Clinical Review of Intravenous Fluid Prescribing Patterns in Tertiary Care Hospitals

Intravenous (IV) fluid therapy represents a fundamental component of patient management in contemporary clinical practice and is extensively utilized across various hospital settings, particularly in tertiary care institutions where critically ill patients are treated¹. The administration of IV fluids is essential for preserving intravascular volume, maintaining electrolyte homeostasis, and ensuring adequate tissue perfusion in a wide range of clinical conditions². It has been reported that a significant proportion of hospitalized patients receive intravenous fluids during their course of treatment, emphasizing its importance as one of the most frequently prescribed therapeutic interventions³.

Although IV fluid therapy is routinely practiced, it is increasingly acknowledged as a complex clinical intervention that demands careful evaluation and individualized decision-making. Fluids should be regarded as pharmacologically active agents, with specific indications, contraindications, dosing considerations, and potential adverse effects?. Inappropriate prescribing practices, including incorrect selection of fluid type, volume, or rate of administration, may result in serious complications such as fluid overload, electrolyte imbalance, acid–base disturbances, and increased risk of morbidity and mortality?. Evidence from clinical studies indicates that nearly one-fifth of hospitalized patients may experience adverse outcomes related to suboptimal fluid management?.

In tertiary care hospitals, the responsibility of prescribing IV fluids frequently lies with junior clinicians, interns, or early-career practitioners, who may not always possess adequate training or clinical expertise in fluid therapy?. Several studies have demonstrated that healthcare professionals often face challenges in accurately assessing a patient’s fluid status, determining appropriate fluid requirements, and selecting the most suitable type of fluid for specific clinical scenarios?. This lack of confidence and structured training contributes to considerable variability and inconsistency in prescribing patterns.

To improve clinical practice, evidence-based guidelines such as those issued by the National Institute for Health and Care Excellence (NICE) have proposed a systematic framework for IV fluid therapy, categorizing it into resuscitation, maintenance, replacement, and reassessment phases?. Despite the availability of such guidelines, adherence remains inconsistent across healthcare institutions due to factors such as limited awareness, absence of standardized hospital protocols, and variability in clinical judgment¹?.

Another important concern in fluid therapy is the inappropriate choice between different types of fluids, particularly crystalloids and colloids. Normal saline continues to be widely used in many clinical settings; however, excessive administration has been associated with complications such as hyperchloremic metabolic acidosis and renal dysfunction¹¹. Recent evidence increasingly supports the use of balanced crystalloids, which are associated with improved physiological outcomes and reduced risk of adverse effects¹². Nevertheless, the adoption of these alternatives varies considerably across institutions and clinical specialties.

Furthermore, inadequate monitoring of patients receiving IV fluids, including poor documentation of fluid balance, lack of regular reassessment, and insufficient electrolyte surveillance, further contributes to inappropriate fluid therapy¹³. The dynamic nature of fluid requirements in hospitalized patients necessitates continuous evaluation to prevent both under-resuscitation and fluid overload.

Given the complexity of IV fluid therapy and the significant impact of prescribing errors on patient outcomes, it is imperative to critically evaluate current prescribing practices in tertiary care settings. Identifying common patterns, gaps in guideline adherence, and areas of clinical concern can provide valuable insights for improving patient care. Therefore, this review aims to comprehensively assess intravenous fluid prescribing patterns in tertiary care hospitals, evaluate compliance with established guidelines, and highlight potential strategies to promote rational, safe, and evidence-based fluid therapy.

2. METHODOLOGY

The present review was conducted as a systematic narrative review with the objective of critically analyzing intravenous fluid prescribing patterns in tertiary care hospital settings. A structured and comprehensive literature search strategy was employed to ensure the inclusion of relevant and high-quality studies addressing fluid therapy practices and their clinical implications.

A detailed search of electronic databases, including PubMed, Scopus, Web of Science, and Google Scholar, was performed to identify studies published between January 2000 and March 2025. These databases were selected to ensure wide coverage of peer-reviewed biomedical literature and to capture both classical and recent evidence related to intravenous fluid therapy¹?.

The search strategy involved the use of multiple keywords and their combinations, such as “intravenous fluid therapy,” “fluid prescribing patterns,” “tertiary care hospitals,” “crystalloids,” “colloids,” “fluid therapy errors,” and “clinical audit of IV fluids.” Boolean operators (AND, OR) were applied to refine the search results and improve specificity. Additional manual screening of reference lists from selected articles was also performed to identify further relevant studies that might not have been captured during the initial search process¹?.

All identified studies were subjected to a preliminary screening based on titles and abstracts, followed by full-text evaluation to determine eligibility. The selection process was guided by predefined inclusion and exclusion criteria to maintain consistency and reduce selection bias.

2.1 Inclusion Criteria

The following criteria were used for selecting studies:

1. Research conducted in tertiary care hospitals or similar advanced healthcare settings
2. Observational studies, prospective or retrospective analyses, randomized controlled trials, clinical audits, and review articles
3. Studies focusing on intravenous fluid prescribing patterns, adherence to clinical guidelines, or associated patient outcomes
4. Articles published in the English language with accessible full text

2.2 Exclusion Criteria

Studies were excluded based on the following conditions:

1. Research conducted in primary care or community healthcare settings
2. Case reports, editorials, letters to the editor, and conference abstracts without sufficient data
3. Studies lacking clearly defined outcome measures or methodological transparency

2.3 Data Extraction And Synthesis

Relevant data from the selected studies were systematically extracted, including information on study design, sample size, clinical setting, types of intravenous fluids prescribed, prescribing indications, adherence to established guidelines, and reported clinical outcomes. Particular emphasis was placed on identifying trends in prescribing behaviour, common errors, and variations in clinical practice.

The extracted data were synthesized using a qualitative approach, allowing for a comprehensive interpretation of findings across diverse study designs. Key themes such as inappropriate fluid selection, deviations from recommended guidelines, and inadequate monitoring practices were analyzed in detail. The review also considered adherence to widely accepted clinical guidelines, particularly those proposed by the National Institute for Health and Care Excellence (NICE), which provide a structured framework for fluid therapy in hospitalized patients?.

To enhance the reliability of the findings, priority was given to studies published in high-impact, peer-reviewed journals. Variations in prescribing practices across different specialties and geographical regions were also examined to provide a broader understanding of the issue¹?.

3. TYPES OF INTRAVENOUS FLUIDS

Intravenous fluids are broadly categorized into crystalloids and colloids, each differing in composition, distribution characteristics, and clinical applications¹¹. The appropriate selection of fluid type is a critical determinant of therapeutic success, as different fluids exert varying effects on intravascular volume, interstitial balance, and electrolyte homeostasis.

3.1 Crystalloids

Crystalloids are solutions composed of water and low-molecular-weight solutes, such as electrolytes or glucose, which readily diffuse across semi-permeable membranes. Due to their ease of availability, lower cost, and favourable safety profile, crystalloids are the most frequently administered intravenous fluids in both emergency and routine clinical care¹².

These fluids distribute rapidly within the extracellular compartment, with only a fraction remaining in the intravascular space after infusion. Despite this, they are widely used for volume resuscitation, maintenance therapy, and correction of electrolyte imbalances.

Classification of Crystalloids:

1. Isotonic solutions:

These fluids have an osmolarity similar to plasma and primarily expand the extracellular fluid compartment.

Examples: 0.9% Normal Saline (NS), Ringer’s Lactate (RL)

2. Hypotonic solutions:

These have lower osmolarity than plasma and facilitate movement of water into cells, making them useful in cellular dehydration.

Example: 0.45% Sodium Chloride

3. Hypertonic solutions:

These possess higher osmolarity and draw water from intracellular to extracellular compartments.

Example: 3% Sodium Chloride

Balanced crystalloids, such as Ringer’s Lactate and Plasma-Lyte, are increasingly preferred over normal saline due to their closer resemblance to plasma electrolyte composition and reduced risk of hyperchloremic metabolic acidosis and renal dysfunction¹².

Figure 1: Fluid distribution in body compartments and effect of intravenous fluids

3.2 Colloids

Colloids are solutions containing high-molecular-weight substances, such as proteins or synthetic polymers, which remain within the intravascular compartment for a longer duration compared to crystalloids¹¹. These fluids exert oncotic pressure, thereby promoting plasma volume expansion with relatively smaller infused volumes.

Commonly used colloids include:

1. Human albumin
2. Dextrans
3. Hydroxyethyl starch (HES)

Although colloids offer theoretical advantages in maintaining intravascular volume, their clinical use has declined due to concerns regarding higher cost, risk of anaphylactic reactions, coagulopathy, and potential renal toxicity, particularly with synthetic starches¹³. Current evidence suggests that crystalloids are generally preferred for most clinical indications, except in selected cases requiring targeted plasma expansion.

Figure 2: Category of IV Fluids

Table 1: Classification and Clinical Characteristics of Intravenous Fluids

3.3 Clinical Considerations In Fluid Selection

The selection of intravenous fluids should be individualized based on patient-specific factors, including age, underlying disease, hemodynamic status, electrolyte balance, and organ function¹?. In critically ill patients, inappropriate fluid selection can significantly influence clinical outcomes.

Key considerations include:

1. Assessment of fluid deficit and ongoing losses
2. Monitoring of serum electrolytes and renal function
3. Avoidance of fluid overload, especially in cardiac or renal patients
4. Preference for balanced crystalloids in most clinical scenarios

Recent clinical evidence supports a restrictive and goal-directed fluid strategy, which has been associated with improved patient outcomes and reduced complications such as pulmonary edema and acute kidney injury¹?.

Figure 3:  Fluid Distribution in Body Compartments