questioning IV fluids

[SN2014]

The person was originally dehydrated (hypovolemic) and hypernatremic.

The first day the MD wanted D5 1/2 NS running at 84

.The 2nd day she switched the fluids to 1/2 NS @ 64

3rd day 1/2NS @20

4th day decided to bolus him with a 1L bag of 1/2 NS @999.

Some of those orders I questioned.. I know that I am not a doctor.. but I am just trying to understand the rationale.

Wouldn't a common fluid management of hypovolemic hypernatremia be a 1 L bolus of NS or LR ( an isotonic fluid), then gradual replacement w/ .45 NS to correct the hypernatremia ? (Without rapid shift of electrolytes) ?

Isn't D51/2NS hypertonic? Is that appropriate?

Have you ever heard of/gave a 1L .45 NS bolus @999ml/hr?

In what situations would that be applicable? Wouldn't that cause a rapid shift in electrolytes? Isn't that risky? (Increased risk of cerebral edema, seizures, etc.)

I don't have much experience but have never heard of 1/2 NS being ran at 999.. neither did my supervisor or co-workers.

Trying to understand the rationales/thought processes.

Input?

[ED Nurse, RN]

Without specific lab values its hard to comment.

[VANurse2010]

The person was originally dehydrated (hypovolemic) and hypernatremic.

The first day the MD wanted D5 1/2 NS running at 84

.The 2nd day she switched the fluids to 1/2 NS @ 64

3rd day 1/2NS @20

4th day decided to bolus him with a 1L bag of 1/2 NS @999.

Some of those orders I questioned.. I know that I am not a doctor.. but I am just trying to understand the rationale.

Wouldn't a common fluid management of hypovolemic hypernatremia be a 1 L bolus of NS or LR ( an isotonic fluid), then gradual replacement w/ .45 NS to correct the hypernatremia ? (Without rapid shift of electrolytes) ?

Isn't D51/2NS hypertonic? Is that appropriate?

Have you ever heard of/gave a 1L .45 NS bolus @999ml/hr?

In what situations would that be applicable? Wouldn't that cause a rapid shift in electrolytes? Isn't that risky? (Increased risk of cerebral edema, seizures, etc.)

I don't have much experience but have never heard of 1/2 NS being ran at 999.. neither did my supervisor or co-workers.

Trying to understand the rationales/thought processes.

Input?

D51/2NS is hypotonic in the body.

[SN2014]

Because the dextrose is quickly metabolized in the body.. leaving behind 1/2 ns...

that makes sense..

But what about the 1/2 NS bolus @999?

[Lev, MSN, RN, NP]

What were the patient's vital signs and urine output through this process?

I have given fluid boluses of 1/2 NS to a patient who was severely hypernatremic and septic with low BPs.

[SN2014]

Starting at day 2, the patient was then hypertensive w/ a systolic BP remaining above 160, to where they even put him on 2.5mg IV Push vasotec Q6 scheduled. No low bp, WBC wnl.

Day 1 NA was 152

Day of 1/2NS bolus NA was 148

[SN2014]

& urine output was adequate until the 1/2 NS bolus

[jadelpn, LPN, EMT-B]

@999 is a bolus of fluid. It is what the pump would be set at as opposed to hanging IV fluid "wide open". Usually given to those who are extremely dehydrated or some other thing--low blood pressure comes to mind.

So I would think adding NS of any quantity to an already hypernatremic patient with a high BP is a bit dodgy. But throw into it that dehydrated patients can present as hypernatremic.

I have had orders before that start slow, and then build(gentle rehydration)....but based on lab values. So hard to rationalize without them.

Awesome question, though!!

[ED Nurse, RN]

@999 is a bolus of fluid. It is what the pump would be set at as opposed to hanging IV fluid "wide open". Usually given to those who are extremely dehydrated or some other thing--low blood pressure comes to mind.

So I would think adding NS of any quantity to an already hypernatremic patient with a high BP is a bit dodgy. But throw into it that dehydrated patients can present as hypernatremic.

I have had orders before that start slow, and then build(gentle rehydration)....but based on lab values. So hard to rationalize without them.

Awesome question, though!!

A true bolus for a hypotensive, hypovolemic pt is not run at 999 on a pump- that takes an hour to infuse. A true bolus is on a pressure bag and goes in within minutes. Running a liter over an hour in a truly hypotensive pt is like pissing into a hurricane.

Hypovolemic pts are going to have increased sodium bc the concentration of sodium is increased due to the decrease in volume.

[VANurse2010]

A true bolus for a hypotensive, hypovolemic pt is not run at 999 on a pump- that takes an hour to infuse. A true bolus is on a pressure bag and goes in within minutes. Running a liter over an hour in a truly hypotensive pt is like pissing into a hurricane.

Hypovolemic pts are going to have increased sodium bc the concentration of sodium is increased due to the decrease in volume.

A bolus over an hour works fine for dehydrated patients with some soft BPs. Not everyone with a soft BP is in shock and needing a pressure bagged bolus.

[Tina, RN]

Very interesting thread... I always like to read about types of IVF and the conditions under which they would be given.

[Sunflowerinsc, ADN, RN]

I would have just asked the Doctor . But with more information , labs, vital signs, weight , LOC, other medications would help to know.