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Nursing Practice Keywords Fluid resuscitation/‘5Rs’/

Crystalloids/Colloids
Review
Intravenous therapy This article has been
double-blind peer reviewed

In this article...
● Guidance on intravenous fluid therapy
● Parameters that may indicate the need for fluid resuscitation
● Compared risks and benefits of colloids and crystalloids

Choosing between colloids and

crystalloids for IV infusion
Key points
Author Lisa Smith is senior lecturer in emergency and urgent care at the University
The loss of of Cumbria.
circulating fluid
volume can lead to Abstract Hypovolaemia resulting from illness or trauma can precipitate imbalances
imbalances in in homoeostasis due to the loss of circulating fluid volume. By addressing
homoeostasis hypovolaemia, homoeostasis can be restored, preventing hypoperfusion and
subsequent organ dysfunction. Administering intravenous fluids can replace any lost
Recognising, circulating volume. The National Institute for Health and Care Excellence outlines five
assessing and ‘Rs’ of fluid therapy: resuscitation, routine maintenance, replacement, redistribution
monitoring patients’ and reassessment. This article provides an overview of fluid therapy, covering the
need for fluid NICE guidance and clarifying the differences between crystalloids and colloids, and
therapy is crucial when to use them.

The ‘5Rs’ of Citation Smith L (2017) Choosing between colloids and crystalloids for IV infusion.
intravenous fluid Nursing Times [online]; 113: 12, 20-23.
administration are:

T
resuscitation,
routine o maintain its finely tuned
maintenance, homoeostasis, the human adult
replacement, body needs an average daily fluid
redistribution and intake of 2.5-3 litres (Moore and
reassessment Cunningham, 2017). It also requires a con-
stant balance in the levels of nutrients,
Crystalloids and oxygen and water to preserve a stable
colloids, both internal environment (Moini, 2016). This
plasma volume balance can be easily altered by illness or
expanders, are used injury, resulting in a loss of one or all of
to increase depleted these elements. This can lead to dehydra-
circulating volumes tion, hypoperfusion leading to reduced
oxygen uptake, and organ dysfunction, so
To administer redressing the imbalance is essential.
intravenous fluids, A reduction in oral fluid intake, the
health professionals redistribution of fluid in the vascular
must understand spaces and a decreased circulating volume
what crystalloids need to be managed. Intravenous fluid
and colloids do and therapy is one way of managing reduced
when to use them fluid intake by reducing its effects and
replacing lost fluids.
Recognising the signs and symptoms of
fluid loss is necessary to identify the need
for fluid administration. Knowledge of
when to administer IV fluids, what type of
fluid to administer, and why they are all
essential. The National Institute for Health
and Care Excellence’s (2017) guidance on IV
fluid therapy in adults in hospital stresses
the need for health professionals to under-
stand the physiology of fluid and electro-
lyte balance. It also outlines five ‘Rs’ of
fluid administration (Box 1). However,
there are many fluid replacement products
available and it is not always clear which
one should be used.
This article provides an overview of the
NICE guidance, highlighting what it
means for health professionals adminis-
tering IV fluids. It also sheds light on the
differences between crystalloid and colloid
solutions, and gives practical guidance on
when each one should be used.
Physiology
For effective tissue and organ perfusion,
maintenance of finely balanced levels of
oxygen, fluid and electrolytes (homoeo-
stasis) is essential. Fluid volumes need to
be distributed into the intracellular and
extracellular spaces (the latter being fur-
ther divided into the interstitial and

Nursing Times [online] December 2017 / Vol 113 Issue 12 20 www.nursingtimes.net

Nursing Practice
Review
intravascular compartments). The move-
ment of fluid between these spaces is con-
tinual. This enables cells to receive their
necessary supply of electrolytes such as
sodium, potassium and carbon. Along
with oxygen, these are fundamental for
cell performance (Peate and Nair, 2016).
Homoeostasis is easily affected by any
insult to the body, be it from illness, injury,
trauma or medication. This imbalance can
quickly lead to worsening illness and/or
impede recovery. Hypovolaemia will
reduce the circulating fluid volumes,
resulting in reduced electrolyte and
oxygen supply to the cells. A large reduc-
tion in fluid volume can result in hypovol-
aemic shock. Patients who go into hypo-
volaemic shock need fluid resuscitation to
maintain their cardiac output and organ
perfusion.
NICE guidance
NICE’s (2017) guidance on IV fluid therapy
indicates that the assessment of patients
should include:
l P
 hysical examination;
l O
 bservation of vital signs over time;
l C
 linical presentation.
It also provides a set of parameters that
may indicate that a patient needs fluid
resuscitation (Box 2).
The parameters highlight the impor-
tance of assessing patients’ fluid and elec-
trolyte balance. This involves ascertaining
their history of fluid intake and any com-
plaints of thirst. Consideration should also
be given to the likelihood of insensible
fluid loss – for example, from altered bowel
function such as diarrhoea, or injuries
such as burns. Comorbidities such as dia-
betes and cardiovascular disease can also
lead to fluid and electrolyte imbalances.
The monitoring of vital signs, along
with the assessment of jugular venous
pressure and observation for possible
oedema and postural hypotension, can
help identify abnormalities in patients’
fluid and electrolyte balance. The National
Early Warning Score (NEWS) and fluid bal-
ance and weight charts are essential tools.
Additional tests such as full blood count
and urea and electrolytes can confirm the
need for IV fluid therapy (NICE, 2017).
The ‘5Rs’ of fluid resuscitation
Resuscitation
To ascertain the fluid requirements of
patients who are acutely ill, an accurate
assessment is needed and should include
the ABCDE – airway, breathing, circulation,
disability, exposure – approach (Frost,
2015). It is also important to investigate the
Nursing Times [online] December 2017 / Vol 113 Issue 12
Box 1. Five ‘Rs’ of intravenous
fluid administration
l Resuscitation
l Routine maintenance
l Replacement
l Redistribution
l Reassessment
Source: National Institute for Health and Care
Excellence (2017)
cause of any potential fluid loss. Finding
and treating that cause, along with the
administration of fluid therapy, is essential
to rule out refractory fluid loss. If not
addressed, this persistent loss of circulating
volume could lead to:
l T he need for further fluid resuscitation;
l I ncreased volumes of fluid
requirements;
l I n severe cases, debilitating illness
or death.
NICE (2017) recommends a bolus of
500ml of crystalloid solution (containing
sodium in the range of 130-154mmol/L)
over less than 15 minutes in patients
requiring fluid resuscitation; this should
be avoided for those who have any evi-
dence of pulmonary oedema as a result of
cardiac failure (Frost, 2015). This initial
fluid resuscitation should be followed by a
reassessment. If further fluid resuscitation
is required, then fluid boluses of 250-
500ml should be given. Patients needing
continuous boluses of up to 2L will need
further medical review.
Routine maintenance
Routine maintenance fluids are needed in
patients who are at ongoing risk of fluid
loss. Reasons for this could be poor fluid
intake, recent surgery, bowel dysfunction
and other comorbidities. Clinical exami-
nation, investigations, vital signs
monitoring (including fluid balance and
weight measurements) can all help to
determine a patient’s need for routine
maintenance fluids.
Replacement
Ongoing assessment of patients’ fluid bal-
ance is paramount. Assessment should
focus on:
l E
 nsuring adequate hydration;
l E
 nsuring electrolyte balance;
l C
 hecking for any potential fluid overload.
When ensuring normal electrolyte
parameters are met, it is particularly
important to consider the potassium
levels. Alterations in potassium – either
hypokalaemia or hyperkalaemia – can
21
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affect patients’ cardiac performance
causing arrhythmias, heart failure and/or
cardiac arrest. If continued fluid loss is
suspected, this should be checked and
losses monitored.
Redistribution
Redistribution of fluid can occur in critical
illness. Fluid is lost from the circulatory
volume and moves into the tissues; this is
called ‘third space loss’ (Frost, 2015). This
may be seen in patients with cardiac
failure, renal failure or sepsis, and oedema
may be present. To manage these patients
effectively, increased monitoring, further
assessment and investigations are needed.
In some cases, specialist intervention,
such as the monitoring of central venous
pressure, kidney function tests or high
dependency care, may be required.
Reassessment
Regular reassessment of patients’ fluid
therapy needs is essential. In those who
require ongoing fluid therapy for three or
more days, the enteral routes of adminis-
tration should be considered (NICE, 2017).
Enteral routes reduce the need for IV access
and, in doing so, reduce the risks of
ongoing IV therapy, such as catheter-
related infections.
Types of fluids
Crystalloids
Crystalloid solutions are isotonic plasma
volume expanders that contain electro-
lytes. They can increase the circulatory
volume without altering the chemical bal-
ance in the vascular spaces. This is due to
their isotonic properties, meaning their
components are close to those of blood
circulating in the body.
Crystalloid solutions are mainly used to
increase the intravascular volume when it
is reduced. This reduction could be caused
by haemorrhage, dehydration or loss of
fluid during surgery.
Box 2. Parameters for fluid
resuscitation
l Systolic blood pressure: <100mmHg
l Heart rate: >90 beats per minute
l Capillary refill: >2 seconds or
peripheries cool to touch
l Respiratory rate: >20 breaths
per minute
l NEWS: ≥5
NEWS = National Early Warning Score
Source: National Institute for Health and Care
Excellence (2017)
www.nursingtimes.net

Nursing Practice
Review
Table 1. Comparative summary of crystalloid and
colloid solutions
Crystalloid solution
Half-life of 30-60 minutes
Three times the volume needed for
replacement
Excessive use can cause peripheral and
pulmonary oedema
Molecules small enough to freely cross
capillary walls, so less fluid remains in the
intravascular spaces
Inexpensive
Non-allergenic
Suitable for vegetarian or vegan patients
Source: Adapted from Pryke (2004)
The most frequently used crystalloid
fluid is sodium chloride 0.9%, more com-
monly known as normal saline 0.9%. Other
crystalloid solutions are compound
sodium lactate solutions (Ringer’s lactate
solution, Hartmann’s solution) and glu-
cose solutions (see ‘Preparations con-
taining glucose’ below). Some crystalloid
preparations containing additives such as
potassium or glucose are used in specific
circumstances, for example, in hypoka-
laemia and hypoglycaemia (Joint Formu-
lary Committee, 2017).
“The question of which
plasma volume expander
to use is controversial”
Crystalloid solutions such as sodium
chloride 0.9%, Ringer’s lactate and Hart-
mann’s solution need to be administrated
in larger volumes than colloid solutions.
As two-thirds of the infused volume will
move into the tissues, only the remaining
third will stay in the intravascular space
(NICE, 2017), leaving a diminished circu-
lating volume in need of further fluid
administration. This increased volume can
cause unwanted side-effects such as
oedema (NICE, 2017).
Excessive amounts of infused sodium
chloride 0.9% can produce hyperchlo-
raemic acidosis due to its high chloride
content, leading to renal dysfunction,
resulting in a reduced glomerular filtra-
tion rate (NICE, 2017; Clarke and Malecki-
Ketchell, 2016; Myburgh and Mythen,
2013). To reduce this risk, compound
sodium lactate solutions (Ringer’s lactate/
Nursing Times [online] December 2017 / Vol 113 Issue 12
Colloid sollution
Half-life of several hours or days
Replaces fluid volume for volume
Excessive use can precipitate cardiac
failure
Molecules too large to cross capillary
walls, so fluid remains in intravascular
spaces for longer
More expensive than crystalloids
Risk of anaphylactic reactions
Some preparations unsuitable for
vegetarian or vegan patients
Hartmann’s solution) can be used (Joint
Formulary Committee, 2017; NICE, 2017).
Crystalloid preparations
containing glucose
Normal saline with the addition of 5%
glucose is often used as a maintenance
fluid. The main function of normal saline
is to replace lost water, as it distributes the
fluid throughout the body – thereby
increasing total body water – but does not
restore intravascular volume. The loss of
water without loss of electrolytes is rare,
but can be seen in patients with diabetes
insipidus and hypercalcaemia. The addi-
tional glucose acts as a source of energy
for patients who are unable to take oral
foods and fluids (Joint Formulary Com-
mittee, 2017).
Hyponatraemia is a side-effect of the
excessive use of 5% glucose. This is coun-
teracted by using mixed solutions, such as
0.18% or 0.45% sodium chloride in 4% glu-
cose, or normal saline and 5% glucose
(Frost, 2015).
Colloids
Colloids are gelatinous solutions that
maintain a high osmotic pressure in the
blood. Particles in the colloids are too large
to pass semi-permeable membranes such
as capillary membranes, so colloids stay in
the intravascular spaces longer than crys-
talloids. Examples of colloids are albumin,
dextran, hydroxyethyl starch (or
hetastarch), Haemaccel and Gelofusine.
Caution should be used when adminis-
tering hetastarch: exacerbated by the
haemodilution effects of fluid administra-
tion, it can negatively affect platelet count,
22
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which can have a temporary negative effect
on clotting times and coagulation (Marx
and Schuerholz, 2010). Hypertension and
tachycardia, cardiac failure, and pulmo-
nary and peripheral oedema are all poten-
tial side-effects of the excessive adminis-
tration of albumin, dextran or hetastarch
(Frost, 2015; Marx and Schuerholz, 2010).
Which fluid to administer?
Crystalloids and colloids are plasma
volume expanders used to increase a
depleted circulating volume. Over the
years they have been used separately or
together to manage haemodynamic insta-
bility. Both are suitable in fluid resuscita-
tion, hypovolaemia, trauma, sepsis and
burns, and in the pre-, post- and peri-oper-
ative period. On occasion, they are used
together (Frost, 2015).
Colloids carry an increased risk of ana-
phylaxis, are more expensive (Frost, 2015)
and come with an added complication for
vegetarian or vegan patients, as some
preparations contain gelatin (Joint Formu-
lary Committee, 2017). However, colloid
solutions are less likely to cause oedema
than crystalloid solutions. Crystalloids are
less expensive, carry little or no risk of ana-
phylaxis, and pose no problem for vege-
tarian or vegan patients. However, evi-
dence on any potential harmful effects of
crystalloids is inconclusive. Table 1
summarises the main characteristics of
crysalloid and colloid solutions.
What the literature says
The question of which plasma volume
expander to use has long been controver-
sial, resulting in several studies and sys-
tematic reviews. In recent years, numerous
research studies have been performed in
different clinical situations to compare
crystalloids and colloids and look at their
advantages and disadvantages (Skytte
Larsson et al, 2015; Jabaley and Dudaryk,
2014; Yates et al, 2014; Burdett et al, 2012).
Jabaley and Dudaryk (2014) published a
study that compared the effects of crystal-
loids and colloids in trauma patients who
needed fluid resuscitation; as haemor-
rhage is the second most common cause of
death from trauma, the need for haemody-
namic stability and the maintenance of
tissue and organ perfusion is essential.
The study had limitations, including small
sample size, funding and reporting bias,
and the results were inconclusive.
Yates et al (2014) studied post-operative
patients who were administered goal-
directed fluid therapy. Their study demon-
strated that colloids had no benefit over
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Nursing Practice
Review
crystalloids in patients who had had colo-
rectal surgery and confirmed that using
crystalloids was just as effective.
Skytte Larsson et al (2015) compared the
effect of colloids and crystalloids on renal
perfusion, filtration and oxygenation after
cardiac surgery. Maintenance of oxygen
delivery and renal perfusion are particularly
important in the post-operative period to
exclude the risk of acute kidney injury.
Skytte Larsson et al concluded that there
was no difference in effectiveness between
colloid and crystalloid solutions in ensuring
adequate oxygen perfusion to the kidneys.
Smorenberg and Groeneveld (2015)
studied the effects of fluid therapy on 42
septic and non-septic patients who had
been assessed as hypovolaemic. Their
study compared the urine output of those
receiving crystalloid and colloid solutions
and determined that patients receiving
crystalloids had higher output volumes
than those receiving colloids.
Perel et al (2013) performed a Cochrane
systematic review of 78 randomised con-
trolled trials comparing colloids and crys-
talloids as plasma volume expanders in
patients who were critically ill. They con-
cluded that colloids did not prove more
effective than crystalloids in reducing the
risk of death in patients with trauma or
burns and in patients post-operatively.
Orbegozo Cortés et al (2014) published a
structured review on crystalloid solutions.
It included 28 studies that had investigated
the physiological effects of crystalloid
solutions in several different clinical situa-
tions. The review concluded that crystal-
loid solutions can have negative effects on
electrolyte balance, coagulation and liver
and kidney function. It found that normal
saline increased blood loss and the need
for blood transfusion, and that Ringer’s
lactate solution increased serum lactate
levels. However, overall the studies were
inconclusive as to whether the changes
brought about by crystalloid solutions
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made any difference to patients’ morbidity
and mortality. This lack of definitive con-
clusions was due to the fact that the 28
studies has been performed in different
clinical settings.
Making use of these studies is problem-
atic because they were conducted across
diverse clinical environments using dif-
ferent research methods, with alternative
hypotheses and, therefore, also with
potentially different outcomes. One size
does not fit all, meaning the answer may
not be the same for all clinical environ-
ments: colloids may be better suited to
some clinical situations and crystalloids
may be better in others.
Implications for practice
To safely administer IV fluids, nurses and
midwives need to ensure that:
● T he patient is getting the right type of
fluid to meet their clinical need;
● T he patient is adequately assessed
before, during and after IV therapy;
● I V therapy is working for the patient
and, if this is not the case, oral or
enteral fluids are considered as an
alternative;
● F luid balance and weight charts are
completed and reviewed;
● R egular blood samples are taken,
checked and reviewed.
Managers of staff administrating IV
fluids need to ensure that:
● S taff receive up-to-date education and
training, including on the ‘5Rs’ of fluid
therapy;
● S taff know what they are giving to
patients and why;
● F luid therapy is delivered in accordance
with the best use of resources.
Nurses and midwives administering IV
fluids should be aware of the variations
between the different fluid types as well as
any potential complications. They also
have a duty of care to understand the
effects, side-effects, precautions and
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For more articles
on intravenous therapy, go to
nursingtimes.net/IVtherapy
contraindications (Nursing and Midwifery
Council, 2015) of each. As with any medica-
tion, patients undergoing infusion
therapy should be closely monitored to
avoid fluid and electrolyte imbalances.
This may mean weighing them daily, as
this is a reliable method of monitoring
fluid status (NICE, 2017). NT
References
Burdett E et al (2012) Perioperative buffered
versus non-buffered fluid administration for
surgery in adults. Cochrane Database of
Systematic Reviews; 12: CD004089.
Clarke D, Malecki-Ketchell A (2016) Nursing the
Acutely Ill Adult: Priorities in Assessment and
Management. London: Palgrave.
Frost P (2015) Intravenous fluid therapy in adult
inpatients. British Medical Journal; 350: g7620.
Jabaley C, Dudaryk R (2014) Fluid resuscitation for
trauma patients: crystalloids versus colloids.
Current Anesthesiology Reports; 4: 3, 216-224.
Joint Formulary Committee (2017) British National
Formulary 72. London: BMJ Group and
Pharmaceutical Press.
Marx G, Schuerholz T (2010) Fluid-induced
coagulopathy: does the type of fluid make a
difference? Critical Care; 14: 1, 118.
Moini J (2016) Anatomy and Physiology for Health
Professionals. Burlington, MA: Jones and Bartlett
Learning.
Moore T, Cunningham S (2017) Clinical Skills for
Nursing Practice. Abingdon: Routledge.
Myburgh JA, Mythen MG (2013) Resuscitation fluids.
The New England Journal of Medicine; 369: 13, 1243.
National Institute for Health and Care Excellence
(2017) Intravenous Fluid Therapy in Adults in
Hospital. Nice.org.uk/cg174
Nursing and Midwifery Council (2015) Standards for
Medicines Management. Bit.ly/NMCMedsManage
Orbegozo Cortés D et al (2014) Isotonic crystalloid
solutions: a structured review of the literature.
British Journal of Anaesthesia; 112: 6, 968-981.
Peate I, Nair M (2016) Fundamentals of Anatomy
and Physiology for Nursing and Healthcare
Students. Chichester: Wiley Blackwell.
Perel P et al (2013) Colloids versus crystalloids for
fluid resuscitation in critically ill patients. Cochrane
Database of Systematic Reviews; 2: CD000567.
Pryke S (2004) Advantages and disadvantages of
colloid and crystalloid fluids. Nursing Times; 100:
10, 32-33.
Skytte Larsson J et al (2015) Effects of acute
plasma volume expansion on renal perfusion,
filtration, and oxygenation after cardiac surgery: a
randomized study on crystalloid vs colloid. British
Journal of Anaesthesia; 115: 5, 736-742.
Smorenberg A, Groeneveld AB (2015) Diuretic
response to colloid and crystalloid fluid loading in
critically ill patients. Journal of Nephrology; 28: 1,
89-95.
Yates DR et al (2014) Crystalloid or colloid for
goal-directed fluid therapy in colorectal surgery.
British Journal of Anaesthesia; 112: 2, 281-289.
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