Malbrain et al. Annals of Intensive Care (2023) 13:89 Annals of Intensive Care
https://doi.org/10.1186/s13613-023-01177-y
REVIEW Open Access
Multidisciplinary expert panel report on fluid
stewardship: perspectives and practice
Manu L. N. G. Malbrain1,2,3,4* , Pietro Caironi5,6 , Robert G. Hahn7, Juan V. Llau8,9, Marcia McDougall10 ,
Luís Patrão11,12, Emily Ridley13 and Alan Timmins14
Abstract
Although effective and appropriate fluid management is a critical aspect of quality care during hospitalization,
the widespread adoption of consistent policies that ensure adequate fluid stewardship has been slow and heterog-
enous. Despite evidence-based guidelines on fluid management being available, clinical opinions continue to diverge
on important aspects of care in this setting, and the consistency of guideline implementation is far from ideal. A mul-
tidisciplinary panel of leading practitioners and experts convened to discuss best practices for ongoing staff educa-
tion, intravenous fluid therapy, new training technologies, and strategies to track the success of institutional fluid
stewardship efforts. Fluid leads should be identified in every hospital to ensure consistency in fluid administration
and monitoring. In this article, strategies to communicate the importance of effective fluid stewardship for the pur-
poses of education, training, institutional support, and improvement of patient outcomes are reviewed and recom-
mendations are summarized.
Keywords Critical care, Perioperative care, Fluid stewardship, Crystalloids, Buffered solutions, Fluid therapy
Introduction
The primary goal of fluid stewardship is to optimize
intravenous (IV) fluid administration, minimize the det-
*Correspondence: rimental effects of inappropriate fluid administration,
Manu L. N. G. Malbrain and thereby potentially improve clinical outcomes. Pro-
1
First Department Anaesthesiology and Intensive Therapy, Medical viding consistent educational content and rationalizing
University Lublin, Lublin, Poland available fluids is also important. Successful institutional
2
International Fluid Academy, Lovenjoel, Belgium fluid stewardship practice is therefore a critical aspect of
3
Medical Data Management, Medaman, Geel, Belgium
4
Medical Management, AZ Oudenaarde Hospital, Oudenaarde, Belgium quality hospital care for many patients.
5
Department of Anesthesia and Critical Care, San Luigi Gonzaga Hospital, Despite the importance of effective fluid manage-
Orbassano, Turin, Italy ment as recognized by the United Kingdom’s National
6
Department of Oncology, University of Turin, Turin, Italy
7
Anesthesia and Intensive Care, Karolinska Institute, Stockholm, Sweden Institute for Health and Care Excellence (NICE) [1] and
8
Anaesthesiology and Post‑Surgical Critical Care, University Hospital other efforts such as the British Consensus Guidelines
Doctor Peset, Valencia, Spain on Intravenous Fluid Therapy for Adult Surgical Patients
9
Anaesthesiology, Department of Surgery, University of Valencia,
Valencia, Spain (GIFTASUP) [2], the Perioperative Quality Initiative
10
Anaesthetics and Intensive Care, Victoria Hospital, Kirkcaldy, Fife, (POQI) [3], and International Fluid Academy (IFA) guid-
Scotland ance [4, 5], inappropriate fluid use continues to be an
11
Intensive Care Unit, Centro HospitalarTondela-Viseu, EPE, Viseu, Portugal
12
UpHill Health, Lisbon, Portugal important gap in care for many institutions, with poten-
13
Fluid Management lead, Department of Nursing, Victoria Hospital, tial for impact on patient outcomes and health care costs
Kirkcaldy, Fife, Scotland [6–10]. Many institutions recognize that this potential
14
Pharmacy Department, Victoria Hospital, Kirkcaldy, Fife, Scotland
care gap results in excessive costs, but this consideration
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/.
, Malbrain et al. Annals of Intensive Care (2023) 13:89 Page 2 of 14
is inconsistent across all organizations. Reasons cited for 1.5 to 2.5 L of water, 50 to 100 mmol of sodium, and 40 to
ongoing fluid mismanagement include poorly ingrained 80 mmol of potassium daily, based upon the daily physi-
habits among staff and a lack of consistent training and ological needs of water and salts. The NICE organiza-
education [4]. Targeted efforts that focus on education, tion in the UK later published a set of guidelines for fluid
recordkeeping and auditing have been shown to improve therapy in hospitalized adults [1]. For maintenance fluids,
adherence to current NICE guidance [11]. Many sur- current NICE guidance recommends 25–30 mL of fluid
veys of clinicians’ knowledge have demonstrated deficits and 1 mmol of sodium, potassium, and chloride per kg
in education [11]. During the 2019 International Fluid body weight over a 24-h period, with an adjustment using
Academy Day (IFAD) meetings held in Campinas, Bra- ideal body weight in obese patients. NICE guidelines for
zil, and Valencia, Spain, participants (mainly physicians) pediatric fluid administration are also available and con-
were encouraged to complete a 57-question survey to sider children’s physiological differences in fluid and elec-
investigate awareness of best practices with respect to trolyte handling [1].
fluid management [12]. Nearly three-quarters of partici- These recommended amounts of fluid and sodium
pants responded that their institutions do not have any are rather restrictive and represent about two-thirds of
general ward or ICU guidelines for IV fluid management, what is contained in the diets of healthy Europeans [14].
and only 6.5% of respondents achieved an above-average However, hospitalized patients with comorbidities, and
score on knowledge testing with respect to fluid manage- particularly the elderly, may have impaired renal func-
ment [13]. tion and altered handling of fluids and electrolytes, i.e.,
Appropriate fluid stewardship practices are essential post-operatively, hence the lower recommendations in
for optimal care in all hospitalized patients. Best prac- the NICE guideline. Frequent monitoring of clinical sta-
tices require adequate clinician awareness, training, and tus and blood tests are essential to ensure adequate fluid
education. The primary aim of this paper therefore was provision.
a fresh appraisal and discussion of the available evidence While the advantages of fluid therapy are apparent in
on this topic. complicated surgeries, the benefits can be questioned in
minor surgical procedures of short duration (< 20 min)
and not associated with fluid losses [15]. Randomized
Methods clinical studies of different infusion rates suggest that
A panel of leading practitioners and clinical researchers uncomplicated surgery lasting 1–2 h can generally be
who are considered effective stewards of fluid manage- managed with a restrictive fluid program consisting of
ment at their home institutions participated in a 2-day 3–5 mL/kg/h of balanced crystalloid fluid [16]. Infusion
virtual Advisory Board meeting (September 15–16, rates lower than 2 mL/kg/h increase the risk of post-
2021) to discuss the current state of fluid management operative nausea [17]. We agree that administration of
practices in Western Europe and identify gaps in train- resuscitation fluid is best guided by individual flow-based
ing and education. To ensure an ample diversity of clini- hemodynamic measurements in complex patients but
cal perspectives on this topic, a nurse and a pharmacist note that advantages are most apparent with signs of
were both included on the panel. This was followed by a organ dysfunction in intensive care and during lengthy
physical meeting held during the 10th International Fluid surgery when the hydro-electrolytic balance is unclear or
Academy Days meeting in Brussels, Belgium (November complicated.
26, 2021). A modified Delphi method was designed to use Both balanced and unbalanced crystalloid fluids are
the collective expertise of the diverse group in answering used in the perioperative period. Several large trials of
clinically important questions and achieved consensus more than 1000 patients have not found that saline pro-
on several topics in accordance to the AGREE reporting motes mortality or major complications (such as myocar-
checklist. This report is a result of the 3-day discussion dial infarction) during surgery. Balanced crystalloid fluids
and reflects our consensus on fluid management based are preferable as many small studies of patients and vol-
on new evidence and our own individual expertise. unteers report a higher number of minor complications
when 2 L or more of saline is given, such as metabolic
Results acidosis, low urine flow, nausea, and abdominal pain [18].
Current clinical evidence and guidelines for fluid The benefit of adding glucose to the IV fluid during the
Enhanced recovery after surgery (ERAS®) programs
management early postoperative phase seems to be minor at best [15].
Current status on perioperative fluid management
The British GIFTASUP describe general rules about how aim for swift recovery after surgery and recommend
to treat patients before, during, and after surgery [2]. The either near-zero fluid balance or goal-directed fluid ther-
guidelines recommend that maintenance fluid consist of apy [19, 20]. Recent ERAS protocol recommendations
https://doi.org/10.1186/s13613-023-01177-y
REVIEW Open Access
Multidisciplinary expert panel report on fluid
stewardship: perspectives and practice
Manu L. N. G. Malbrain1,2,3,4* , Pietro Caironi5,6 , Robert G. Hahn7, Juan V. Llau8,9, Marcia McDougall10 ,
Luís Patrão11,12, Emily Ridley13 and Alan Timmins14
Abstract
Although effective and appropriate fluid management is a critical aspect of quality care during hospitalization,
the widespread adoption of consistent policies that ensure adequate fluid stewardship has been slow and heterog-
enous. Despite evidence-based guidelines on fluid management being available, clinical opinions continue to diverge
on important aspects of care in this setting, and the consistency of guideline implementation is far from ideal. A mul-
tidisciplinary panel of leading practitioners and experts convened to discuss best practices for ongoing staff educa-
tion, intravenous fluid therapy, new training technologies, and strategies to track the success of institutional fluid
stewardship efforts. Fluid leads should be identified in every hospital to ensure consistency in fluid administration
and monitoring. In this article, strategies to communicate the importance of effective fluid stewardship for the pur-
poses of education, training, institutional support, and improvement of patient outcomes are reviewed and recom-
mendations are summarized.
Keywords Critical care, Perioperative care, Fluid stewardship, Crystalloids, Buffered solutions, Fluid therapy
Introduction
The primary goal of fluid stewardship is to optimize
intravenous (IV) fluid administration, minimize the det-
*Correspondence: rimental effects of inappropriate fluid administration,
Manu L. N. G. Malbrain and thereby potentially improve clinical outcomes. Pro-
1
First Department Anaesthesiology and Intensive Therapy, Medical viding consistent educational content and rationalizing
University Lublin, Lublin, Poland available fluids is also important. Successful institutional
2
International Fluid Academy, Lovenjoel, Belgium fluid stewardship practice is therefore a critical aspect of
3
Medical Data Management, Medaman, Geel, Belgium
4
Medical Management, AZ Oudenaarde Hospital, Oudenaarde, Belgium quality hospital care for many patients.
5
Department of Anesthesia and Critical Care, San Luigi Gonzaga Hospital, Despite the importance of effective fluid manage-
Orbassano, Turin, Italy ment as recognized by the United Kingdom’s National
6
Department of Oncology, University of Turin, Turin, Italy
7
Anesthesia and Intensive Care, Karolinska Institute, Stockholm, Sweden Institute for Health and Care Excellence (NICE) [1] and
8
Anaesthesiology and Post‑Surgical Critical Care, University Hospital other efforts such as the British Consensus Guidelines
Doctor Peset, Valencia, Spain on Intravenous Fluid Therapy for Adult Surgical Patients
9
Anaesthesiology, Department of Surgery, University of Valencia,
Valencia, Spain (GIFTASUP) [2], the Perioperative Quality Initiative
10
Anaesthetics and Intensive Care, Victoria Hospital, Kirkcaldy, Fife, (POQI) [3], and International Fluid Academy (IFA) guid-
Scotland ance [4, 5], inappropriate fluid use continues to be an
11
Intensive Care Unit, Centro HospitalarTondela-Viseu, EPE, Viseu, Portugal
12
UpHill Health, Lisbon, Portugal important gap in care for many institutions, with poten-
13
Fluid Management lead, Department of Nursing, Victoria Hospital, tial for impact on patient outcomes and health care costs
Kirkcaldy, Fife, Scotland [6–10]. Many institutions recognize that this potential
14
Pharmacy Department, Victoria Hospital, Kirkcaldy, Fife, Scotland
care gap results in excessive costs, but this consideration
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/.
, Malbrain et al. Annals of Intensive Care (2023) 13:89 Page 2 of 14
is inconsistent across all organizations. Reasons cited for 1.5 to 2.5 L of water, 50 to 100 mmol of sodium, and 40 to
ongoing fluid mismanagement include poorly ingrained 80 mmol of potassium daily, based upon the daily physi-
habits among staff and a lack of consistent training and ological needs of water and salts. The NICE organiza-
education [4]. Targeted efforts that focus on education, tion in the UK later published a set of guidelines for fluid
recordkeeping and auditing have been shown to improve therapy in hospitalized adults [1]. For maintenance fluids,
adherence to current NICE guidance [11]. Many sur- current NICE guidance recommends 25–30 mL of fluid
veys of clinicians’ knowledge have demonstrated deficits and 1 mmol of sodium, potassium, and chloride per kg
in education [11]. During the 2019 International Fluid body weight over a 24-h period, with an adjustment using
Academy Day (IFAD) meetings held in Campinas, Bra- ideal body weight in obese patients. NICE guidelines for
zil, and Valencia, Spain, participants (mainly physicians) pediatric fluid administration are also available and con-
were encouraged to complete a 57-question survey to sider children’s physiological differences in fluid and elec-
investigate awareness of best practices with respect to trolyte handling [1].
fluid management [12]. Nearly three-quarters of partici- These recommended amounts of fluid and sodium
pants responded that their institutions do not have any are rather restrictive and represent about two-thirds of
general ward or ICU guidelines for IV fluid management, what is contained in the diets of healthy Europeans [14].
and only 6.5% of respondents achieved an above-average However, hospitalized patients with comorbidities, and
score on knowledge testing with respect to fluid manage- particularly the elderly, may have impaired renal func-
ment [13]. tion and altered handling of fluids and electrolytes, i.e.,
Appropriate fluid stewardship practices are essential post-operatively, hence the lower recommendations in
for optimal care in all hospitalized patients. Best prac- the NICE guideline. Frequent monitoring of clinical sta-
tices require adequate clinician awareness, training, and tus and blood tests are essential to ensure adequate fluid
education. The primary aim of this paper therefore was provision.
a fresh appraisal and discussion of the available evidence While the advantages of fluid therapy are apparent in
on this topic. complicated surgeries, the benefits can be questioned in
minor surgical procedures of short duration (< 20 min)
and not associated with fluid losses [15]. Randomized
Methods clinical studies of different infusion rates suggest that
A panel of leading practitioners and clinical researchers uncomplicated surgery lasting 1–2 h can generally be
who are considered effective stewards of fluid manage- managed with a restrictive fluid program consisting of
ment at their home institutions participated in a 2-day 3–5 mL/kg/h of balanced crystalloid fluid [16]. Infusion
virtual Advisory Board meeting (September 15–16, rates lower than 2 mL/kg/h increase the risk of post-
2021) to discuss the current state of fluid management operative nausea [17]. We agree that administration of
practices in Western Europe and identify gaps in train- resuscitation fluid is best guided by individual flow-based
ing and education. To ensure an ample diversity of clini- hemodynamic measurements in complex patients but
cal perspectives on this topic, a nurse and a pharmacist note that advantages are most apparent with signs of
were both included on the panel. This was followed by a organ dysfunction in intensive care and during lengthy
physical meeting held during the 10th International Fluid surgery when the hydro-electrolytic balance is unclear or
Academy Days meeting in Brussels, Belgium (November complicated.
26, 2021). A modified Delphi method was designed to use Both balanced and unbalanced crystalloid fluids are
the collective expertise of the diverse group in answering used in the perioperative period. Several large trials of
clinically important questions and achieved consensus more than 1000 patients have not found that saline pro-
on several topics in accordance to the AGREE reporting motes mortality or major complications (such as myocar-
checklist. This report is a result of the 3-day discussion dial infarction) during surgery. Balanced crystalloid fluids
and reflects our consensus on fluid management based are preferable as many small studies of patients and vol-
on new evidence and our own individual expertise. unteers report a higher number of minor complications
when 2 L or more of saline is given, such as metabolic
Results acidosis, low urine flow, nausea, and abdominal pain [18].
Current clinical evidence and guidelines for fluid The benefit of adding glucose to the IV fluid during the
Enhanced recovery after surgery (ERAS®) programs
management early postoperative phase seems to be minor at best [15].
Current status on perioperative fluid management
The British GIFTASUP describe general rules about how aim for swift recovery after surgery and recommend
to treat patients before, during, and after surgery [2]. The either near-zero fluid balance or goal-directed fluid ther-
guidelines recommend that maintenance fluid consist of apy [19, 20]. Recent ERAS protocol recommendations
