But Can You Just PO?

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Fluid management in the Emergency Department (ED) is crucial in the adequate resuscitation of the acutely ill and decompensating patient. Patients present to the ED with hypovolemia secondary to a plethora of causes—some requiring IV fluid resuscitation and others requiring none. Considering the nationwide IV fluid shortage, judicious use of fluids is imperative. Thus, this begs the question, who really needs IV fluids, and can the patient simply hydrate orally? This article serves to briefly discuss IV fluids administration in the ED and the instances where they are not indicated. 

Within the human body, there are two main forces that counteract to ensure fluids balance: oncotic pressure and hydrostatic pressure. Various pathologies such as kidney injury, liver injury, and heart failure alter the balance between these forces, leading to extravascular fluids accumulation and intravascular fluid depletion. Other conditions that lead to intravascular fluid depletion include but are not limited to starvation/dehydration, vomiting, diarrhea, burns/trauma, hyperglycemia, and hemorrhage. Oral intake is the most preferred method for receiving fluids. However, alternative routes such as IV access offer a direct means to administer fluids into the vascular system in patients unable to tolerate oral intake. IV fluid hydration is not a benign process, and prescribing IV fluids should be given the same level of thought as prescribing other medications.  

Complications of wrongfully administering IV fluids include but not limited to:  

  • Hyponatremia: 

    • Especially with hypotonic solutions 

    • Manifests as altered mental status, cerebral edema, seizures 

  • Hypernatremia:  

    • Hypernatremia can occur due to administering hypertonic saline or incorrectly formulated hyperalimentation solutions 

  • Hyperkalemia:  

    • Increased risk in renal failure when administering potassium-containing solutions 

    • Increased risk for cardiac arrythmias  

  • Volume Overload 

    • Present with peripheral edema, dyspnea, pulmonary edema, hepatomegaly  

  • Compartment Syndrome 

    • Increased risk when administering large volumes of fluids exceeding 5 L in 24 hours 

    • Often presents with oliguria, a tense abdomen, and increased airway pressure.   

  • Metabolic Acidosis 

    • Normal saline is a slightly acidic solution that can potentially lead to metabolic acidosis. Lactated ringer is closer to the body’s pH 

  • Other Complications 

    • Hematoma, phlebitis and thrombophlebitis, air embolism, infiltration, extravascular and intraarterial injections, infection, and device embolism 

The indications for fluid administration encompass resuscitation, rehydration, correction of electrolyte derangements and maintenance. Patients needing resuscitation lack hemodynamic stability, and fluids are used to address acute volume loss. Rehydration corrects a fluid deficit that the patient cannot fix with oral fluids alone. Patients receiving maintenance fluids are hemodynamically stable, but they are unable to orally meet their daily fluid and electrolyte requirements.  

There is substantial evidence that IV fluids can be beneficial in patients with sepsis complicated by hypotension and labor. There are still many pathologies encountered frequently in the ED that do not have substantial evidence supporting their treatment with IV fluids.  Below are some types of patient populations that do not clinically benefit from IV fluid administration in the ED:  

Table 1: Clinical Presentations without Evidence to suppor the administration of IV fluids

Oral rehydration therapy (ORT) does have a substantial body of literature supporting its use in the pediatric literature for mild to moderate dehydration (such as in acute GI illness). A number of studies have compared the effects of ORT and IV rehydration therapy in infants and children with acute GI illness.  Atherly‐John et al. compared the effects of these two among the acute gastroenteritis children and reported that the use of ORT was associated with shorter hospital stay and increased patient satisfaction. Out of 18 patients receiving ORT, 4 failed to respond well and were escalated to IV therapy. A systematic review by Freedman et al. demonstrated that use of ORT was characterized by shorter stays at the hospital. IV fluid administration was more associated with phlebitis. However, they also concluded that ORT patients had a greater risk of developing paralytic ileus, as compared to IV therapy. Contraindications to ORT include evidence of severe dehydration which is defined as a volume loss greater than 10%. Patients present with somnolence, increased heart rate, oliguria, anuria, thready pulses, tachypnea, few or no tears, decreased blood pressure, sunken fontanelle, and prolonged capillary refill. Other contraindications include those who are unable to drink liquid (respiratory problems or impaired unconsciousness) and patients in shock, persistent vomiting, or with an ileus.  

In addition to the evidence supporting its efficacy, ORT can be cost effective in comparison to IV fluids (in the appropriate context). A 25th-75th percentile range for the cost of ORS and zinc per child is $1.50–$5.00. In contrast, an IV therapy infusion can cost between $382–$905 for 1–3 hours. Hospitals can purchase ORT packets for use in EDs as well as giving patients the formula to make their own at home. Preparation requires: 

  • One liter of safe water 

  • Half a small spoon of salt (3.5 grams) 

  • Four big spoons (or eight small spoons) of sugar (40 grams) 

Dosing can be administered as follows: (1)  

  • Children under 24 months: 50 to 100 ml after each loose stool (approximately 500 ml daily) 

  • Children from 2 to 10 years: 100 to 200 ml after each loose stool (approximately 1000 ml daily) 

  • Children over 10 years and adult: 200 to 400 ml after each loose stool (approximately 2000 ml daily) 

Summary  

Patients with mild to moderate dehydration should receive oral rehydration solution, and those with severe dehydration should receive IV fluids. This has been particularly validated in pediatric literature; however, this can be applicable to the adult patient population within the right circumstances i.e ability to protect airway and the lack of clinical findings suggesting a need for IV fluid resuscitation. If the patient can safely drink orally, and the patient is hemodynamically stable, then consider oral fluid rehydration. Patients should be classified as complicated and likely needing IV fluids if they have head trauma, significant ketosis/acidosis, inability to protect airway or intubation, hypercalcemia, sepsis/septic shock, or are in labor. IV fluid hydration is required in head trauma and hypercalcemia for osmotic gradient balance and for correction for volume depletion caused by hypercalcemia-induced diabetes insipidus, respectively.  

References

  1. Castera MR, Borhade MB. Fluid Management. [Updated 2023 Oct 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532305/ 

  2. Aghsaeifard Z, Heidari G, Alizadeh R. Understanding the use of oral rehydration therapy: A narrative review from clinical practice to main recommendations. Health Sci Rep. 2022 Sep 11;5(5):e827. doi: 10.1002/hsr2.827. PMID: 36110343; PMCID: PMC9464461. 

  3. Perez SR, Keijzers G, Steele M, Byrnes J, Scuffham PA. Intravenous 0.9% sodium chloride therapy does not reduce length of stay of alcohol‐intoxicated patients in the emergency department: A randomised controlled trial. Emerg Med Australas 2013;25(6):527–34.

  4. Terayama T, Sasa R, Nakatani Y, et al. Effect of intravenous fluid therapy for acute alcohol intoxication on length of time from arrival at the emergency department until awakening: A prospective observational cohort study. Acute Med Surg 2023;10(1):e841.

  5. Zitek T, Sigal T, Sun G, Manuel CM, Tran K. I-FiBH trial: intravenous fluids in benign headaches—a randomised, single-blinded clinical trial. Emerg Med J 2020;37(8):469–73.

  6. Homma Y, Shiga T, Hoshina Y, et al. IV crystalloid fluid for acute alcoholic intoxication prolongs ED length of stay. Am J Emerg Med 2018;36(4):673–6.

  7. Balbin JEB, Nerenberg R, Baratloo A, Friedman BW. Intravenous fluids for migraine: a post hoc analysis of clinical trial data. Am J Emerg Med 2016;34(4):713–6.

  8. Jones CW, Remboski LB, Freeze B, Braz VA, Gaughan JP, McLean SA. Intravenous Fluid for the Treatment of Emergency Department Patients With Migraine Headache: A Randomized Controlled Trial. Ann Emerg Med 2019;73(2):150–6.


Authorship

Written by Charlene Kotei, MD, PGY-2, University of Cincinnati Department of Emergency Medicine

Peer Review, Editing, Posting by: Jeffery Hill, MD MEd, Associate Professor, University of Cincinnati Department of Emergency Medicine

Cite As: Kotei, C. Hill, J. But Can You Just PO? TamintheSRU. www.tamingthesru.com/blog/2024/12/16/but-can-you-just-po. Published 12/17/2024