IV fluids in the ED: When do we really need them?

Author: Anatoliy Goltser, MD (APD/Attending Physician, St Joseph’s Medical Center Stockton) // Reviewed by: Jessica Pelletier, DO, MHPE (APD/Assistant Professor of EM/Attending Physician, University of Missouri-Columbia); Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

Introduction

With the recent severe nationwide shortage of intravenous (IV) fluids due to Hurricane Helene, we feel it is timely to provide a summary of the evidence regarding common uses of IV fluids for patients presenting to the emergency department (ED).

Volume status

Assessing volume status, especially in critically ill patients, can be challenging. Much of our understanding of the clinical signs of hypovolemia comes from studies performed on phlebotomy volunteers^1,2 while our understanding of fluid overload comes from heart failure patients.² 

There is substantial evidence for a few findings regarding volume status assessment. For acute large-volume loss in otherwise healthy patients (>1 L of blood volume), there is good evidence that orthostasis is sensitive and specific, which may be present in patients who have relatively normal vitals while supine.^1,2 For hypervolemia in heart failure patients, orthopnea >2 pillows is the most reliable clinical finding,^3,4 though an increase in peripheral edema and increased weight can be useful as well.²

Unfortunately, reliable volume status assessment features are helpful in a minority of clinical scenarios. For patients who are elderly, orthostasis is an unreliable clinical finding and may be present in the absence of dehydration.⁵ Clinical signs such as capillary refill, skin turgor, and axillary dryness are also fraught with poor inter-rater agreement.^6-8  In patients who are on long-term hemodialysis, typical non-invasive signs of volume assessment seem to be unreliable as well.⁹  

In terms of assessing volume status in general, Joseph et al. 2023¹⁰ found that clinicians were 56% accurate in their assessments of patients admitted for heart failure when compared to the gold standard of blood volume measurement – a nuclear study utilizing radiolabeled red blood cells and albumin.¹¹ A study by Stephan et al. 2001¹² found similar results among a cohort of critically ill patients.

Sepsis

There has been much controversy over the last two decades around the various nuances of volume resuscitation in ED patients with suspected sepsis, much of which goes beyond the scope of this limited review. The latest Society of Critical Care Medicine (SCCM) sepsis guidelines from 2021 recommend giving patients with signs of hypoperfusion an initial 30 ml/kg bolus as a best practice statement¹³ based on the PROCESS,¹⁴ ARISE,¹⁵ and PROMISE¹⁶ trials. Patients were enrolled in these trials if they had signs of shock, with mortality ranging from 18-29%. One of the hallmarks of sepsis care, based on the Rivers 2001¹⁷ trial and still recommended by the latest SCCM guidelines is early detection of sepsis and initiation of early resuscitation.¹³ While there is good data that early antibiotics for patients in septic shock reduce mortality^18-19 the role of early and aggressive volume resuscitation and its impacts on patient-centered outcomes remain unclear.

Over the past few years, mounting evidence has suggested that a restrictive approach may be non-inferior and possibly superior to the traditional 30 ml/kg approach, depending on the population being studied. Since the 2010s multiple trials have explored the feasibility of fluid restrictive resuscitation both on initial resuscitation in the ED, as well as in the intensive care unit (ICU). Since then, at least three separate meta-analyses^20-22  have found that on the whole, a restrictive fluid administration approach (variously defined) is at least as effective and possibly better than a liberal approach. 

The CLOVERS²³ and CLASSICS²⁴ trials suggest that a restrictive approach in ICU patients with septic shock after an initial fluid bolus in the ED is at least as effective and may hold benefits for some patients. In terms of the initial 30 ml/kg bolus in the ED, large trials are lacking but multiple small feasibility trials^25-27  have shown a trend toward improved outcomes in the fluid-restrictive groups. A notable limitation is that the amount of fluids administered in fluid-restrictive groups have varied widely,  from 500 ml to almost 50 ml/kg in the first 72 hours.

In lower-resource settings, the evidence is stronger against a liberal approach to volume resuscitation. Andrews et al. in 2017²⁸ showed increased mortality in sepsis patients in Zambia who received early and aggressive IV hydration compared with those in the standard therapy group. Similar to Andrews et al., the FEAST trial²⁹ from 2011 conducted in Uganda, Kenya, and Tanzania, also showed significantly increased harms in the aggressive volume resuscitation group in children with sepsis and signs of shock. 

For children in well-resourced settings, the data is less clear. Inwald et al. 2018³⁰ attempted to study this in the United Kingdom (UK) and Ireland; in a feasibility trial, they were able to enroll only 75 patients in 9 months across 13 medical centers. However, there were no major clinical outcome differences in the 10 ml/kg vs 20 ml/kg bolus groups partly due to a lower than expected incidence of adverse outcomes in this cohort. The latest SCCM pediatric sepsis guidelines³¹ recommend against a fluid bolus in children who are not hypotensive and who do not have access to intensive care, with a weak recommendation to give a 10-20 ml/kg initial bolus and up to a 40-60 ml/kg bolus in children with hypotension who do have access to critical care resources.

While a full pathophysiologic review of the benefits vs harms of bolusing IV fluids is beyond the scope of this review, Marik et al. 2019³² give a detailed review of this and make a compelling argument that the previous one-size-fits-all resuscitation strategy should be abandoned and clinicians should use a holistic approach to guide volume resuscitation based on individual patient presentations. 

As of now, there are no clear guidelines to reliably determine which patients would benefit from IV fluids and how much. Over the last few years, however, ultrasound has been increasingly playing an important role in the conversation with multiple studies looking at using ultrasound to predict fluid responsiveness in septic patients – for example, using the velocity time integral with passive leg raise. (For links to FOAM-ED ultrasound content, see the section after take-home points.) According to a meta-analysis by Chen et al. 2024,³³ use of ultrasound may lead to a reduction in mortality, less volume of fluids given, and decreased hospital stay. Tullo et al. 2023³⁴ performed a literature review describing the various uses of ultrasound in guiding volume resuscitation that shows promise, especially in identifying those patients who would benefit most from either receiving fluids or having a more fluid restrictive approach. However, at this time, it is still too early to make broad-based recommendations regarding the widespread use of ultrasound to guide volume responsiveness evaluation in clinical care.

Oral rehydration for gastroenteritis

Oral rehydration is considered the standard of care for infants and children with acute mild-moderate dehydration,³⁵ with good data to support this practice in a variety of settings.^36-37  There is little evidence regarding oral rehydration in adults with gastroenteritis, though it seems reasonable that adults with mild dehydration could be safely hydrated orally.³⁸

Assessing the severity of dehydration relies on clinical signs detailed in the section above. Several dehydration scales exist, the major ones being the World Health Organization (WHO) scale, the Gorelick scale, and the Clinical Dehydration Scale (CDS).^39-40  These have been primarily studied for use in triage purposes where they seem to have some utility, though a meta-analysis by Falszewska⁴¹ concluded that their general use is limited. For a more detailed discussion on the limitations of clinical volume assessment, including the lack of an agreed-upon gold standard, see the section on volume status above. In practice, these scales are widely used and are recommended as a reference (e.g. ACEP, Life in the Fast Lane).

Table 1. WHO scale for dehydration in children. < 2 signs from columns B/C = no signs of dehydration; ≥ 2 signs in column B = moderate dehydration; ≥ 2 signs in column C = severe dehydration. Modified from: Pringle, K., Shah, S.P., Umulisa, I. et al. Comparing the accuracy of the three popular clinical dehydration scales in children with diarrhea. Int J Emerg Med 4, 58 (2011). https://doi.org/10.1186/1865-1380-4-58

During the 2017 IV fluid shortage, Patino et al. proposed a protocol for oral rehydration for pediatric and adult patients with mild dehydration, recommending two large sips, or about 30 ml, every 3-5 minutes for a total of 1 L over the course of about 2 hours. For patients with moderate dehydration, there is evidence to support rehydration using a nasogastric (NG) tube has similar outcomes when compared with IV fluids,⁴² with protocols available online (for example, this one from Ireland).

For patients with severe dehydration, the evidence regarding rehydration methods is lacking. The available recommendations³⁵ recommend a 20 ml/kg fluid bolus for these patients. It’s important to note that patients with dehydration from gastroenteritis were excluded from the 2011 FEAST study.²⁹ It is also important to note that it is generally agreed upon that patients with hyponatremic (sodium < 132 mEq/L) and hypernatremic (sodium > 150 mEq/L) dehydration probably require IV rehydration.³⁵

Headache syndromes

It is common practice to give IV fluids to palliate headache symptoms in the ED. The justification for this has been that dehydration may precipitate a headache. In 2013 Richer et al.⁴³ found that IV fluids did not improve symptoms in headache patients in a single pediatric ED. In 2019 and 2020 two small single-center randomized prospective studies both showed that IV fluids provide no additional benefit to standard headache management.^44-45

These studies do have some limitations including small sample sizes – 49 and 60 patients respectively. The I-FiBH trial⁴⁵ excluded patients who were deemed to have “severe dehydration”. Thirty percent of the patients in the I-FiBH trial had “vomited” prior to enrollment but there is no mention of the percentage of patients thought to have moderate dehydration. Pregnant patients were excluded in both trials.

It is reasonable to conclude from the available evidence that routine IV fluids are not necessary for most patients presenting to the ED with headaches. It may be reasonable to consider IV fluid administration in patients with moderate dehydration or prolonged vomiting.

Renal colic

The rationale supporting IV fluids is that they may facilitate stone passage and optimize renal perfusion, especially in patients who have been vomiting or have some degree of dehydration. The rationale against IV fluids is that they may worsen pain by increasing the ureteral pressure, leading to worsening obstructive symptoms and perhaps exacerbating any kidney injury sustained from the obstruction.

Data on the benefits of IV fluids for renal colic patients has been limited to two small studies and a Cochrane meta-analysis from 2012⁴⁶ examining those two studies. The first study was by Edna et al.⁴⁷ from 1983 looking at 60 participants who either received IV fluids over 6 hours or received no fluids. There was no difference in pain or necessity for urologic intervention between the two groups. The second study by Springhart et al.⁴⁸ in 2006 enrolled 58 patients divided into two groups. One group received a 2 L normal saline (NS) bolus over 2 hours, and the second group received 20 ml/hr of NS. There was no difference in pain or stone passage rates between groups.

Tarplin et al. 2015,⁴⁹ performed a retrospective review of 5,000 patients across the Cleveland Clinic health system looking at the prevalence of IV fluid used for renal colic and found that about 80% of patients were given fluid boluses despite the absence of signs of dehydration. The Patino et al.³⁸ oral rehydration protocol did not include patients with known or suspected renal colic, but depending on resource availability, this may be an area where we may have opportunities to conserve resources without patient harm.

IV antibiotics before discharge

For most patients, IV antibiotics confer no advantage over oral antibiotics.^50-53 IV antibiotics are indicated for patients who are unable to tolerate oral intake (e.g. due to gut hypoperfusion or ileus), shock, suspected bacteremia, deep-seated infections like osteomyelitis, and those at risk for failure of outpatient treatment. 

One controversy that remains is whether or not an initial dose of IV antibiotics in the ED may prevent repeat ED visits and possibly failure of outpatient treatment.⁵⁴ This was examined retrospectively by Poh et al. looking at patients diagnosed with urinary tract infection (UTI) at three separate medical centers in Taiwan. The patients who received a dose of IV antibiotics (20%) were more likely to be older with more comorbidities and have vital sign alterations such as fever and/or tachycardia. After performing a logistic regression controlling for age and comorbidities they found that in this population, an initial dose of IV antibiotics was associated with a slightly lower chance of a repeat visit to the ED at 72 hours. Another retrospective study by Chung et al. 2023⁵⁵ looked at 429 patients over age 65 with a UTI and found that patients who received IV antibiotics were more likely to return to the ED at 72 hours. Choudhari et al. 2018⁵⁶ retrospectively analyzed visits from 30,000 children from 36 hospitals across the US and found that patients who received IV antibiotics were just as likely to return at 72 hours as those who did not. In summary, it is unclear whether receiving antibiotics in the ED prior to discharge actually changes patient-centered outcomes. If patients can tolerate oral antibiotics, they typically constitute adequate therapy.

Wound irrigation

A recent ACEP resolution encouraged emergency medicine practitioners to use tap water for routine wound irrigation.⁵⁷ This practice is supported by a recent Cochrane review⁵⁸ as well as a literature review by Holman⁵⁹ describing multiple head-to-head studies showing no difference in infection or contamination rates. The caveat is that this data only applies to settings where tap water is potable. 

For chemical exposure of the eye requiring immediate and copious irrigation, tap water is often preferred due to its availability and cost, as well as an absence of substantial benefit for buffered solutions.⁶⁰

Clinicians often recommend sinus irrigation for patients with upper respiratory infections or sinus infections with associated nasal congestion. Only sterile water is recommended for this indication in light of case reports of invasive amebic infections.⁶¹

Saline vs. balanced solution

The debate around this topic has recently been re-ignited with the publication of SALT-ED,⁶² SMART,⁶³ and BASICS⁶⁴ trials. For a more detailed discussion on the topic, check out this emDOCs article by Leonard et al. 2021.⁶⁵

Since then there have been several meta-analyses^66-68  looking at the effects of saline vs balanced solution in critically ill adults. Chen et al. and Wang et al. both found increased rates of acute kidney injury (AKI) in the saline cohort, similar to the SMART and SALT-ED trials. Dong et al. found no difference in AKI between the two cohorts but found decreased mortality in the saline group among traumatic brain injury (TBI) patients, similar to the BASICS study.

For diabetic ketoacidosis (DKA) patients, a subgroup analysis of the SMART and SALT-ED trials⁶⁹ showed a slightly more rapid resolution of symptoms in the balanced solution group – a median 3-hour difference for DKA resolution, and a median 4-hour difference for insulin infusion. A recent meta-analysis of 11 trials on the topic⁷⁰ found no significant difference in time to resolution of symptoms, incidence of AKI, or hypokalemia.

For the treatment of severe dehydration in kids, a recent Cochrane review⁷¹ found that patients treated with a balanced solution required less time in the hospital by a mean of 0.35 days compared to those treated with normal saline. The balanced solution group also had higher serum pH and sodium bicarbonate, and less incidence of hypokalemia. 

Take-Home Points:

• Clinical volume assessment may be unreliable, especially for patients who are elderly or have comorbidities resulting in disruption of volume regulatory mechanisms such as congestive heart failure and end-stage renal disease. For patients without frank signs of shock, it is reasonable to trial oral hydration prior to moving on to IV fluids.
• While some patients with septic shock may benefit from a more restrictive fluid resuscitation than the current 30 ml/kg recommends, there is insufficient evidence to support this practice routinely; and as of this writing, there is not an established way to reliably identify these patients. A volume-restrictive resuscitation strategy for patients admitted with sepsis to the ICU is equally effective compared to a traditional liberal approach.
• Routine use of IV fluids for headache syndromes and renal colic is probably of no benefit.
• Routine use of IV antibiotics prior to discharge is of little benefit for pediatric patients and probably for adults as well. There may be a role for IV antibiotics for some elderly patients at high risk of bacteremia or treatment failure in certain health systems that have robust outpatient resources, but its routine use is otherwise of little benefit and should be abandoned.
• Tap water irrigation for most wounds and eyes is as safe and effective as saline. 
• Balanced solutions may improve outcomes in critically ill adults, patients with baseline kidney disease and hyperchloremia, DKA, and children with severe dehydration. In critically ill patients with TBI, saline may be the fluid of choice.

Further #FOAMed:

• POCUS for Assessing Volume Responsiveness – Core Ultrasound 
• Volume Assessment Using POCUS in the Emergency Department 

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