i.v.

essentials

Fluid management basics

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By Wanda Williams, APNP-BC

Nurse Practitioner • Alvin C. York VA Medical Center • Murfreesboro, Tenn.
Charlotte Davis, BSN, RN, CCRN
CCU/CVICU Direct Care Nurse • Heritage Medical Center • Shelbyville, Tenn.
Direct Care Nurse/Charge Nurse • Alvin C. York VA Medical Center • Murfreesboro, Tenn.
Kandie Brothers, MSN, RN, CNL
Prevention and Management of Disruptive Behavior Coordinator • VA Medical Center • Nashville, Tenn.

Fluid management is a primary treatment • elevated or low heart rate

We make up option for managing patients with acute, • elevated or low BP
60% of the chronic, or critical illnesses. Common condi- • confusion or delirium
adult body, and tions that require fluid replacement include: • absence of sweating or tears
80% of the • prolonged or severe vomiting • rapid breathing.
infant body! • prolonged or severe diarrhea Common signs of volume overload
• infection include:
• gastrointestinal (GI) suctioning • increased weight
• heart failure • ascites
• septic shock • elevated or low BP
• respiratory failure • elevated or low heart rate
• hemorrhage • increased oral secretions
• cardiovascular collapse • tachypnea (increased respiratory rate of
• surgical procedures greater than 20/minute)
• trauma • increased pulmonary capillary wedge
• administration of nephrotoxic pressure (PCWP)
medications. • increased central venous pressure
In this article, we’ll review the • jugular vein distention (JVD)
basics of current fluid manage- • increased intracranial pressure
ment practices. • shortness of breath
• dyspnea
Balancing act • initial increased urinary output
The adult body comprises 60% water; • decreased level of consciousness
infants, 80%. When the fine balance of water • headache
is either depleted or overloaded, the body • blurred vision
can respond by causing cardiac symptoms, • irritability.
such as abnormal heart rhythms or an If you suspect volume depletion or vol-
elevated or low heart rate or BP (see ume overload, immediately consult with the
Understanding fluid balance). medical team to ensure the patient is quickly
Common signs of volume depletion are: evaluated and treatment initiated. Fluid
• lethargy can be replaced by encouraging patients to
• decreased urine output (for example, increase their oral fluid intake in nonemer-
infants who have no wet diapers for more gent situations. In acute or emergent situa-
than 3 hours or children, teens, and adults tions, such as when the patient’s heart rate,
who have no urine output for more than BP, breathing, and mental status are
8 hours) altered, more aggressive treatment, such
• dry oral mucous membranes as administration of I.V. fluids, may be
• dry skin with decreased elasticity necessary.
• sunken eyes or fontanels in infants Keep in mind that patients with certain
• thirst acute or chronic diseases may have difficulty
• headache safely accommodating the addition of I.V.

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 Understanding fluid balance

Total daily fluid gains Total daily fluid losses

2.6 L 2.6 L
Skin
Liquids
1.5 L 600 mE

Solid foods Lungs

800 mE 400 mE

Water of oxidation Kidneys

1.5 L
300 mE
Intestine
100 mE

fluid to their circulating volume. When and how rapid infusion of normal saline
caring for a patient with a diagnosis of solution affects mean pulmonary artery
congestive heart failure (CHF), liver failure, pressure (MPAP) and PWCP.
pulmonary edema, kidney disease, low The I.V. fluid utilized in the study was an
cardiac ejection fraction (EF), dilated car- isotonic solution of 0.9% normal saline solu-
diomyopathy, or severe cardiovascular tion. Isotonic solutions are often given to
disease, closely monitor for signs of fluid correct suspected volume depletion because
volume overload and cardiac distress (see they contain a salt concentration that’s simi-
Proceed with caution). lar to the cells and blood flowing within
the circulatory system. Rapid infusion was
Age, sex, and volume defined as an infusion of greater than 100
Recent research from the American Heart mL/minute of 0.9% normal saline solution.
Association (AHA) evaluated whether age The research study evaluated 60 patients of
and sex affect how patients respond to various ages and both sexes from three
rapid I.V. infusion of normal saline solution, major medical centers.
how patients with heart failure with pre- The research concluded that rapid
served ejection fraction (HFpEF) respond, administration of normal saline solution

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 i.v. essentials

increased the filling pressure inside the than 1 L of I.V. fluid to increase their PCWP
heart in healthy patients. However, the to a crisis level of 25 mm Hg.
rapid infusion of normal saline solution This study suggests that women over
increased the MPAP and PCWP dramati- age 55 and those patients with a known
cally faster and higher in women over diagnosis of CHF or HFpEF should receive
age 55. Women over age 55 required less an initial I.V. fluid loading trial because these
I.V. fluid to attain a therapeutic PCWP. All patient populations require less I.V. fluid to
women of various ages required only 1 L obtain optimal outcomes. Fluid volume trials
of rapidly infused normal saline solution to consist of administering small volumes of
reach a PCWP of 16 mm Hg; men usually saline (less than 200 mL/30 minutes). After
required 2 L to attain the same result. the initial loading trial, the patient should be
Research showed that women, in general, reassessed to evaluate the need for additional
responded well to infusions of 1 L of I.V. fluids or treatment. Administering larger
normal saline solution and that it improved volumes may cause fluid volume overload,
their heart’s cardiac output. Patients with a cardiac distress, pulmonary congestion, and
known diagnosis of HFpEF required less cardiovascular collapse.
During the fluid loading trial, assess for
signs of fluid volume intolerance, such as
elevated heart rate, elevated respiratory
rate, shortness of breath, hypertension,
chest pain, and low urinary output. When
administering I.V. fluid to any patient,
consider administering a fluid volume trial
because some patients may have undiag-
nosed CHF, renal disease, liver disease, or
HFpEF.

Don’t forget the lungs and

the brain
Be aware that infusing I.V. fluid can also
impact other organs, such as the lungs
and brain. When performing an assess-
Proceed with caution ment, routinely auscultate the patient’s
CHF is a dysfunction that causes reduced cardiac output. It can range lung sounds to identify signs of pulmonary
from the slight loss of normal heart function to the presence of signs and congestion, such as crackles in the lower
symptoms that no longer respond to medical treatment. In severe CHF, lobes of the lungs. When rapidly adminis-
the heart can’t pump enough blood to meet the body’s metabolic needs. tering I.V. fluid, you should also monitor
The addition of supplemental I.V. fluid can cause additional stress on the for new-onset changes in mentation, such
weakened heart. When receiving report on any CHF patient, ask if the
as increased irritability, confusion, or
patient has a daily fluid intake restriction ordered, what his or her EF is
lethargy, which can signal a neurologic
(if known), and whether the patient has any recent weight gain that
could signal potential fluid retention.
emergency.
When administering I.V. fluids to patients with CHF or HFpEF, closely Administering large amounts of I.V. fluid
monitor for signs of cardiac distress caused by fluid overload. A daily can cause pulmonary congestion as fluid
weight should be obtained at the same time each morning and recorded shifts into the lungs. In severe cases, it may
per your healthcare facility’s policy. If any signs of cardiac distress cause pulmonary edema—the collection of
arise, consider stopping the I.V. fluid and consult with the medical fluid within the small alveoli of the lungs. As
team immediately. Continuing the rapid infusion of I.V. fluid can lead the lungs fill with fluid, oxygen and carbon
to complete cardiovascular collapse. Rapidly infusing large volumes dioxide are unable to transfer through the
of I.V. fluid in a patient with CHF, HFpEF, or a reduced EF can cause thin fragile walls of the alveoli.
the pressure within the heart and blood vessels to increase as fluid
A 2010 research study performed by the
accumulates. This fluid may be forced to shift into other organs such
Mayo Clinic evaluated how rapid I.V.
as the lungs.
fluid infusions impacted the large and

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small airways of the lungs. The conclusion
confirmed that rapid I.V. fluid infusions Common labs cheat
resulted in obstructive and restrictive

sheet
Labs commonly ordered to evaluate for
changes in the smaller airways of the dehydration or fluid volume overload
lungs and the alveolar pulmonary beds. include:
As fluid accumulates in the small alveolar • serum sodium
beds, normal air exchange is blocked, • urine sodium
which may result in cerebral and tissue • serum osmolarity
hypoxia. • urine osmolarity
• brain natriuretic peptide (BNP might increase
You should suspect pulmonary conges-
with age, especially in women, making it less
tion, pulmonary edema, or potential
reliable as a diagnostic tool)
hypoxia if the patient exhibits the following • creatinine.
symptoms:
• shortness of breath
• pink-tinged sputum room for the brain to swell in TBI. Therefore,
• dyspnea administration of large volumes of I.V.
• agitation fluid in TBI patients can contribute to cere-
• lethargy bral anoxia. Maintaining the fluid balance
• low oxygen saturation levels in neurologic patients ensures adequate
• crackles circulating volume is maintained to perfuse
• cough the brain tissue and minimize complications
• increased respiratory rate from cerebral edema.
• increased work of breathing
• JVD. Monitoring maven
The brain is very sensitive to rapid When administering I.V. fluid, closely
changes in sodium and water balance. monitor your patient’s cardiac, respiratory,
Severe hyponatremia (fluid overload) can and neurologic status for changes. Research
cause neurologic changes because the has shown that I.V. fluid should be tailored
brain cells become overly saturated with to each individual based on his or her
water. This oversaturation of water pre- known medical history, age, and sex for
vents the normal electrical impulses from optimal patient outcomes. ■
efficiently transmitting signals, which may
cause neurologic changes such as nausea, Learn more about it
confusion, lethargy, seizures, coma, and Ceridon ML, Synder EM, Strom NA, Tschirren J, Johnson
BD. Influence of rapid fluid loading on airway structure
even death. and function in healthy humans. http://www.onlinejcf.
Administering large amounts of I.V. com/article/S1071-9164(09)01039-2/abstract.
fluid is often contraindicated in patients Cotter G, Metra M, Milo-Cotter O, Dittrich HC, Gheorghiade
M. Fluid overload in acute heart failure—re-distribution and
with traumatic brain injury (TBI). The other mechanisms beyond fluid accumulation. Eur J Heart
immediate treatment plan for new-onset Fail. 2008;10(2):165-169.
TBI patients is to reduce the circulating Fujimoto N, Borlaug BA, Lewis GD, et al. Hemodynamic
responses to rapid saline loading: the impact of age, sex,
water volume within the brain to allow for and heart failure. Circulation. 2013;127(1):55-62.
additional room to swell (cerebral edema). Grogan M. Ejection fraction: what does it measure?
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The cranial vault (skull) is an unmovable AN00360.
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O’Connell JB. HFpEF: the therapeutic mystique preserved.
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begins to occur. The authors have disclosed that they have no financial
relationships related to this article.
Administration of large volumes of I.V.
fluid can hydrate the brain, leaving little DOI-10.1097/01.NME.0000426300.80485.91

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