the total number of L per stay and per day from 2008 to 2017 is shown in Figure 4 (normalized for number of stays and bed occupying days in 2017).

Figure 4. Evolution of the national consumption of infusion fluids (in L) administered per stay (left) and per bed occupying day (right) in Belgium from 2008 to 2017.

Figure 5 shows the evolution of the number of litres of infusion fluids administered as a total without the extra fluids administered as medication or dilution solution. These figures are closer to the literature data with a consumption of 4.4 L per stay and 0.61 L per bed occupying day (see below).

Figure 5. Evolution of the number of litres of infusion flea administered in Belgium as a total (top), per stay (middle) and per lying day (bottom) without medication or dilution solution in the period from 2008 to 2017.

A recent study conducted in Fife in Scotland, by Marcia McDougall and colleagues shows an average consumption of 5 L per stay and 0.65 L per bed occupying day at the start of the fluid stewardship program with a decrease to 3.7 L per stay and 0.4 L per bed occupying day post-implementation (3). Good clinical practice and well thought-out IV fluid use should therefore aim for a consumption of a maximum of 4 L or less per (acute) stay or 0.4 L or less per bed occupying day. With the implementation of a Fluid Stewardship program, it is possible to achieve this objective in any hospital. In Belgium, the analysis of the forfait farmaceutische specialiteiten (FFFS) can be very helpful in carrying out the baseline analysis.

Unfortunately, infusion fluids are all too often do not get the attention they deserve and they are not seen as a real medicine or drugs. As with antibiotic stewardship, we must pay attention to the 4 D's (4)

DRUG

Approach an IV fluid the same way as any other drug
Select the type IV fluid with the most suitable composition for the patient
Think about the indication of why you are using the fluid
Consider contraindications, comorbidities and side effects

DOSE

Consider timing, the starting dose, the rate of administration and cumulative dose:
1. Fluid tbolus: 4 ml/kg/15 min
2. Mini-fluid challenge: 1 ml/kg/5 min
3. SSCG: 30 ml/kg/1 hour
Determine the daily need for
1. Water: 1ml/kg/hr of 25 ml/kg/d
2. Glucose: 1 – 1.5g/kg/d (to prevent starvation ketosis)
3. Sodium: 1 – 1.5 mmol/kg/d
4. Potassium: 1 mmol/kg/d
5. Chloride: 1 mmol/kg/d
Consider pharmacodynamics and pharmacokinetics
1. Infusion: Same volume effect of crystalloids vs colloids as long as infusion runs
2. Distribution: decreased in shock, hypotension, during surgery, after induction and sedation
3. Elimination: decreased in shock, hypotension, during surgery, after induction and sedation

DURATION

Always ask the 4 questions
1. When to start with IV liquid?
2. When to stop taking IV liquid
3. When to start dewatering?
4. When to stop dewatering?
Stop IV infusion if the patient no longer responds to fluid administration without an increase in cardiac output (or blood pressure)
Monitor for hypo- and hypervolemia
Use dynamic indices of fluid responsiveness

DE-ESCALATION

Limit IV fluids as soon as the patient can drink again and take oral fluids
Give concentrated enteral nutrition
Start deresuscitation in case of fluid overload and accumulation
Fluid accumulation causes increased morbidity and mortality

In addition to a high cost price and the fact that fluids consume a significant part of the FFFS (Fig. 6), infusion fluids often cause important morbidity (fluid overload or accumulation with end organ damage, acute kidney failure, electrolyte disorders, etc.) and mortality, especially in the case of their inappropriate use (5).

Figure 6. Example of representation of national available data on FFFS with median, mean and best of class.

The goal of fluid stewardship is to obtain a picture of the current infusion practices in some Belgian hospitals and if possible also in Europe (via Ehden project, OMOP-CDM and globally via OHDSI). From this, targeted conclusions can be drawn to prevent overuse and ill-considered infusion use and to develop some useful and clear guidelines to support education and training of doctors and nurses as well as other care givers. Implementation of Fluid Stewardship is the only way to go and this is a team effort and requires change from pharmacists, nurses and doctors.

Definition fluid stewardship

Fluid stewardship is defined as a series of coordinated interventions, introduced to select the optimal fluid, dose and duration of therapy that results in the best clinical outcome, the prevention of side effects and complications and cost reduction (6-8). Recent research suggests that additional knowledge is needed on the proper administration and monitoring of fluids in all hospital departments (3, 9).