By Katharina Floss, DipClinPharm, MRPharmS, Mark Borthwick, MSc, MRPharmS, and Christine Clark, PhD, FRPharmS

Safe and appropriate prescribing of intravenous fluidsrequires an understanding of fluid and electrolytehomeostasis, the physiological responses to injury

and disease, and the properties of IV fluids. Problems arising from inappropriate fluid therapy can

increase morbidity and prolong hospital stays. In addition,research has shown that the quality of IV fluid prescribingand monitoring is inconsistent and, generally, is left tojunior doctors, whose knowledge may be limited.1–3

Pharmacists should be prepared to advise on IV fluidprescriptions in the same way as for other medicines.

The basicsWithin the body, water is distributed into intracellular andextracellular compartments. The extracellularcompartment comprises both the interstitial andintravascular (plasma) compartments.

Water can move freely across the membranes thatseparate the compartments to maintain osmoticequilibrium. Osmotically active substances —predominantly albumin — bind water in the intravascular

compartment and thereby ensure that the circulatingblood volume is adequate.

Fluid and electrolyte levels in the body are keptrelatively constant by several homeostatic mechanisms.Normally, fluid (ie, water) is gained from intake of foodand drink, and a small amount is generated fromcarbohydrate metabolism. Fluid is lost via the urine, sweatand faeces, as well as through insensible losses from thelungs and skin. Typical fluid requirements for a healthyadult are around 30ml/kg/day (see Box 1, p275). However,because the kidneys can concentrate urine considerably,the minimum obligatory water intake is considered to be1,600ml/day from any source, allowing for a urine outputof 500ml.4

In healthy individuals, volume homeostasis is regulatedlargely by antidiuretic hormone (ADH). Osmoreceptors inthe hypothalamus and baroceptors (located in the aorta, thegreat veins, right atrium and carotid artery) detect smalldecreases in osmolality and blood pressure, triggering therelease of ADH. This elicits a sensation of thirst andreduces renal excretion of water. The renin-angiotensinsystem also plays a role and is activated by falling renalperfusion pressure. It is important to remember thatnormal homeostatic mechanisms may not work well aftermajor injury or during episodes of severe illness.

Intravenous fluid therapy can be used to replace large fluid losses or to maintain fluid status whenoral intake is insufficient; appropriate prescribing requires an understanding of basic fluid physiology

Intravenous fluidsprinciples of treatment

Batu

que

| Dre

amst

ime.

com

This is one of two CLINICAL FOCUSarticles in this issue of ClinicalPharmacist that are linked to a Centre for Pharmacy PostgraduateEducation learning@lunch flex module on themanagement of fluids — designed for hospitalpharmacists and technicians in England.

You can use these articles to provide keybackground knowledge on the topic beforeparticipating in a learning@lunch flex session atyour hospital. The module contains reflectivequestions, case studies and practice activitiesto allow you to put your learning into action.

You can order copies of this module via yourCPPE key contact at the hospital or by emailingJayne Plant on jayne@cppe.ac.uk. Find outmore at www.cppe.ac.uk/learning@lunch.

274 Clinical Pharmacist October 2011 Vol 3CL

INIC

AL F

OCU

S

Indications for IV fluids Where possible, fluids should be provided enterally, sinceparenteral fluid therapy exposes patients to risks such asfluid overload (by overriding physiological safeguards) andadverse effects associated with individual fluids. IV fluidtherapy is required when enteral intake is insufficient (eg,when a patient is “nil by mouth” or has reducedabsorption), to replace large fluid losses or when veryrapid replacement is necessary. Losses can occur from the gastrointestinal tract (due to

fistulas, vomiting or diarrhoea) or the urinary tract (eg,diabetes insipidus), or be caused by blood loss from traumaor surgery. Febrile patients or those who are suffering fromsevere burns will have increased insensible losses.Fluids can also accumulate into spaces that normally

contain minimal fluid volumes (eg, the peritoneal orpleural cavities) during surgery or as a result ofinflammatory conditions (eg, sepsis). This is caused byvasodilation and “leakage” of vascular epithelial walls andis sometimes referred to as “third spacing”. Breakdown ofnormal compartment integrity can result in loss ofcirculating intravascular volume.

Assessing fluid requirementsA patient’s medical history will give an indication of his orher expected fluid status. A detailed diagnosis is vital togain information on the likely composition of the fluid lost.Practitioners also need to be aware of any concurrentconditions that can alter fluid distribution or make patientsmore susceptible to adverse effects from fluid therapy.

Identifying dehydration On physical examination, signsof dehydration include:

� Thirst� Reduced skin turgor � Dry mucus membranes� Increased capillary refill time � Altered level of consciousness

If a patient is suffering from intravascular volumedepletion, then his or her heart rate will increase toimprove cardiac output and raise blood pressure. Bloodpressure only falls after the intravascular volume hasdropped by 20–30%.Urine becomes concentrated in cases of volume

depletion — more severe cases result in a fall in urine

output. Raised plasma urea (above 6mmol/L) and sodiumlevels (above 145mmol/L) can indicate dehydration, as canacidosis on a blood gas analysis.Signs and symptoms need to be evaluated as a whole,

since their specificity in isolation is limited. It should beborne in mind that co-existing conditions or drugtreatments may alter results (eg, tachycardia may besuppressed by concurrent drug therapy). Information onassessing response to IV fluid therapy is set out in Box 2(p279)

Fluid balance An accurately recorded fluid balance,documenting overall intake and output, is required forappropriate IV fluid prescription. Losses via urine, drains,stoma or nasogastric aspirates should be documented. Inaddition, insensible losses via the respiratory tract and skin(adjusted for body temperature) should be estimated.It is important to interpret all observations in the

context of a patient’s clinical diagnosis — eg, anoedematous patient may show a positive fluid balance butstill be intravascularly depleted, resulting in insufficienttissue perfusion and oxygenation. Further details areprovided in the accompanying article (p285).

Special considerations Some conditions requirespecial consideration. Patients with major burns requirecopious amounts of IV fluids, calculated according to bodyweight and percentage of body surface area affected. In traumatic brain injury, fluid volume is often adjusted

according to mean arterial pressure in an attempt tomaintain optimal cerebral perfusion pressure. A delicatebalance has to be met between providing sufficient fluid tomaintain organ perfusion and avoiding an increase inblood loss due to dilutional coagulopathy (see below) or asudden increase in cardiac output. Fluid administration has to be particularly carefully

balanced in individuals with heart failure, renalimpairment or apparent respiratory failure since thesepersons are at higher risk of fluid overload. Compared with adults, children have a higher risk of

electrolyte disturbances caused by fluid therapy, owing totheir lower ability to compensate. Therefore, paediatricfluid prescriptions require special scrutiny andpharmacists unfamiliar with this patient group should nothesitate to seek advice from experienced colleagues.

Types of fluidIV fluids are generally categorised according to theirphysical composition. The two main categories are:

� Crystalloids — solutions of small molecules inwater (eg, sodium chloride [NaCl], glucose)

Box 1: Approximate fluid balance (80kg male)WATER INTAKE (ml) WATER LOSS (ml)

Drink 1,500 Urine 1,500

Food 800 Faeces 200

Cellular respiration 300 Skin and lungs 900

SUMMARYIntravenous fluid therapy is required when enteral intake is insufficient, toreplace large fluid losses or when very rapid replacement is necessary. Anaccurate record of overall intake and output is required for appropriate IVfluid prescription. IV solutions can be crystalloid (containing small molecules such as

sodium chloride or glucose) or colloid (dispersions of large organicmolecules). Solutions with electrolyte compositions more closely matchedwith plasma are often called “balanced solutions” (eg, Hartmann’s solution).Successful therapy may be indicated by improvement in a patient’s clinicalsigns (eg, weight, urine output, capillary refill time), biochemistry andcomfort. Serious complications can result from over-administration of fluids.

Vol 3 October 2011 Clinical Pharmacist 275CLIN

ICAL FOCUS

�PRACTITIONERSNEED TO BE AWAREOF ANYCONCURRENTCONDITIONS THATCAN ALTER FLUIDDISTRIBUTION ORMAKE PATIENTSMORE SUSCEPTIBLETO ADVERSEEFFECTS FROMFLUID THERAPY

�

� Colloids — dispersions of large organic molecules(eg, gelatin, albumin, etherified starches, dextran) ina carrier solution

In addition, individual fluids distribute into the variousfluid compartments in different ways (see accompanyingarticle, p285, for specific details). In general, colloidsremain in the intravascular space where they bind water,owing to their exertion of oncotic pressure; crystalloidsdistribute more readily into other tissues .

Crystalloid solutions NaCl distributes into the wholeextracellular space (ie, into both intravascular andinterstitial spaces, although not in equal proportions).

NaCl 0.9%, also known as “normal saline”, is isotonicwith respect to plasma and is commonly used for fluidtherapy. Hypo- and hypertonic solutions of NaCl are alsoavailable, but their use is limited; hypotonic NaCl is usedto treat hypernatraemia and hypertonic NaCl issometimes used to correct hyponatraemia (very strongsolutions are used to manage aspects of head injury).Careful monitoring is required for these uses.

Glucose solutions distribute throughout theintravascular, interstitial and intracellular compartments

(see accompanying article, p285). Glucose 5% solution hasthe same tonicity as plasma and is used for maintenancefluid therapy. The glucose itself is metabolised quickly andis, in effect, providing free water. Hypertonic solutions ofglucose (10% or 50%) are used when glucose substitutionis required (eg, to treat hypoglycaemia).

Despite having the same tonicity as plasma, bothnormal saline and glucose 5% have an electrolytecomposition that is different from plasma. Fluid solutionswith electrolyte compositions that are more closelymatched with plasma are often called “balanced solutions”.For example, compound sodium lactate (“Hartmann’ssolution” or “Ringer’s lactate solution”) containspotassium, calcium, magnesium, lactate and sodiumchloride.

Colloid solutions The characteristics of colloid infusionsdepend mainly on their molecular size.

Etherified starches are starch molecules that have been“etherified” with hydroxyethyl groups and a range of theseis available. Etherified starches have relatively highmolecular weights (tetrastarch 130,000 daltons;pentastarch 200,000 daltons; and hetastarch 450,000daltons) and can provide volume expansion for 6–24 hours.

276 Clinical Pharmacist October 2011 Vol 3CL

INIC

AL F

OCU

S

The duration of action depends on the molecular size ofthe starch (larger molecules tend to have a longerduration), the rate of degradation and the permeability ofthe vascular endothelium.

Modified fluid gelatin is derived from animal collagenand has a molecular weight of 30,000 daltons. Its effectivehalf-life is about four hours, but its volume-restoring effectmay be shorter in patients with capillary leakage.

Dextran solutions are synthetic polysaccharidecolloids, classified according to average molecular weight.Dextran 70 is the only remaining UK-licensed preparation.

Albumin is a natural colloid, derived from whole blood.It is commercially available in isotonic (4.5–5% albumin)and hypertonic (20% albumin) solutions.

Traditionally, colloid infusions were only availabledispersed in NaCl solutions, but in the past decade bothetherified starches and gelatine in balanced carriersolution have been licensed in the UK.

ApproachesDeciding which fluid is appropriate for a given patient, andhow much should be administered, will depend on the aimof treatment: to replace normal losses (ie, maintenancetherapy) or to correct existing fluid deficits (ie,replacement).

Maintenance therapy For patients who requiremaintenance fluids (and who have healthy kidneys and nocomorbidities that would affect fluid homeostasis),administering a glucose-based fluid and a second fluid toboost intravascular volume (usually a sodium-based fluid)is suitable. This will often be prescribed as a combinationof NaCl 0.9% and glucose 5% infusions, or as “dextrose-saline” (generally glucose 4% and NaCl 0.18%). Usually,

up to 3L will be administered over 24 hours. Dextrose-saline solution is not recommended for long-termmaintenance because it does not provide the requireddaily amount of sodium, unless excess volume isadministered.

In addition to providing water, maintenance fluidsshould also provide sodium and potassium. Calcium,

Vol 3 October 2011 Clinical Pharmacist 279CLIN

ICAL FOCUS

Box 2: Assessing response to IV fluid therapy

Like for medicines therapy, patients receiving IV fluids should bemonitored for clinical response and adverse effects.

Various studies have shown that outcomes for postsurgical andcritical care patients can be improved by targeting fluid volumes tohaemodynamic measures rather than according to a set formula ofmillilitres per kilogram of body weight. There are several ways toevaluate fluid therapy. Successful therapy may be indicated by:

� Clinical signs (eg, improved urine output, reduced capillaryrefill time and reduced heart rate)

� Biochemical signs (eg, normalisation of sodium, urea andcreatinine levels)

� Improvement in patients’ mental status and subjectiveexperience (eg, they may feel “less thirsty”)

However, these signs can be masked by other factors; forexample, urine output can remain low for 24 hours after surgery aspart of the normal response to injury, despite adequate fluid input.Urine output can also be affected by diuretics that are startedinappropriately to maintain urine output without consideration of apatient’s fluid status.

Daily weighing is the simplest and most reliable means ofmonitoring fluid status. However, it does not provide anyinformation about the distribution of administered fluids. Invasive

techniques can provide a more detailed picture of the intravascularvolume status.

Invasive techniques The measurement of central venous pressure(CVP) via a central venous catheter is often used to assessintravascular volume. Absolute values will be influenced by severalpatient-specific parameters, but the trend of CVP in response to a“fluid challenge” (see below) is a good indication of whether apatient’s fluid volume is approaching the optimum.

Cardiac output measurements, obtained using techniques suchas oesophageal Doppler or thermodilution, can also be used toassess intravascular volume. These methods allow targeted titrationof fluid volumes, but are restricted to use in critical care areas andexpert knowledge is required to interpret the results.

Fluid challenge To conduct a fluid challenge, a 250ml bolus of asuitable fluid (eg, sodium chloride 0.9% or Hartmann’s solution) isadministered over about 15 minutes. If CVP remains unchanged, orrises only temporarily, further fluid boluses are required. Asustained increase in CVP of 3–5mmHg indicates that sufficientfluid volume has been provided and fluid administration can bechanged to a maintenance rate. (In the absence of invasivemonitoring, other clinical parameters such as a timely increase inurine output can be used but these methods are less accurate.)

Returning from surgery: patients may require IV fluids in the postoperative period

Luci

an O

man

| Dr

eam

stim

e.co

m

magnesium and phosphate supplementation should beconsidered if oral intake is interrupted for more than a fewdays and should be guided by plasma levels.

Practical examples of calculating maintenance fluidrequirements can be found in the accompanying article(p285).

Fluid replacement or resuscitation Deciding whichfluids are appropriate for a patient requiring fluidreplacement depends on the type of fluid that has beenlost and the body compartments that require additionalvolume. A patient’s renal and cardiac function, acid-basebalance, glucose levels and electrolyte levels also need tobe considered.

Fluid resuscitation is required in situations where apatient is experiencing acute circulatory shock orintravascular volume depletion. The objective is to restorecirculating blood volume and increase cardiac output,thereby restoring tissue perfusion and oxygen delivery.

Any sodium or colloid-based fluid can be used torestore intravascular volume. Fluids that distributethroughout total body water (eg, glucose) do not restoreintravascular volume and can exacerbate interstitialoedema in patients who are suffering from inflammatoryconditions (eg, sepsis).

Practitioners should remember that any fluidadministered during the resuscitation phase (and itsassociated electrolyte load) will have to be cleared orredistributed by the body. This may take several days orweeks in a patient with impaired homeostasis.

If large volumes of fluid are required, a balancedcrystalloid solution (eg, Hartmann’s solution) is preferredbecause of the complications associated with excessiveNaCl load. The selection of colloids versus crystalloids

and of saline versus balanced fluids is discussed in Box 3and Box 4 (p282), respectively. Practical aspects of fluidreplacement and resuscitation are discussed in theaccompanying article (p285).

The timing of fluid replacement and resuscitation cansometimes be as important as the volume and type of fluidadministered. Studies investigating the timing ofresuscitation for critically ill patients have shown thataggressive and early fluid resuscitation (ie, patients receivemost of their resuscitation fluids within six hours ofdeterioration, along with other interventions if required)achieves better outcomes than delayed fluid resuscitation(ie, most fluids are administered more than six hours afterthe start of deterioration).11, 12

ComplicationsA range complications can occur as a result of fluidtherapy. Perhaps the most obvious complication is theadministration of too much fluid. When this occurs, theheart can fail to pump the expanded circulatory volumeeffectively.

Over-distension of the left ventricle can cause heartfailure and, consequently, pulmonary oedema. A patientwith pulmonary oedema will be short of breath and have acough, respiratory crackles on auscultation and reducedoxygen saturation. These clinical features are oftenaccompanied by an increased heart rate, which must not beconfused with tachycardia caused by hypovolaemia. Renalfailure and pre-existing ventricular impairment canexacerbate the condition.

Abdominal compartment syndrome and acuterespiratory distress syndrome are both knownconsequences of excessive fluid resuscitation and fluidoverload. Particular care has to be taken when treating any

280 Clinical Pharmacist October 2011 Vol 3CL

INIC

AL F

OCU

S

Box 3: Colloids vs crystalloids

Colloids allow fast restoration of intravascular volume, but therehas been much debate about their safety and superiority overcrystalloids for fluid resuscitation. A recently updated meta-analysis showed no difference in

mortality between patients treated with colloids and those treatedwith crystalloids for fluid resuscitation.5 In the original Cochranereview, there was particular controversy regarding albumininfusions. Subsequently, the SAFE study compared albumin 4%and NaCl 0.9% for fluid resuscitation in intensive care anddemonstrated no difference in outcomes.6 In addition, colloidinfusions are significantly more expensive than crystalloidinfusions. In the UK, the use of albumin is now restricted toconditions in which the synthesis of clotting factors is reduced (eg,severe hepatic failure). The lower overall volume load associated with colloids is often

pointed out as an advantage of their use. For replenishingintravascular volume, 3L of a crystalloid solution is assumed,generally, to be equivalent to 1L of colloid solution. However, theSAFE study reported a ratio of 1.4L of normal saline to 1L ofalbumin.6 Gelatin has a similar molecular size to albumin so thedifference in administered volume is unlikely to be substantial. It may be possible to use smaller volumes of solutions containing

large starch molecules (eg, hetastarch) to replenish intravascular

volume. In particular, for conditions where there is increasedepithelial wall permeability (eg, sepsis, other inflammatoryconditions, prolonged anaesthesia), starches may be more effectiveat reducing leakage into the interstitial space by increasing oncoticpressure. Evidence is needed about whether and how thistranslates into improved clinical outcomes. Another Cochrane meta-analysis7 failed to show any difference in

outcome between different types of colloids. However, a widevariety of studies was included and further research is required.Each colloid has its own adverse effect profile, which should betaken into account when making choices for individual patients. Current evidence suggests that certain types of etherified

starches are associated with increased morbidity. Although thismay not be transferable to all starch infusions, seriousconsideration should be given before treating patients with largeamounts of any etherified starch.It is worth noting that another factor complicating the colloid

versus crystalloid debate is that there are doubts around theintegrity of some of the research — publications from oneparticular researcher were retracted by 16 peer-reviewed journalsafter it emerged that ethical approval had not been sought anddata had potentially been falsified.8 This cast doubt on the resultsof meta-analyses in which the researcher’s data had been included.

�THE TIMING OFFLUID REPLACEMENTAND RESUSCITATIONCAN SOMETIMES BEAS IMPORTANT ASTHE VOLUME ANDTYPE OF FLUIDADMINISTERED

�

Box 4: Saline vs balanced fluids

High-volume administration of sodium chloride-basedIV fluids, and the resulting load of sodium andchloride ions, can cause marked biochemicaldisturbances and hyperchloraemic acidosis. For patients with underlying tendencies towards

acidosis (eg, those with carbon dioxide retentionsecondary to respiratory failure, or those withincreased lactate levels following surgery),compensation mechanisms can easily beoverwhelmed, resulting in severe metabolic acidosis.Therefore, many clinicians prefer the use of abalanced crystalloid or colloid solution when largevolumes are required (such as in major traumasurgery), and for patients with impaired compensatorymechanisms (eg, the critically ill). Recently updated consensus guidelines advise on

the use of a balanced infusion for maintenancetherapy in all surgical patients.9

Despite this, it is not clear if the use of balancedfluids translates into meaningful benefits in clinicaloutcomes. Additionally, the anions contained in thesebalanced fluids (lactate, malate) could be associatedwith their own risks if administered in excess.10

patient with co-existing cardiac or respiratory failure, orwho is at risk of haemodynamic instability. By the timeperipheral or lung oedema are obvious, patients havealready been harmed by excessive volume or wrong choiceof IV fluid.13, 14

Biochemical abnormalities Biochemical abnormalitiesoccur frequently in patients receiving IV fluids and reflectthe response to the fluid administered. In particular,infusions of NaCl 0.9% can result in over-provision ofsodium and chloride and cause hyperchloraemic acidosis(see Box 4). It is worth noting that there are risks associatedwith rapid correction of both hypo- and hypernatraemia,but these are outside the scope of this article.

Allergic reactions Allergic reactions, although rare, canbe associated with synthetic colloids such as etherifiedstarches, gelatin and dextran.

Haemodilution Administering IV fluids in large volumeswill inevitably lead to haemodilution and a fall inhaemoglobin levels. This usually corrects itself within afew days as the extra fluid is cleared by the kidneys.However, blood transfusion may be required depending ona patient’s condition and local transfusion criteria.

Dilutional coagulopathy Dilutional coagulopathy is aneffect of high-volume fluid administration. In addition,some colloid infusions impair components of the clottingcascade (eg, dextran solutions are known to beantithrombotic).

The higher molecular weight etherified starches (eg,hetastarch, pentastarch) have been associated withincreased bleeding; this is probably of less clinicalconsequence with colloids of smaller molecular size.

�BIOCHEMICALABNORMALITIESOCCUR FREQUENTLYIN PATIENTSRECEIVING IVFLUIDS

�

CLINICAL FOCU

SVol 3 October 2011 Clinical Pharmacist 283

This article was first published in Hospital Pharmacist(2008;15:271) and has been revised by Katharina Floss, who is directorate pharmacist forcritical care, theatres and anaesthetics at OxfordRadcliffe Hospitals NHS Trust. Mark Borthwick isconsultant pharmacist for critical care at JohnRadcliffe Hospital and Christine Clark is a pharmacistand freelance journalist.E: katharina.floss@orh.nhs.uk

Renal impairment Recently, it has been suggested thatstarch solutions have the potential to cause renalimpairment. A possible explanation for this ishyperoncotic acute renal failure. If these products aregiven with insufficient water, the oncotic pressure ofplasma is raised to the point where it effectively opposesthe filtration pressure in the kidneys, thereby impairingnormal glomerular filtration. To avoid this, starchinfusions should be accompanied or followed by acrystalloid infusion of the same volume.

References1 Lobo DN, Dube MG, Neal KR, et al. Problems with solutions: drowning in

the brine of an inadequate knowledge base. Clinical Nutrition2001;20:125–30.

2 Ferenczi E, Data SS, Chopada A. Intravenous fluid administration inelderly patients at a London hospital: a two-part audit encompassingward-based fluid monitoring and prescribing practice by doctors.International Journal of Surgery 2007;5:408–12.

3 Walsh SR, Cook EJ, Bentley R, et al. Perioperative fluid management: aprospective audit. International Journal of Clinical Practice 2008;62:492–7.

4 Sterns RH. Maintenance and replacement fluid therapy in adults. Up toDate, version 19.2, 2010. www.uptodate.com (accessed 25 July 2011).

5 Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation incritically ill patients. Cochrane Database of Systematic Reviews 2011;issue 16.

6 The SAFE study investigators. A comparison of albumin and saline forfluid resuscitation in the intensive care unit. New England Journal ofMedicine 2004;350:2247–56.

7 Bunn F, Trivedi D, Ashraf S. Colloid solutions for fluid resuscitation.Cochrane Database of Systematic Reviews 2011; issue 3.

8 Dyer C. Researcher didn’t get ethical approval for 68 studies,

investigators say. BMJ 2011;342:d833.

9 British Association for Parenteral and Enteral Nutrition. British consensusguidelines on intravenous fluid therapy for adult surgical patients(GIFTASUP). March 2011. www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdf (accessed 28 July 2011).

10 Morris C, Boyd A, Reynolds N. Should we really be more ‘balanced’ onour fluid prescribing? Anaesthesia 2009;64:703–5.

11 Rivers E, Nguyen B, Hanstad S, et al. Early goal-directed therapy in thetreatment of severe sepsis and septic shock. New England Journal ofMedicine 2001;345:1368–77.

12 Dellinger RP, Levy MM, Carlet JM, et al. Surviving sepsis campaign:International guidelines for management of severe sepsis and septicshock: 2008. Critical Care Medicine 2008;36:296–327.

13 Grocott MPW, Mythen MG, Gan TJ. Perioperative fluid management andclinical outcomes in adults. Anesthesia and analgesia2005;100:1093–106.

14 Cotton BA, Guy JS, Morris JA, et al. The cellular, metabolic and systemicconsequences of aggressive fluid resuscitation strategies. Shock2006;26:115–21.

Based on evidence from a recent study in The New England Journal of Medicine conducted using ChloraPrep,1 pre-operative skin preparation with 2% chlorhexidine in 70% isopropyl alcohol has been included in the care bundle for the prevention of surgical site infection.2

To find out more please visit www.chloraprep.co.uk

Prescribing Information ChloraPrep® ( L3 7 0/0 02) hlor Prep with int (PL31760-0001) 2% chlorhexidine gluconate w/v / 70% sopropyl alcohol v/v cutaneous solution. Indication infection f sk prior o vasive medical procedures osage & administr Prep – 0.67ml, 0 l Prep with nt – 3ml, 10.5ml,

lume dependent on inv sive procedure being undertak Applicator squeezed to break ampoule and elease antiseptic solution onto sponge Solution applied by gently pressing sponge against skin and moving back nd forth for 30 seconds e area covered should be allowed to air dry Side effects cautions & contr

indications: Very rarely allergic or skin reactions reported with chlorhexidine, isopropyl alcohol and Sunset Yellow. Contra-indicated for patients with known hypersensitivity to these constituents. or external use only on intact skin. Avoid contact with eyes, mucous membranes, middle ear and neural tissue. Should not be used in children under 2 months of age. Solution is flammable. Do not use with ignition sources until dry, do not allow to pool, and remove

d materials efore use vigorous use on fr gile or sensitive skin or repeated use may lead to local skin t the first sign of local skin reaction, a io e o p Per applicator costs (ex

. 7 l S P 0 1 ml FR P ) - 5 p 1 5 l – 7 3ml – 85p; 5 - £ . 2 26ml - £6.50 ChloraPrep with Tint: 3ml – 89p; 10.5ml £3.07; 26ml - £6.83 Legal category: GSL eting Authorisation Holder: areFusion UK 244 Ltd, n a Surrey RH2 9PW ate of pr July 2011

References: et al. N Engl J Med 2010; 362: 18-26. 2. Department of Health (2011) High Impact Intervention:

Care bundle to prevent surgical site infection. Available at: http://hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-Prevent-Surgical-Site-infection-FINAL.pdf. Date accessed: 12.04.11. 3. UK PL 31760/0001 CHL158A Date of preparation: September 2011 with ChloraPrep

The Department of Health has recently updated its high impact intervention care bundle for the prevention of surgical site infection to include pre-operative skin preparation with 2% chlorhexidine in 70% isopropyl alcohol1

ew GuidanceThe Depart ew Guidanceb dl f ew Guidancebundle for

Guidanceeparatio ew pr

ew GuidanceThe Depart

New Guidance

ti n bundle for t

Ne New Guidance

The Departm Ne G idNew Guidance

New has New f New of s

New GuidanceT ment of Health Guidancee ti Guidanceevention

New hexi New Guidancee with 2% chlo New he prNew Guidance

T ment of Health New GuidanceNew Guidance

with 2% hlorh i evention of s New

has

New New h the prNew Guidance

ment of Health has N New

N G idNew Guidance

New Gu pdated i New Gu i f ti New Gu infectio

Guidanceecently u w Guidancee i l it w Guidancee urgical sit

uo w Guidancee idine in 70 New Gu % isopr

New Gu pdated i

Guidanceecently u

New GuidanceNew Guidance

idi i 70% i u urgical site infectio New Guw Guidance

ecently updated its high impact intervention carN GNew Gu

w rw

r r G idancew Guidance

New Guidancee impact intervention car idancee ts high impact intervention car idancee to include pr idancee on to include pr idanceopyl a

dance-op New ohol

New Guidancee l d New Guidancee clude prNew Guidancee impact intervention car

idancee ts high impact intervention car

New Guidance

danc 1

New Guidance

11l lcoh lw Guidance

e op on to include prNew Guidance idance

ts high impact inte N G idNew Guidance

id idance

ae New Guidancee ti kin New Guidancee ative skin

ce rv

cepe

New Guidancee ntion carNew Guidance

e ntion carNew GuidanceNew Guidance

ce New GuidanceNew Guidance

perative skin e

New Guidance ce

rv

ce

e rvention carN G idanceNew Guidance ce

Guidanceeparatio ew pr

bundle for the pr70% isopropyl alcoholin e-operative skin prpr

nal of Medicine conducted using ChloraPrJourBased on evidence fr

p n pNe

New hexi New Guidancee with 2% chlo

evention of surgical site infection.bundle for the pr has been included in the car70% isopropyl alcohol

2% chlorhexidineeparation with e-operative skin prnal of Medicine conducted using ChloraPr

ecent study in The New Englandom a rBased on evidence fr

w orh

uo w Guidancee idine in 70 New Gu % isopr

2evention of surgical site infection.e has been included in the car

2% chlorhexidine

1ep,nal of Medicine conducted using ChloraPrecent study in The New England

0% p u

New ohol idanceopyl a

ecent study in The New England

py lco w Guidance

New GuidanceNew Guidance

o find out moTTo find out mor

licensed and evidence-based skin pr

The and only

.chloraprep.co.ukwwwe please visit o find out mor

eparation system that allowslicensed and evidence-based skin pr

and

.chloraprep.co.uk

eparation system that allows

The and only

ignition with use not Do .flammableis Solution .ageof months middle ear and neur,anes mucous membr,Avoid contact with eyes

a-indicated for patients with known hypersensitivity to these constituentsContrreported with chlorhexidinearely allergic or skin reactions ery rVindications:

e area covered should be allowed to air dryT.and forth for 30 seconds Solution applied by gently pressing sponge against skin and moving back.release antiseptic solution onto sponge

sive procedure being undertakolume dependent on invV26ml. 3ml, 1.5ml,aPrep – 0.67ml, Chloration:Dosage & administr

infection f sk prior o v:Indicationisopropyl alcohol v/v cutaneous solution.int (PL31760-0001) 2% chlorhexidine gluconate w/v / 70%TaPrep with (PL31760/0002) & Chlor®aPrepChlor

escribing InformationPr

removeand pool,to allow not do ,dryuntil sources ignition Should not be used in children under 2.al tissue middle ear and neur

or external use only on intact skin. F.a-indicated for patients with known hypersensitivity to these constituents.ellowY isopropyl alcohol and Sunset ,reported with chlorhexidine

a-ecautions & contr pr,Side effectshe area covered should be allowed to air dry Solution applied by gently pressing sponge against skin and moving back

Applicator squeezed to break ampoule anden.asive procedure being undertak 10.5ml,int – 3ml,TaPrep with Chlor 26ml ; 10.5ml, 3ml,

asive medical procedures Disinfection of skin prior to invint (PL31760-0001) 2% chlorhexidine gluconate w/v / 70%

Putting evidence into practice

you to meet these new guidelines

ep with ChloraPrPutting evidence into practice

3you to meet these new guidelines

CHL158A Prevent-Surgical-Site-infection-FINAL.pdf. Date accessed: 12.04.11. 3. UK PL 31760/0001 Care bundle to prevent surgical site infection. Available at: http://hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-

N Engl J Med 2010; 362: 18-26. 2. Department of Health (2011) High Impact Intervention:et al. Darouiche R 1.References:

Surrey RH2 9PW, Reigate 43 London Road,CareFusion UK 244 Ltd,Holder: 26ml - £6.83 10.5ml £3.07; 3ml – 89p;int:TaPrep with Chlor

1 5 l – 7 1.5ml (FREPP) - 55p; 0.67ml (SEPP) - 30p;aPrep:Chlor a io e o pAt the first sign of local skin reaction,.reactions

gile or sensitive skin or repeated use may -vigorous use on fr Over.before useed materials soak

September 2011ation:Date of preparPrevent-Surgical-Site-infection-FINAL.pdf. Date accessed: 12.04.11. 3. UK PL 31760/0001 Care bundle to prevent surgical site infection. Available at: http://hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-

N Engl J Med 2010; 362: 18-26. 2. Department of Health (2011) High Impact Intervention:

July 2011ation:eparDate of pr UK , Surrey RH2 9PWeting AuthorisationMark GSL Legal category: 26ml - £6.83

26ml - £6.50 10.5ml - £2.92; 3ml – 85p; 1.5ml – 78p;AT)VAer applicator costs (ex P application should be stopped.

lead to local skinagile or sensitive skin or repeated use may