IV Fluid Safety
full update April 2025
The FAQ below answers common questions about safely using IV fluids.
Clinical Question |
Answer/Pertinent Information |
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What is meant by “isotonic” and “isosmotic?” |
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What is the approximate osmolarity of some common IV fluids? |
The osmolarity of IV solutions is usually printed on the bag. The bag might also state that the solution is isotonic, hypertonic, or hypotonic/hemolytic. Here are some examples of approximate osmolarities of common IV fluids: Isosmotic/Isotonic:
Hypoosmotic/Hypotonic:
Very Hypoosmotic/Hypotonic
Hyperosmotic/Hypertonic:
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What is considered an isotonic fluid, and when is it used? |
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How do the isotonic solutions (e.g., normal saline, Lactated Ringer’s) compare? |
Fluid/ cost per litera |
Balanced Fluids(not all-inclusive) (LR [~$5], Isolyte S pH 7.4[<$10], Normosol-R [~$5], Plasma-Lyte A[~$15]) |
Normal saline |
Compositionb |
Balanced Fluids Electrolytes (for products listed above):
Buffers (may contain one or more of the following):
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Normal saline Electrolytes
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Preferred Indications or Potential Benefits |
Balanced Fluids
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Normal saline
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When to Avoid Use, or Possible Complications |
Balanced Fluids
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Normal saline
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Use in Patients with Kidney or Liver Impairment |
Balanced Fluids
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Normal Saline
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Impact on Potassium Levels |
Balanced Fluids
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Normal Saline
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What are the concerns with hypotonic solutions, or D5W? |
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What can be done to reduce harm associated with hypotonic solutions? |
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When might a sodium-free (D5W) or lower-sodium solution be appropriate? |
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What are some concepts regarding safe use of hypertonic solutions? |
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What steps can be taken to ensure that patients don’t receive unnecessary IV fluids? |
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Abbreviations: AKI = acute kidney injury; D5W = dextrose 5% in water; D10W = dextrose 10% in water; DKA = diabetic ketoacidosis; GI = gastrointestinal; IV = intravenous; KVO = keep vein open; LOS = length of stay; LR = Lactated Ringer’s; NNT = number needed to treat; NS = normal saline; TBI = traumatic brain injury
- US wholesale acquisition cost (WAC). Medication pricing by Elsevier, accessed April 2025.
- Information from US product labeling unless otherwise indicated: Dextrose solution (Baxter Healthcare, November 2024), Dextrose solution (B. Braun Medical, March 2024), Lactated Ringer’s (Baxter, March 2025); Isolyte S pH 7.4 (July2018); Normosol-R (October 2018); Plasma-Lyte A (August 2019); sodium chloride 0.9% injection (Baxter, March 2018).
Levels of Evidence
In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.
Level |
Definition |
Study Quality |
A |
Good-quality patient-oriented evidence.* |
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B |
Inconsistent or limited-quality patient-oriented evidence.* |
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C |
Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening. |
*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).
[Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. https://www.aafp.org/pubs/afp/issues/2004/0201/p548.html.]
References
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- ISMP. Plain D5W or hypotonic saline solutions post-op could result in acute hyponatremia and death in healthy children. October 1, 2009. https://www.medscape.com/viewarticle/710427 (Accessed April1, 2025).
- Sterile water should not be given “freely.” Pennsylvania Patient Safety Advisory. 2008;5(2):52-6. https://patientsafety.pa.gov/ADVISORIES/Pages/200806_53.aspx. (Accessed April 1, 2025).
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- Gosmanov AR, Gosmanova EO, Dillard-Cannon E. Management of adult diabetic ketoacidosis. Diabetes Metab Syndr Obes. 2014 Jun 30;7:255-64.
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- Metheny, Norma A. PhD, RN, FAAN; Moritz, Michael L. MD. Administration of 3% Sodium Chloride Via a Peripheral Vein: A Literature Review. Journal of Infusion Nursing 44(2):p 94-102, March/April 2021.
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- Rowell SE, Fair KA, Barbosa RR, et al. The Impact of Pre-Hospital Administration of Lactated Ringer's Solution versus Normal Saline in Patients with Traumatic Brain Injury. J Neurotrauma. 2016 Jun 1;33(11):1054-9.
- Mhanna A, Beran A, Srour O, et al. Balanced crystalloids versus isotonic saline in pediatric sepsis: a comprehensive systematic review and meta-analysis. Proc (Bayl Univ Med Cent). 2024 Feb 8;37(2):295-302.
- Self WH, Semler MW, Wanderer JP, et al. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):819-828.
- Product monograph for 3% and 5% sodium chloride injection, USP. Baxter Corporation. Mississauga, ON L5N 0C2. July 2018.
- ISMP. Best practice #10 FAQ. August 29, 2016. https://www.ismp.org. (Accessed July 29, 2022).
- Erstad BL, Huckleberry YC. Extremely hypo-osmolar intravenous solutions to treat hypernatremia: the time has come to stop. Am J Health Syst Pharm 2022 Jun 23;79(13):1122-1125.
- Hasim N, Bakar MAA, Islam MA. Efficacy and Safety of Isotonic and Hypotonic Intravenous Maintenance Fluids in Hospitalised Children: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. Children (Basel). 2021 Sep 8;8(9):785.
- Hall AM, Ayus JC, Moritz ML. Things We Do For No Reason: The Default Use of Hypotonic Maintenance Intravenous Fluids in Pediatrics. J Hosp Med. 2018 Sep;13(9):637-640.
- Silverthorn DU. Isosmotic is not always isotonic: the five-minute version. Adv Physiol Educ. 2016 Dec;40(4):499-500.
- Choo WP, Groeneveld AB, Driessen RH, Swart EL. Normal saline to dilute parenteral drugs and to keep catheters open is a major and preventable source of hypernatremia acquired in the intensive care unit. J Crit Care. 2014 Jun;29(3):390-4.
- Ostermann M, Randolph AG. Resuscitation Fluid Composition and Acute Kidney Injury in Critical Illness. N Engl J Med. 2022 Mar 3;386(9):888-889.
- Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med. 2018 Mar 1;378(9):829-839.
- Aoyagi Y, Yoshida T, Uchino S, et al. Saline versus 5% dextrose in water as a drug diluent for critically ill patients: a retrospective cohort study. J Intensive Care. 2020 Sep 11;8:69.
- Clinical Pharmacology powered by Clinical Key. Tampa, FL: Elsevier; 2025. https://www.clinicalkey.com. (Accessed April 1, 2025).
- Sanchez J, Lichtenberg R. Does my patient need maintenance fluids? Cleve Clin J Med. 2019 Oct;86(10):653-655.
- Kraft MD, Btaiche IF, Sacks GS, Kudsk KA. Treatment of electrolyte disorders in adult patients in the intensive care unit. Am J Health Syst Pharm. 2005 Aug 15;62(16):1663-82.
- Hawkins WA, Smith SE, Newsome AS, et al. Fluid Stewardship During Critical Illness: A Call to Action. J Pharm Pract. 2020 Dec;33(6):863-873.
- Hawkins WA, Butler SA, Poirier N, et al. From theory to bedside: Implementation of fluid stewardship in a medical ICU pharmacy practice. Am J Health Syst Pharm. 2022 Jun 7;79(12):984-992.
- Finfer S, Micallef S, Hammond N, et al. Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults. N Engl J Med. 2022 Mar 3;386(9):815-826.
- Zampieri FG, Machado FR, Biondi RS, et al. Effect of Intravenous Fluid Treatment With a Balanced Solution vs 0.9% Saline Solution on Mortality in Critically Ill Patients: The BaSICS Randomized Clinical Trial. JAMA. 2021 Aug 10;326(9):1–12.
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- Madieh J, Hasan B, Khamayseh I, et al. The safety of intravenous peripheral administration of 3% hypertonic saline: A systematic review and meta-analysis. Am J Med Sci. 2023 Aug;366(2):135-142 [abstract].
- Brown CS, Rabinstein AA, Zhao Y, Wieruszewski ED. Safety of peripheral 3% hypertonic saline bolus administration for neurologic emergency. Am J Emerg Med. 2023 Jul;69:83-86 [abstract].
- Emrath ET, Fortenberry JD, Travers C, et al. Resuscitation With Balanced Fluids Is Associated With Improved Survival in Pediatric Severe Sepsis. Crit Care Med. 2017 Jul;45(7):1177-1183.
- Diz JC, Luna-Rojas P, Díaz-Vidal P, et al. Effect of Treatment With Balanced Crystalloids Versus Normal Saline on the Mortality of Critically Ill Patients With and Without Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Anesth Analg. 2025 Jan 20.
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- Chen H, Lu X, Xu B, et al. Lactated Ringer Solution Is Superior to Normal Saline Solution in Managing Acute Pancreatitis: An Updated Meta-analysis of Randomized Controlled Trials. J Clin Gastroenterol. 2022 Feb 1;56(2):e114-e120.
- Antoniak D, Twohig P, Olson K, et al. Lactated Ringer's or Normal Saline for Initial Resuscitation in Patients Hospitalized With Acute Pancreatitis: A Retrospective Database Analysis. Pancreas. 2023 Mar 1;52(3):e203-e209.
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- Umpierrez GE, Davis GM, ElSayed NA, et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care. 2024 Aug 1;47(8):1257-1275.
- ISMP Canada. ISMP Canada Safety Bulletin. Reducing the Risk of Hospital-Acquired Hyponatremia: Intravenous Fluid Management and Monitoring. 2024 June 18;24(6). https://ismpcanada.ca. (April 8, 2025).
- Acarregui MJ. Fluid and electrolyte management in the newborn. May 18, 2022. In: Iowa Neonatology Handbook. https://uihc.org/childrens/educational-resources/fluid-management-nicu-handbook. (Accessed April 8, 2025).
Cite this document as follows: Clinical Resource, IV Fluid Safety. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights. April 2025. [410469]