Stopping Iv Fluids: Stroke Patients' Unique Needs

Intravenous fluids are commonly administered to stroke patients, but there is no clear consensus on the best fluid management for such cases. Fluids given into a vein (intravenous, or IV) or under the skin (subcutaneous) are used for patients with acute stroke and poor oral fluid intake. However, the balance between the benefits and harms of different fluid regimens is unclear.

The type, volume, duration, and mode of fluid delivery can vary for each patient. Isotonic fluids (crystalloids) are solutions that contain similar amounts of dissolved salts as in normal cells and blood. Hypertonic fluids (colloids) usually contain more (or larger) dissolved particles than in normal cells and blood.

There is no evidence that colloids are associated with lower odds of death or dependence in the medium term after a stroke compared with crystalloids, though colloids are associated with greater odds of pulmonary oedema.

The risk of death or dependence is similar for stroke patients given colloids or crystalloids

Colloids are hypertonic fluids that usually contain more (or larger) dissolved particles than in normal cells and blood. Crystalloids are isotonic fluids that contain similar amounts of dissolved salts as in normal cells and blood. Fluids given into a vein (intravenous, or IV) or under the skin (subcutaneous) are commonly used in people with stroke, but there are no clear guidelines on the best fluid management in such cases.

A 2015 Cochrane review found no evidence that colloids were associated with lower odds of death or dependence in the medium term after stroke compared with crystalloids. However, colloids were associated with greater odds of pulmonary oedema. The review found no evidence to guide the best volume, duration, or route of administration of parenteral fluids in people with acute stroke.

Twelve studies (2351 participants) compared colloids with crystalloids. The odds of death or dependence were similar in participants allocated to colloids or crystalloid fluid regimens (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.79 to 1.21, five studies, I² = 58%, low-quality evidence). The odds of death were also similar between colloids and crystalloids (OR 1.02, 95% CI 0.82 to 1.27, 12 studies, I² = 24%, moderate-quality evidence). The odds of pulmonary oedema were higher in participants allocated to colloids (OR 2.34, 95% CI 1.28 to 4.29, I² = 0%).

Stroke patients given crystalloids have a lower risk of pulmonary oedema

Stroke patients are often given fluids intravenously (IV) or subcutaneously if they are unable to swallow. Fluids given to stroke patients can be categorised as either crystalloids or colloids. Crystalloids are solutions that contain similar amounts of dissolved salts as in normal cells and blood, whereas colloids contain more (or larger) dissolved particles than in normal cells and blood.

A 2015 Cochrane review found no evidence that colloids were associated with lower odds of death or dependence in the medium term after a stroke compared with crystalloids. However, stroke patients given crystalloids had a lower risk of pulmonary oedema, a complication that can lead to breathlessness due to excess collection of watery fluid in the lungs.

The review also found no evidence to guide the best volume, duration, or route of administration of parenteral fluids in people with acute stroke.

There is no evidence to guide the best volume, duration or mode of parenteral fluid delivery for people with acute stroke

Intravenous (IV) fluids are commonly administered to stroke patients, but there is a lack of clear guidelines on the best fluid management in such cases. Fluids can be given in different volumes, for different durations, and through different modes of delivery.

A 2015 review of 12 studies with 2,351 participants found no evidence to guide the best volume, duration, or mode of parenteral fluid delivery for people with acute stroke. The studies compared hypertonic (colloids) with isotonic fluids (crystalloids); of these, five studies (1,420 participants) also compared 0.9% saline with another fluid. The duration of fluid delivery was between two hours and 10 days.

The review found that people with acute stroke given crystalloids (including 0.9% saline) had a similar risk of death or dependence as people given other fluid types. Crystalloids were also associated with a lower risk of pulmonary oedema, a complication that can lead to breathlessness due to excess fluid collection in the lungs. However, it was difficult to draw conclusions about which fluids were better for reducing brain swelling (cerebral oedema) or a serious lung infection (pneumonia).

Another study published in 2017 supports the use of IV fluids in acute ischemic stroke patients, stating that it may be associated with a reduced risk of neurological deterioration.

A 2014 study evaluating the hydration practices of acute stroke patients found that the average time to first fluid administration was 284 minutes, and that many patients spent time without fluids.

A 2016 review on fluid management of neurological patients highlights the importance of isotonic rather than hypotonic fluids and the avoidance of hypovolemia and dextrose solutions. It also notes that fluid management in brain-injured patients is aimed at maintaining adequate cerebral blood flow and oxygenation, and that hypovolemia is bound to contribute to secondary brain injury.

In summary, while IV fluids are commonly used for stroke patients, there is currently no evidence to guide the best volume, duration, or mode of parenteral fluid delivery. More research is needed to optimise fluid management and improve outcomes.

Administration of 0.9% NaCl for 72 hours in patients with acute ischemic stroke is safe and may reduce the risk of neurological deterioration

Intravenous fluids are often discontinued for stroke patients due to the risk of fluid overload, which can lead to cerebral edema and cardiac failure. However, a 2017 study found that the administration of 0.9% NaCl for 72 hours in patients with acute ischemic stroke is safe and may reduce the risk of neurological deterioration.

A positive fluid balance is associated with poor outcomes in subarachnoid haemorrhage

In another study, 142 patients with aneurysmal subarachnoid haemorrhage were analysed. It was found that greater cumulative fluid balance within the first 7 days in the ICU was independently associated with a higher risk of poor outcome up to 1 year after the initial insult.

In a third study, 237 patients with nontraumatic subarachnoid haemorrhage were admitted to the neurologic ICU. It was found that a higher daily fluid intake was associated with higher admission Hunt and Hess grade, increased pulmonary fluid accumulation, prolonged mechanical ventilation, higher daily Subarachnoid Hemorrhage Early Brain Edema Score, occurrence of anaemia, delayed cerebral ischemia, and poor functional outcome.

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