Reason for IV fluids

Specialties Emergency

Published

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!!!!!

Specializes in Emergency, Telemetry, Transplant.
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.

And I would think that increasing throughput times (with more people spending more time in the waiting room, etc.) would do much more to decrease customer service "scores" compared to the relatively few people who blame the ED for "not doing anything" if they don't get fluids.

Specializes in Private Duty Pediatrics.
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.

What does GBW mean? I didn't find that on Google

And what is DHN? The Deaf and Hearing Network? Digestive Health & Nutrition? (Hey, I tried.)

Specializes in Forensic Psychiatry.
What does GBW mean? I didn't find that on Google

And what is DHN? The Deaf and Hearing Network? Digestive Health & Nutrition? (Hey, I tried.)

GBW is generalized body weakness and DHN is dehydration.

I don't work in ER but normally when people get admitted they get fluids and my whole family had ER visits and no IV fluids had been given. Maybe just your ER? Interesting topic.

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.

Sounds like insurance fraud to me. Risky business for the docs and the hospital if complicit.

Specializes in Critical Care.
Sounds like insurance fraud to me. Risky business for the docs and the hospital if complicit.

Unfortunately providing services, medications, etc that are aren't well justified is pretty common, this is an area where nursing could do a better job of questioning these orders and determining if it's appropriate to initiate them. Because of bundled billing on the inpatient side, instances of fraudulent billing for unnecessary services is much more common in EDs and outpatient services where services are billed individually.

Specializes in ICU, CVICU, E.R..
What does GBW mean? I didn't find that on Google

And what is DHN? The Deaf and Hearing Network? Digestive Health & Nutrition? (Hey, I tried.)

It's common "unofficial" medical lingo used in the medical field. GBW is short for Generalized Body Weakness, and DHN is short for dehydration. Back in the days when MDs wrote their progress notes on paper, they would use these unofficial terms back then ad nauseam.

There are a million more of these "unofficial" short cuts that only those working in the medical field would know lol

Specializes in ER, Corrections, Mental Health.

I get wanting to make the patient feel like we did something but sometimes it really hinders thru-put. What about when the lobby is at a 6 hour wait and we are starting lines and running fluids on patients that don't really need them? Now we are backing up even more. Double edged sword I guess.....

I get wanting to make the patient feel like we did something but sometimes it really hinders thru-put. What about when the lobby is at a 6 hour wait and we are starting lines and running fluids on patients that don't really need them? Now we are backing up even more. Double edged sword I guess.....

That reminds me of one local ER. They start on IV on everyone regardless of their complaint. Nothing like seeing a waiting room full of people with IV's.

It also prevents people from leaving before seeing the doctor. Money for the hospital because ER patients get an IV regardless of whether they need IV fluids.

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!

So just cap the catheter with a clave and flush it... no need for fluid and tubing for "just in case".

They are even doing this for pt coming in with uncontrolled HTN- probably the last thing they need- more volume??

Much of what we do in the ER is pretty pointless.

IVF is just a small part of it. People who are "dehydrated" and tolerate po can just drink. It's what they should have been doing in the first place. And, if you think of all the actual abd pains that drink 1 liter of contrast, it is pretty damn obvious that these poor "dehydrated" souls can drink.

And, if they are ACTUALLY vomiting (a small fraction of NVD complaints), SL Zofran has similar onset/efficacy as IV. So- you could give a SL Zofran and a liter of water. Every 5 minutes, 2 shot glasses of water, and they will be magically cured in an hour.

Even even if they actually have diarrhea, they can still drink water. It's what the rest of the world does.

But, when we start an IV, medicate, hydrate and send them home with a DX of dehydration we are basically telling them that they had a real problem, and it's a good thing they came in to the hospital where we can treat it with our special IV meds.

And, plenty of the IV meds we give could be given PO. Steroids for routine exacerbation COPD for example. In fact, there is a question whether IV steroids are any better at all for certain issues.

IV ABX are great for something that is rapidly progressing, or potentially dangerous. But, for any problem going on for days, reach therapeutic levels an hour or 2 later just doesn't matter.

If you think about all the ER problems that could easily have been dealt with at the PCP, it becomes pretty clear that a lot of the more invasive, costly stuff we do is not needed. But it does reinforce using the ER for primary care. As much as we complain about that, it is a good business model.

But, if all we did in the ER was treat emergencies in an evidence based fashion, many of us would be out of work. This ridiculous system of ours allows me to live working only Per Diem, taking breaks when I want so I really shouldn't complain or advocate change.

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