Why do they always start with IV fluids?

StudentOfHealing · Mar 17, 2014

I didn't have time to read the above comments as usual cus I have a lot going on but if no one said it yet ... being bed bound can cause fluid volume deficit because it causes diuresis because the fluid shifts from the legs up to the chest area and you get increased pressure in the atria and the heart thinks it's on an overload state and the atria release ANP which cause diuresis.

Note: I think for my example it'd really have to be some lengthy bed rest. Also, this may be a good rationale as to why bed rest helps with fluid overload.

Hope I'm not too off.

Back to studying for NCLEX.

StudentOfHealing · Mar 17, 2014

This thread reminds me a little bit of when I was very new in critical care, and we had some hemodynamic drips that increased BP (dopamine, chiefly) and some that decreased BP (nitroprusside, at the time). Because I didn't know much (umm, anything) about their mechanisms of actions, I thought it illogical to give both to the same patient at the same time. I mean, really, why would we do that?
(Extra points for any bona fide first-program student who can tell me why that is ... not you, Esme!)
I learned from that not to jump to conclusions when I see something that doesnt make sense, especially if I am not too knowledgable in the specialty (yet).
So here we are: often a kid who's sick enough to admit ought to have an IV because he's at higher risk for doing something bad, at which point it will be really hard to get one in. Look beyond the surface, see into the possibilities ... be prepared.

I have to think about what Dopamine does.

Knowledge recall: At 3mcg dopamine causes dilation of renal arteries hence renal perfusion.

I believe higher doses stimulate beta 1 (so we can increased HR and force of contraction) aka positive chronotrope?

But it also stimulates the alpha 1 receptors so that causes vasoconstriction.

The nitroprusside causes vasodilation. Vasodilation means less SVR or afterload meaning less WORKLOAD on the heart.

Sounds like this patient has a low bp cus their heart is the issue??? So... maybe you want to give enough dopamine to sustain a good BP and improve contractility and enough nitroprusside to reduce workload on the heart? Which sounds weird bc the decreased workload is coming from the peripheral vasodilation..... ((((unless there's a dose that ONLY causes CORONARY vasodilation?))))) ..... So I'm agreeing with the poster above! Their answer sounds well thought out. I'm confused.

(Please tell me the correct reasons cus I'm sure I'm off) haha

I had a patient once on Levophed (which acts on alpha 1) AND Milrinone.... pt had HF ... was ready for an LVAD.

Now reallyyyy back to nclex studying. >.

nurseprnRN, BSN, RN · Mar 18, 2014

You got it. I sent a PM to explain to missmollie (I think) to explain exactly that. WTG.

KelRN215, BSN, RN · Mar 20, 2014

I GUARANTEE there are children admitted there who are not started on IVF. If you admit a child with SIADH and a sodium of 123, you best not be starting said child on IVF, unless it's 3% normal saline running at a VERY slow rate. If you admit a child with ESRD on chronic dialysis with anuria you also best stay away from the IVF. I'd say it's possible that this is part of an admitting orderset and the MDs just don't take it out. Pharmacy and Nursing should be questioning the orders if they're inappropriate.

What do you mean by "they always give IVF of at least 1000 mL or 500 [mL]"? For an infant, their total daily fluid requirement may be less than that. Perhaps the size of the bag(s) you are seeing are 500-1000 mL but that doesn't mean that's the amount the child receives. An infant weighing 2.5 kg (5 lb 8 oz) would have a maintenance fluid requirement of 10 mL/hr or 240 mL/day. The floor is most certainly not bolusing a child that size with 500 or 1,000 mL. Fluid boluses for children are dosed in mg/kg- typically 10-20 mL/kg. So a child shouldn't be getting a 1,000 mL bolus until he weighs 50 kg (unless he's really clinically showing us that he needs aggressive rehydration in which case more fluid might be appropriate, but said child would also likely require pressors and a PICU bed).

Have you looked at these children's orders?

nurseprnRN, BSN, RN · Mar 20, 2014

I GUARANTEE there are children admitted there who are not started on IVF. If you admit a child with SIADH and a sodium of 123, you best not be starting said child on IVF, unless it's 3% normal saline running at a VERY slow rate. If you admit a child with ESRD on chronic dialysis with anuria you also best stay away from the IVF. I'd say it's possible that this is part of an admitting orderset and the MDs just don't take it out. Pharmacy and Nursing should be questioning the orders if they're inappropriate.

Of course you're right about this. Thank you so much for doing a better job of completing the thought than the rest of us!

AgentBeast, BSN, RN · Mar 21, 2014

Positive inotropic action from dopamine

Decreased afterload from the nitroprusside

THELIVINGWORST, ASN, RN · Mar 21, 2014

I just wanna say, y'all are so smart.

RobtheORNurse · Mar 21, 2014

In my limited pediatric experience, Trauma, I would think the IV is a standard of care because a child can go bad really fast and then it is too late to try to get an IV started. Their vascular system collapses quickly, making it very difficult, if not impossible to get venous access. I would rather have an IV lifeline than having to start an interosseous line in an emergency.

shayshani01 · Mar 21, 2014

Very good question. I am currently teaching Pediatrics and I'm going to see if my students can critically think this one out.

Yes, all that was stated - the immature immune system, the dehydration, body weight are considered when you have a talk about the health of a child and maintaining hydration.

intothecosmos · Mar 21, 2014

RobtheORnurse, you hit it exactly. I work in peds, and if they come in with infection, they will most certainly have an IV running for at least most if not all of the stay. For one, infections can go septic fast in kiddos and you want to always have that access to give them meds. Also, a lot of the meds given via IV are very caustic to the vein, so having fluid running behind it helps keep the line patent. Lines tend to clot off faster without that extra fluid running TKO. Plus, the kids do get dehydrated quickly, especially if they are running a fever. If they are sick, they also don't want to eat or drink as normal, so extra help needs to be given to keep them from getting dehydrated.

For the other kids, like sleep apnea, you want to have that line in just in case.

I also wanted to chime in on that other question, because we had something similar in our PICU. We had a kid who had morphine going and narcan at the same time. Both are antagonists of the other so we couldn't figure out why they were both running together. I did a little digging and discovered that for children receiving morphine, there is a high risk of infection associated with the pruritis caused by the side effects of morphine. Especially if children scratch at themselves, scratch until they bleed, scratch at the tape holding the IV in place, etc. Plus, it's just annoying to be itchy all the time. Narcan given in small doses can inhibit the pruritis caused by the morphine while not having any effect on the pain control action of the morphine. Maybe the two medicines listed were the same. They were both titratable to keep the BP from going out of control by working on differing parts of the vascular system. Just a guess.