Reason for IV fluids

[Matt8700, RN, EMT-B]

Hello,

I have a burning questions and cannot seem to find any literature that answers it for me in my own research.

What is the indication for IV fluids in a patient that does not seem to need them? I'm not talking about your nausea, vomiting, fevers, etc. I understand that. However in the ER we seem to give fluids to almost everyone and I can't figure out why. I asked a PA and the answer I got was "everyone likes fluids!"

I like to be able to explain the treatment modality to the patient. It's easy to do when they have been vomiting or have a fever, but sometimes I can't figure out why were ordered at all!

Examples might be a diagnosis of general weakness in a 30 year old, no PMHx and perfectly normal labs. What's the purpose? No evidence of dehydration. No vomiting. Why the fluids?

Another example may be a trip and fall in a 70 year old, no LOC, only orders are for scans without contrast. Why the fluids?

I know it might sound dumb, but I'm just curious why almost anyone that comes through the ER doors gets a liter, unless they are a true level 5, like a dental pain or work note!

thanks for any insight you can provide!!!!!

[Scrubs_n_sirens, MSN, RN]

Americans in general do not drink enough and have some form of dehydration that may not be clinically present.

If the person has a UTI, help hydrate them to flush em out.

Other than that, I don't see why we do it so much. It's an over ordered intervention. But, unless they are fluid overloaded, I guess there's no real reason against it besides time to infuse, cost, risk of infection by iv.

[offlabel]

Well, I think that most folks that have an IV ordered for them probably do have some defensible reason. The occasional gratuitous IV sticks in our minds more and our bias is reinforced. My opinion.

That said, it may just be a cultural throw back to the days when the idea of a hep lock or saline lock just wasn't done in the ER. Everyone got an IV in the late 70's and 80's because we were just getting more aggressive in emergency care as it was really coming into its own as a specialty. Algorithms and standing protocols were coming on as never before and IV's were a big part of that.

So the answer might just be "because we've always done it that way".

[floridaRN38]

Today actually I hung a bag of saline on a young girl. The docs rational was because it is "just something to make her feel like we did something". Instead of just discharging her since she came to the ER.

[Lunah, MSN, RN]

I like to point out that patients are tolerating PO and have normal labs and vitals, then ask why the liter? That is typically when the order is canceled. :) I think it's as close to an "ER knee-jerk reaction" as we'll ever see.

[Pheebz777, BSN, RN]

Well, we all know that the best determination of hydration status is reflected in the urine. When patient hands over a urine sample that's dark amber in color, well that tells me a lot. Most of the patients coming thru the E.D. may be hours or even days behind on their fluid intake and not even know it. Most don't keep up when they're feeling sick or miserable.

In a busy E.D. I could understand the MD's tackling this issue head on before waiting for lab results to order IV fluids. This also helps the nurses in not having to go back to the same patient to give fluids after the fact. And having a patient go to the restroom to PEE may not be the most comfortable feeling for them, but that's music to our medical ears!

Generally there's no harm in giving fluids accross the board except for the obvious fluid overloaded ESRD, CHF'er, etc.

However unless the MD is giving fluids for a bug in the ear, a 20yr old with an ingrown toe nail, ant bite, eye pain, I don't see why they would order fluids. Is that what is happening in your E.D.?

[Pheebz777, BSN, RN]

Just reading your examples, the 30yr old with GBW could have some mild dehydration by presenting with GBW alone. Labs can be perfect, she doesn't need to be vomitting, having sunken eyeballs, pale, to be labeled dehydrated. The MD's have a few million diagnosis to rule out before coming to a conclusion and DHN is one they probably want to rule out right off the bat!

And the 70 who fell, why did he fall? He could have had some mild DHN as well causing alterations in muscle movement, gauge of distance, altering his visual senses. And giving him fluids would provide intravascular support, electrolyte replenishment, and make him PEE, hoping he's not brewing an early UTI.

Also not knowing his history, at his age, he is prone to coagulopathies. Falling increases that risk, hydrating with fluids decrease that risk.

[Altra, BSN, RN]

Are these fluids being ordered after labs have been resulted?

The above responses have given a variety of reasons why fluids might be given during a work up, until we have lab evidence of a lack of anything actually clinically wrong with the patient. But if fluids are being ordered after lab results ... I'm inclined to think this is more about a customer-service driven desire to appear to have "done something". And apparently your management is ok with the resulting drag on throughput times.

[englishgarden]

Of course not everyone coming into the ER needs IV fluids, but many times it is important to establish an IV access in an acute patient and maintain the line by giving fluids. There is nothing worse then having a patient go south on you without IV access!

[vintagemother, BSN, CNA, LVN, RN]

Americans in general do not drink enough and have some form of dehydration that may not be clinically present. /

This is what I'm thinking, too. So many people are dehydrated and unaware. As well, many different s/s and disease processes are exacerbated by/secondary to dehydration.

From Acute onset confusion to UTI to anyone with renal probs to ETOH intox, etc.

As long as they're not fluid overloaded, I think IVF are safe and often helpful.

While drinking PO water can have the same impact, I'm thinking about the tonicity of water as opposed to NS. I think NS is better absorbed by tissues and that IV NS will hit the tissues sooner because it doesn't have to go through the digestive tract.

I must say, that during school and since preventing in an ED, I am a believer in hydration- 2L!! That's my benchmark I try to reach when feeling under the weather.

I've, evidently, drank the "kool aide" so to speak, as far as believing in Hydration. [emoji23]

[canoehead, BSN, RN]

I worked in an ER that ordered a litre of fluid on almost everyone. The doc's response was "if they're sick enough to come to the ER they're sick enough to need fluid." That was BEFORE he went in to assess the patient. The doctors would see only two patients an hour...apparently there was a conflict with the employer, and I thought he was using the IV fluid to stall.

This particular ER did procedures according to chief complaint...so if the patient came in with chest pain, they got a formula of labs and procedures before the doctor saw them. That is fine, but if they've been worked up for chest pain twice today, it turned out to be indigestion, maybe we don't need to do the whole thing again. The hospital's purpose was to maximize reimbursement. I know not to assume based on one patient, I worked there six months, and the boss verbalized as much several times. If they could bill for IV fluid, they would give it, even for a healthy 30yof complaining of UTI symptoms.

[MunoRN, RN]

There are certainly patients coming to the ED that need IV fluids, but a lot of it seems to come from the old ED wisdom that IV fluids and O2 can cure just about anything.

I have worked with an ED physician who claimed they get pressured by the inpatient docs to order IV fluids since that helps justify them ordering IV fluids which is one way to bump a patient's status from observation to full inpatient (so long as the fluids are ordered to run at 100 ml/hr or greater). Basically, this means that the physician who has to do the same H&P either way, can significantly increase what they get reimbursed for that H&P by justifying inpatient status instead of observation.