Review Article | Published:

Intravenous fluid therapy in critically ill adults

Nature Reviews Nephrologyvolume 14pages541557 (2018) | Download Citation


Intravenous fluid therapy is one of the most common interventions in acutely ill patients. Each day, over 20% of patients in intensive care units (ICUs) receive intravenous fluid resuscitation, and more than 30% receive fluid resuscitation during their first day in the ICU. Virtually all hospitalized patients receive intravenous fluid to maintain hydration and as diluents for drug administration. Until recently, the amount and type of fluids administered were based on a theory described over 100 years ago, much of which is inconsistent with current physiological data and emerging knowledge. Despite their widespread use, various fluids for intravenous administration have entered clinical practice without a robust evaluation of their safety and efficacy. High-quality, investigator-initiated studies have revealed that some of these fluids have unacceptable toxicity; as a result, several have been withdrawn from the market (while others, controversially, are still in use). The belief that dehydration and hypovolaemia can cause or worsen kidney and other vital organ injury has resulted in liberal approaches to fluid therapy and the view that fluid overload and tissue oedema are ‘normal’ during critical illness; this is quite possibly harming patients. Increasing evidence indicates that restrictive fluid strategies might improve outcomes.

Key points

  • Intravenous fluid administration is one of the most common interventions in acute and critical care medicine, but much of the physiological theory on which practice has been based is flawed.

  • Intravenous fluids were established in clinical practice and licensed for use without robust investigation of their efficacy or safety, although large, high-quality, investigator-initiated trials have now provided such data.

  • Crystalloid fluids should be used for first-line therapy; in most patients, buffered salt solutions seem to offer benefits over normal saline.

  • Albumin administration might be beneficial in patients with sepsis, cirrhosis or infections, but albumin in hypotonic carrier fluid is contraindicated in patients with acute traumatic brain injury.

  • Synthetic colloids, notably hydroxyethyl starch and gelatins, should not be used owing to their unacceptable safety profiles and lack of proven benefits over crystalloids.

  • Strategies that restrict fluid administration might reduce morbidity and mortality, but larger trials are still needed to confirm these promising initial data.

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Change history

  • 04 October 2018

    Corrections: Fig. 1: ‘MAP’ inserted before ‘60–65 mmHg; Fig. 3: ‘Echocardiography’ amended to ‘Electrocardiographic’. Fig. 4b additions: two cell nuclei; text labels ‘Large pore transporting plasma proteins’, ‘Small pore network’, ‘Intercellular cleft’; ‘Intact’ and ‘Damaged’; legend updated.


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The authors’ research is funded by Department of Health – National Health and Medical Research Council (NHMRC) grants 1117230 to S.F., 1081884 to J.M. and 1136432 to R.B.

Author information


  1. The George Institute for Global Health, University of New South Wales, Sydney, Australia

    • Simon Finfer
    •  & John Myburgh
  2. School of Medicine, University of Melbourne, Melbourne, Australia

    • Rinaldo Bellomo


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All authors contributed to researching data for this article, discussions of its content, writing the paper and review or editing of the manuscript before submission.

Competing interests

S.F., J.M. and R.B. declare that their employers have received research grants and travel reimbursement from Baxter Healthcare, CSL Bioplasma and Fresenius Kabi for the conduct of investigator-initiated clinical trials.

Corresponding author

Correspondence to Simon Finfer.



A state characterized by the loss of an effective intravascular volume.


The capability of a solution to exert osmotic pressure across a cellular membrane.

Strong ion difference

Strong ions are cations and anions that exist as dissociated charged particles at physiological pH. The strong ion difference of a solution is the difference between the sums of concentrations of strong cations and strong ions. In plasma, the strong ion difference is (Na+ + K+ + Ca2+ + Mg2+) − (Cl − [other strong anions]) and is normally around 40 mEq/l.

Patient-centred outcomes

Outcomes that measure how a patient feels, functions or survives.

Damage control resuscitation

A systematic approach to the management of severe trauma that involves haemostatic resuscitation, including permissive hypotension to limit non-blood-product fluid resuscitation, which can worsen the coagulopathy of trauma. Might also incorporate damage control surgery, which prioritizes management of the metabolic derangement of ongoing bleeding over the need for definitive surgery.


A solution having a colloid osmotic pressure similar to that of plasma.


A solution having a colloid osmotic pressure higher than that of plasma.

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