Reason for IV fluids

[Matt8700]

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!!!!!

[Dragonnurse1, ASN, RN]

Our ER had 3 tracks, fast, Chest Pain Center and trauma. The track patient rarely got hep locks or IV's (unless the patient was a kidney stoner or had N/V >1h for children or 5h for adults) but in the CPC everyone got a hep lock when blood was drawn. Older patients generally got lines because they tended to go down faster, were almost always dehydrated or chief complaint warranted one. Overloaded patients got hep locks only. We gave fluids selectively. Perhaps things have changed in the last few years. I do not understand giving fluids just to make patients feel like something is being done.

[bgxyrnf, MSN, RN]

I seems a bit foolish to start a line of everyone, regardless of complaint. If someone comes in regularly for trivial issues and does not need a line, but gets one, then what happens when the person does coming needing a line, and now have poor access d/t years of unnecessary sticks?

Then we get to bust out the ultrasound and go after the deep veins.

[ahefner, BSN]

I took my son to the ER a few weeks ago after a head trauma (fall while rollerblading - sans helmet) and thankfully they did not give him fluids! He probably would have made me check him out AMA if they had tried to start an IV!

Also, his head CT was good.

[PNM2600]

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

Say you have a pt come in with seemingly benign symptoms, but suddenly they have a siezure. If you have the IV started, you have a line already established. Perhaps there's no crisis, but the Dr decides to order a test w/contrast you have a line already. No worries if nurses are tied up with a bigger emergency. Also, I'd think every ER patient is treated like a potential serious Emergency. Not to commit "FRAUD" but to provide best care possible. It's a prophylactic measure. IMHO

[DarknTwistyERRN]

We had a MD who said he was taught to give everyone who wasn't a renal patient a liter bolus and then continuous infusion @ 125mL/hr. My response was, "Not everyone wants to pay for an IV and fluids if they're not medically necessary." He said I should ask them! :) So, if it was someone with whom fluids were clearly not medically indicated (not that most people wouldn't benefit from at least a liter) and wouldn't need a line otherwise, I'd lead with, "Would you like some IV fluids?" Sometimes they said yes and sometimes they said no. I no longer felt guilty.

[OkieSunRN]

I've wondered why we don't get more fluids ordered a KVO rate. That explains it.

[siegolindoRN]

its a multifactorial thing; on one end you have clinical practice, patient expectations, usage deals through supply chain, etc and on the other, the financial impact. Both are influenced by the medical director and/or senior administration.

An IV bag is separate charge from the line its connected to (single lumen PVL) and the time for said infusion to complete (3 charges total). I have worked at EDs where nurses documented against a charge ticket and others where it was built into the EMR.

Its difficult to argue fraud, as many clinicians can attest too, since most people don't do a very good job at keeping themselves hydrated per medical standards.

[DatMurse]

most people who feel sick do not take in enough fluids. unless they have CHF, hypoalbuminemia, ascites, 3rd spacing, or some other symptom that can cause fluid overload there is no reason a small reasonable rate of 50-100 hr would cause an issue.

In the cancer ward it may be related to a chemo.

People's bodies are very resilient to minor things.

[EDRNCCmom, MSN, RN]

Say you have a pt come in with seemingly benign symptoms, but suddenly they have a siezure. If you have the IV started, you have a line already established. Perhaps there's no crisis, but the Dr decides to order a test w/contrast you have a line already. No worries if nurses are tied up with a bigger emergency. Also, I'd think every ER patient is treated like a potential serious Emergency. Not to commit "FRAUD" but to provide best care possible. It's a prophylactic measure. IMHO

I agree with your thought line. Certain patients warrant a line even if no medications are ordered. I have had too many patients who come in looking stable but quickly crump. Especially those young patients (40-50 years) old who come in with syncope. I have had several of them who brady down into the 30's or lower when doing orthostatic's on them. And they have bought themselves a pacer! I frequently explain to my patients who are on the cardiac monitor that the IV line is being placed in case something unusual occurs on the monitor and they need life saving interventions. I try to always draw my labs with my line so that the patients only potentially get poked once but they then have a patent line established if needed.

[Llana87]

Like some other people have stated, dehydration. Most of us walked around dehydrated and do not even realize it. As you know, it is needed sometimes in certain medical conditions like heavy vomiting, diarrhea, hyperglycemia ect. This should be obvious.

The other reason I think fluids are ordered on most people, including those may not need it, would be patient satisfaction.

Yes, I said it. Most people are so clueless when it comes to what their true medical needs are. If they come to the ER they expect to be served just as though it were a hotel or restaurant. So giving fluids is a good way to make them feel like something was done for them thus hopefully increasing patient satisfaction scores. At least that is how admin views it. Forget the fact that most of the people who make up administration are not medical at all.

So that would be my answer. To make the people who waste beds in the ER not feel like that is what they are doing. It makes them feel as though they really "have a bad disease" and gives them something to post of facebook about so that they can "get prayers."

Please forget my cynical ways. I have been doing it a long time and that is the answer I have arrived to when it comes to giving fluids to someone with a hang nail.

Also, some people truly may need the fluid even if their medical problem does not appear to warrant it.

[2manycookies]

My first thought on reading the OP was that it's got to be a $ issue! I've worked at the same hospital for over 6 years and have done some admin type stuff along with nursing. Our liter bags of saline cost the PT or ins. co $350 each. So, maybe the docs aren't reaping that benefit but SOMEBODY is getting paid. Clinically speaking this seems similar to me to putting O2 on PT's regardless of whether they need it or not. (not talking about following cardiac/stroke protocols) Say, for instance you give someone 50 of fent and they maintain there sats well above 90%- I don't put O2 on those peeps, just keep them on the monitor and have it ready just in case. I know nurses however in my ED that will put anyone who gets an IV narc on 2 liters of O2 whether they need it or not. In the end I think that it's better to refrain from intervention unless it's preventative or restorative.

[GCom24, ASN, RN]

Very good read on why NS is not a one size fits all solution and is given far too liberally.

PulmCrit: We should engineer a new crystalloid