Ordering IV fluids in the ER

[matt87]

Hello,

First I want to begin by saying that I am a nurse and not a physician. However I do have a question that I would like some clarification and was hoping that some on here would be willing to share their wisdom.

I work in an ER and have come to wonder why so many patients get IV fluids ordered? I'm not asking about the obvious ones, like nausea and vomiting, dehydration, etc. I'm more asking about the ones that I can't justify. I'm am very respectful of the fact that I am not a doctor and was hoping that you all could share some of your expertise?

For instance, I have seen orders for 1 liter NS for the following complaints:

- 60 year old with a c/o elevated bp. Pressure in the ER is 179/92 but she has no other complaints and says she feels fine, was just worried about her pressure. Why a liter?

-26 year old with generalized weakness for five days. VSS with no temp. Labs drawn from triage (Cbc, cmp, and ua) and all are normal. Why a liter?

-28 year old with hives for a month. No s/s shock, lungs clear, SpO2 100%. Why the liter?

I like to be knowledgeable when I go into a patients room about why I'm initiating a certain treatment. It's easy to explain fluids to someone with a fever, infection, dehydration, etc, but some of these I don't get.

Maybe you all can give me the rationale / insight so I can learn something?

PS: the docs I work with told me that they do it "so the patient feels like we did something."

Thanks so much for your help! And sorry to post on your site, I was just hoping for a little help.

---

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[Merely]

Hello,

First I want to begin by saying that I am a nurse and not a physician. However I do have a question that I would like some clarification and was hoping that some on here would be willing to share their wisdom.

I work in an ER and have come to wonder why so many patients get IV fluids ordered? I'm not asking about the obvious ones, like nausea and vomiting, dehydration, etc. I'm more asking about the ones that I can't justify. I'm am very respectful of the fact that I am not a doctor and was hoping that you all could share some of your expertise?

For instance, I have seen orders for 1 liter NS for the following complaints:

- 60 year old with a c/o elevated bp. Pressure in the ER is 179/92 but she has no other complaints and says she feels fine, was just worried about her pressure. Why a liter?

-26 year old with generalized weakness for five days. VSS with no temp. Labs drawn from triage (Cbc, cmp, and ua) and all are normal. Why a liter?

-28 year old with hives for a month. No s/s shock, lungs clear, SpO2 100%. Why the liter?

I like to be knowledgeable when I go into a patients room about why I'm initiating a certain treatment. It's easy to explain fluids to someone with a fever, infection, dehydration, etc, but some of these I don't get.

Maybe you all can give me the rationale / insight so I can learn something?

PS: the docs I work with told me that they do it "so the patient feels like we did something."

Thanks so much for your help! And sorry to post on your site, I was just hoping for a little help.

If the docs told you that I feel like you're dealing with ******* docs? Who knows tho I'll let someone else more qualified answer

 

[TheFutureFatMan]

If the docs told you that I feel like you're dealing with ******* docs? Who knows tho I'll let someone else more qualified answer

Interestingly enough, I just got the riot act read to me for calling someone out for that.

I was told that physicians take care of the head too, not just the body. Sometimes feeling like a doctor did something goes a long way.

I'm a little at odds with that, particularly in an ED setting where those costs are being absorbed by everyone else.

But. That was how they justified it, and while I might disagree that doctor is anything but a *******.

 

[Psai]

Real question is why are any of those people in the emergency department

 

[TheFutureFatMan]

Real question is why are any of those people in the emergency department

Heard.

 

[ACSurgeon]

Hello,

First I want to begin by saying that I am a nurse and not a physician. However I do have a question that I would like some clarification and was hoping that some on here would be willing to share their wisdom.

I work in an ER and have come to wonder why so many patients get IV fluids ordered? I'm not asking about the obvious ones, like nausea and vomiting, dehydration, etc. I'm more asking about the ones that I can't justify. I'm am very respectful of the fact that I am not a doctor and was hoping that you all could share some of your expertise?

For instance, I have seen orders for 1 liter NS for the following complaints:

- 60 year old with a c/o elevated bp. Pressure in the ER is 179/92 but she has no other complaints and says she feels fine, was just worried about her pressure. Why a liter?

-26 year old with generalized weakness for five days. VSS with no temp. Labs drawn from triage (Cbc, cmp, and ua) and all are normal. Why a liter?

-28 year old with hives for a month. No s/s shock, lungs clear, SpO2 100%. Why the liter?

I like to be knowledgeable when I go into a patients room about why I'm initiating a certain treatment. It's easy to explain fluids to someone with a fever, infection, dehydration, etc, but some of these I don't get.

Maybe you all can give me the rationale / insight so I can learn something?

PS: the docs I work with told me that they do it "so the patient feels like we did something."

Thanks so much for your help! And sorry to post on your site, I was just hoping for a little help.

- doctors often order things just to be safe. If you play the odds game, a patient in the ER hasn't been eating/drinking normally. Also, odds are a patient in the ER is more likely to be hurt by under-resuscitation than over resuscitation. Ideally, the doctor would see the patient before placing orders. We all know that many orders are placed based on what the doctor hears from the nurse (i.e. Fluids, labs etc).

- I usually have the problem of my sick SBO or appendicitis patient only receiving a liter when they need much more than that based on lack of urine and a hx of poor oral intake for many days.

Sorry we don't have an explanation that validates what you're observing. The only redeeming factor is that these fluids usually won't hurt the patient.

 

[osckey]

I've heard some of the docs I used to work with mention that most people are normally dehydrated anyways and that they'd rather already have a line in them and ready to go should the patient actually turn for the worse.

 

[lymphocyte]

Hello,

First I want to begin by saying that I am a nurse and not a physician. However I do have a question that I would like some clarification and was hoping that some on here would be willing to share their wisdom.

I work in an ER and have come to wonder why so many patients get IV fluids ordered? I'm not asking about the obvious ones, like nausea and vomiting, dehydration, etc. I'm more asking about the ones that I can't justify. I'm am very respectful of the fact that I am not a doctor and was hoping that you all could share some of your expertise?

For instance, I have seen orders for 1 liter NS for the following complaints:

- 60 year old with a c/o elevated bp. Pressure in the ER is 179/92 but she has no other complaints and says she feels fine, was just worried about her pressure. Why a liter?

-26 year old with generalized weakness for five days. VSS with no temp. Labs drawn from triage (Cbc, cmp, and ua) and all are normal. Why a liter?

-28 year old with hives for a month. No s/s shock, lungs clear, SpO2 100%. Why the liter?

I like to be knowledgeable when I go into a patients room about why I'm initiating a certain treatment. It's easy to explain fluids to someone with a fever, infection, dehydration, etc, but some of these I don't get.

Maybe you all can give me the rationale / insight so I can learn something?

PS: the docs I work with told me that they do it "so the patient feels like we did something."

Thanks so much for your help! And sorry to post on your site, I was just hoping for a little help.

Assuming what you've observed wasn't misinterpreted... Two things:

1. You've discovered a deep, dark secret of medicine: the competency of physicians varies like the competency of car mechanics. Some are wizards, some are whomps. Sometimes there are no rational explanations for treatment. So it goes.

2. Think about what you observed from a dynamic point of you. Not all information is available to an ED physician immediately.

For example: 26 year old with generalized weakness for five days. You mention VSS and normal labs, but 1) how sensitive are vital signs for detecting hypovolemia or dehydration? (not great for either) and 2) how long did those labs take to come back? Why not bolus some fluids in the meantime to gauge symptomatic improvement?

 

[Dr. Death]

Real question is why are any of those people in the emergency department

For their annual checkup

 

[HooliganSnail]

Hello,

First I want to begin by saying that I am a nurse and not a physician. However I do have a question that I would like some clarification and was hoping that some on here would be willing to share their wisdom.

I work in an ER and have come to wonder why so many patients get IV fluids ordered? I'm not asking about the obvious ones, like nausea and vomiting, dehydration, etc. I'm more asking about the ones that I can't justify. I'm am very respectful of the fact that I am not a doctor and was hoping that you all could share some of your expertise?

For instance, I have seen orders for 1 liter NS for the following complaints:

- 60 year old with a c/o elevated bp. Pressure in the ER is 179/92 but she has no other complaints and says she feels fine, was just worried about her pressure. Why a liter?

-26 year old with generalized weakness for five days. VSS with no temp. Labs drawn from triage (Cbc, cmp, and ua) and all are normal. Why a liter?

-28 year old with hives for a month. No s/s shock, lungs clear, SpO2 100%. Why the liter?

I like to be knowledgeable when I go into a patients room about why I'm initiating a certain treatment. It's easy to explain fluids to someone with a fever, infection, dehydration, etc, but some of these I don't get.

Maybe you all can give me the rationale / insight so I can learn something?

PS: the docs I work with told me that they do it "so the patient feels like we did something."

Thanks so much for your help! And sorry to post on your site, I was just hoping for a little help.

Ok, from an actual ED doc here.

- 60 y/o with "elevated BP" is tricky, because they are 60 and now they are in your ER, who knows what they said to the doc. As much as I loooooove discharging patient's fast, the 60 y/o with "elevated BP' is exactly the kind that you get burned on. Keep in mind, who told them to come to the ED? Often the PCP. They go home, 2 weeks later go for the big heart attack, and BAM. They were in your ER just last week and now they are dead. Tough situation. The patient has to have absolutely no symptoms at all......none, and preferably just here for a med refill for me just to send that guy home......that being said, I probably would have done 500cc....

- generalized weakness in a 26 year old is dehydration...or they have a sinus infection......either way the 1L bolus will make them feel better, they can handle the intravascular volume, and it is DIAGNOSTIC as well. How did they feel afterward? Helps move them out the door. Although keep in mind, I only give them the fluid IF I am going to draw labs, which I often won't do with this case......but again, who knows what they said to the doctor.

- 26 year old with hives same thing..........they can handle the fluid, and if I have decided to draw labs, then give it to them...it makes them feel better. Although this patient especially I would NOT draw labs on, and quickly move to discharge, but again. WHO knows what there actual story is, and what they tell the doctor.

Patient's tell the doctor A LOT of stuff they just don't feel like talking to the nurse about. It's tough to actually determine the course of action when you don't have the full picture, including the patient's expectations, and just how they LOOK in front of you.

Generally speaking there are a select few groups of patient's who can NOT tolerate a large fluid challenge
- Low ejection fraction
- Frank Pulmonary Edema
- DIALYSIS

Those are the big ones, for nearly every one else a liter of saline is nothing to think twice about. It's cheap, harmless, diagnostic and therapeutic, something to do while the labs are running.

The real misuse of IV fluids is on the floor, patient's who are eating and drinking do NOT need maintenance fluid, but that is a completely different discussion.

 

[Psai]

I don't know if there's any pathophysiology that I can explain to you but the placebo effect is a very real thing. Even if you don't have anything major going on, seeing the doctor do something for you is big. I remember reading about a guy who came in for some huge trauma and was in a lot of pain. The doctor ordered some iv pain meds but the guy felt better just from having the doctor there and seeing the iv fluid flow in even though the pain meds hadn't even been given yet.

A bit of fluids won't hurt and it can help. In this age of satisfaction scores and other nonsense, the last thing you want is for your patient to say "the doctor didn't do anything for me" and leave you a bad score. As long as you're not drowning a chfer with a few extra liters of maintenance, you're probably good.

 

[Brahnold Bloodaxe]

A bit of fluids won't hurt and it can help. In this age of satisfaction scores and other nonsense, the last thing you want is for your patient to say "the doctor didn't do anything for me" and leave you a bad score. As long as you're not drowning a chfer with a few extra liters of maintenance, you're probably good.

I would personally hate to be hooked up to an IV without there being a concrete and compelling reason for it.

 

[lymphocyte]

60 y/o with "elevated BP" is tricky, because they are 60 and now they are in your ER, who knows what they said to the doc. As much as I loooooove discharging patient's fast, the 60 y/o with "elevated BP' is exactly the kind that you get burned on. Keep in mind, who told them to come to the ED? Often the PCP. They go home, 2 weeks later go for the big heart attack, and BAM. They were in your ER just last week and now they are dead. Tough situation. The patient has to have absolutely no symptoms at all......none, and preferably just here for a med refill for me just to send that guy home......that being said, I probably would have done 500cc....

@HooliganSnail, this is really helpful, thank you, but why? (Or is it tongue-in-cheek?) Only the weakness one made sense to me. The rest seemed more like, "eh, why not"?

Rehydration therapy (even just 500mL) can be hundreds of dollars out of pocket for some patients. That's not benign.

http://www.nytimes.com/2013/08/27/health/exploring-salines-secret-costs.html

I completely agree about not knowing the whole story, but just on the facts presented, I simply don't get it.

 

[IlDestriero]

I would personally hate to be hooked up to an IV without there being a concrete and compelling reason for it.

You might feel different when you paid a $200 copay for your vague sense of unease ED visit. And as noted, IV fluids often make people feel better. Feeling better is one of the goals of the ED visit and will make the patient comfortable with the decision to go home and F/U with their PCP after ruling out the "bad things".


--
Il Destriero

 

[alpinism]

Hello,

First I want to begin by saying that I am a nurse and not a physician. However I do have a question that I would like some clarification and was hoping that some on here would be willing to share their wisdom.

I work in an ER and have come to wonder why so many patients get IV fluids ordered? I'm not asking about the obvious ones, like nausea and vomiting, dehydration, etc. I'm more asking about the ones that I can't justify. I'm am very respectful of the fact that I am not a doctor and was hoping that you all could share some of your expertise?

For instance, I have seen orders for 1 liter NS for the following complaints:

- 60 year old with a c/o elevated bp. Pressure in the ER is 179/92 but she has no other complaints and says she feels fine, was just worried about her pressure. Why a liter?

-26 year old with generalized weakness for five days. VSS with no temp. Labs drawn from triage (Cbc, cmp, and ua) and all are normal. Why a liter?

-28 year old with hives for a month. No s/s shock, lungs clear, SpO2 100%. Why the liter?

I like to be knowledgeable when I go into a patients room about why I'm initiating a certain treatment. It's easy to explain fluids to someone with a fever, infection, dehydration, etc, but some of these I don't get.

Maybe you all can give me the rationale / insight so I can learn something?

PS: the docs I work with told me that they do it "so the patient feels like we did something."

Thanks so much for your help! And sorry to post on your site, I was just hoping for a little help.

There's your answer.

 

[235009]

I can't tell you how many times I've had a patient come for a follow up primary care appointment and complain that they went to the ED for some complaint and the doctor didn't do anything for them. Then I look at the chart and there is a whole slew of blood tests, a radiology study or two and a consult or two. But since the patient didn't get an IV medication they think they were ignored or mistreated. Don't forget also that after you leave the room some administrator is walking in handing out a satisfaction survey. Unfortunately we have turned medicine in America into a consumer product and for every person focused on curing sick people there are three suits focused on the business aspects.


Sent from my iPhone using SDN mobile app

 

[HooliganSnail]

@HooliganSnail, this is really helpful, thank you, but why? (Or is it tongue-in-cheek?) Only the weakness one made sense to me. The rest seemed more like, "eh, why not"?

Rehydration therapy (even just 500mL) can be hundreds of dollars out of pocket for some patients. That's not benign.

http://www.nytimes.com/2013/08/27/health/exploring-salines-secret-costs.html

I completely agree about not knowing the whole story, but just on the facts presented, I simply don't get it.

For that scenario, I would take into account that a 60Y patient is more likely to have a reduced systolic ejection fraction, in which case they may not be able to handle the full liter. You can always give another 500cc bolus, but you can't take one away. That is just my thought process....

This is taking into account that I often don't have full information on a patient in the ED, something that is often overlooked when the medicine teams on the floor are using the "retrospectoscope" and judging our medical decision making down in the ED.

 

[Mansamusa]

I don't know if there's any pathophysiology that I can explain to you but the placebo effect is a very real thing. Even if you don't have anything major going on, seeing the doctor do something for you is big. I remember reading about a guy who came in for some huge trauma and was in a lot of pain. The doctor ordered some iv pain meds but the guy felt better just from having the doctor there and seeing the iv fluid flow in even though the pain meds hadn't even been given yet.

A bit of fluids won't hurt and it can help. In this age of satisfaction scores and other nonsense, the last thing you want is for your patient to say "the doctor didn't do anything for me" and leave you a bad score. As long as you're not drowning a chfer with a few extra liters of maintenance, you're probably good.

http://www.jneurosci.org/content/25/34/7754.long mu-opioid receptors in the house. I wrote a paper on this topic and there is a great lit review about placebos/nocebos' physiological effects, but I'm too lazy find it.

 

[Law2Doc]

1. For most patients it won't hurt
2. a lot of the time you don't really know what the patients real reason for being in the ED is, so having a line in them and addressing toxins/drugs/dehydration/stones with fluids presumptively isn't a bad guess. You can stop the fluids if you find out what ails them before it runs out.
3. Placebo effect.
4. If they have some ailment that is going to require contrast imaging this is a renal-friendly approach.
5. It's sort of like a restaurant - you bring them water early on and they won't complain that the service is so slow.

 

[235009]

5. It's sort of like a restaurant - you bring them water early on and they won't complain that the service is so slow.

Bahahahahaha! Love it!


Sent from my iPhone using SDN mobile app

 

[LilMermaid1]

Interesting post. I am a pre-med student. I went to the ER two weeks ago due to excruciating lower stomach pains. During the onset, i felt a flash of cold then was extremely hot. I got to the ER, and the nurse hooked me up to an IV. They gave me NS and drawed labs. I thought it was interesting that they gave me this IV before understanding what was going on...

 

[deleted245139]

Risk/benefit .... it's the theme here. You're getting poked for labs, may as well make it a single poke and place the line for possible meds. Saline isn't completely benign, but minimal harm aside from the initial poke. Easy early intervention and addresses a large portion of the docs differential. It's been said above.... we don't have time to wait for piecemeal results and singular interventions (for the most part). Speed and efficiency in your decision making is very important

 

[235009]

Interesting post. I am a pre-med student. I went to the ER two weeks ago due to excruciating lower stomach pains. During the onset, i felt a flash of cold then was extremely hot. I got to the ER, and the nurse hooked me up to an IV. They gave me NS and drawed labs. I thought it was interesting that they gave me this IV before taking understanding what was going on...

What could you have possibly had that would've made giving you fluids wrong. For someone your age it's either something benign (gastroenteritis/functional/menstrual pain/etc) or surgical (appy/torsion/etc). Either way the fluid won't hurt and will probably make you feel better (at least psychologically) if its part of the benign list.

 

[LilMermaid1]

What could you have possibly had that would've made giving you fluids wrong. For someone your age it's either something benign (gastroenteritis/functional/menstrual pain/etc) or surgical (appy/torsion/etc). Either way the fluid won't hurt and will probably make you feel better (at least psychologically) if its part of the benign list.

I didn't say it was wrong. I just thought it was strange that something was given to me without a deeper understanding of what was going on. You're right through, I did feel better about 30-40 minutes after. After a series of tests, they did not find anything abnormal. I did, however, start my menstrual cycle that day...

 

[deleted245139]

I didn't say it was wrong. I just thought it was strange that something was given to me without a deeper understanding of what was going on. You're right through, I did feel better about 30-40 minutes after. After a series of tests, they did not find anything abnormal. I did, however, start my menstrual cycle that day...

No offense... But im,thinking that doc DID give it deeper thought. I rarely order a test because I don't know what's going on. I order a test to confirm or deny my initial suspicion

 

[LilMermaid1]

No offense... But im,thinking that doc DID give it deeper thought. I rarely order a test because I don't know what's going on. I order a test to confirm or deny my initial suspicion

Hmm, gotcha. This was all before the doc met me though...

However, with the points you mentioned previously, I could understand why the doc did that (a line for possible meds, just in case).

 

[235009]

Hmm, gotcha. This was all before the doc met me though...

However, with the points you mentioned previously, I could understand why the doc did that (a line for possible meds, just in case).

I never met you and came up with a short differential that included what you ended up having. There's a saying in medicine: "common things being common". Knowing your age, sex and chief complaint is enough to come up with a reasonable differential and initiate diagnosis/treatment. The nurse probably documented something on triage so it's not like the doc gave you a IV fluids with zero information.

 

[cbrons]

IV fluids are overused and kill more people than they help. Ask Paul Marik.

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[e30ftw]

I would agree that IVF/IVmeds in general are overused. It sounds like the ER doc at your work answered your question appropriately. "So the patient feels like we did something.."

All three of the original patients could probably just be discharged after a thorough history/physical without any labs/imaging/meds. Any thing done to them was likely CYA and patient satisfaction related. The correct way to treat asymptomatic hypertension is PCP follow up. The weakness patient could've needed something but that all depends on the actual case, more than likely just needed reassurance. Refer the guy with hives to an allergist, give him a Rx for hydroxyzine +/- epi pen. LOS < 30 min for all cases..

 

[tnedoots]

For the ED attendings, I am curious as to how the cost to the patient/insurer of an IV factors into decision making for you. The way medicine seems to be moving is towards (as someone already mentioned above) a customer satisfaction based system. And giving an IV for placebo effect could help customer satisfaction. However, there is a lot in the media regarding ED charges, especially the out-of-network billing issues.

So, outside of the good/bad medicine conversation, how do you, as an attending, approach that decision? Is the focus on the fact that it can't really harm and makes the pt think more is being done? Or is the cost to the patient a factor at all?

I ask this out of curiosity. I'm an MS3 who has been planning on going into EM since applying to med school. I would like an attending's take on how the media and ACA have influenced medical decision making in the ED.

 

[deleted245139]

For the ED attendings, I am curious as to how the cost to the patient/insurer of an IV factors into decision making for you. The way medicine seems to be moving is towards (as someone already mentioned above) a customer satisfaction based system. And giving an IV for placebo effect could help customer satisfaction. However, there is a lot in the media regarding ED charges, especially the out-of-network billing issues.

So, outside of the good/bad medicine conversation, how do you, as an attending, approach that decision? Is the focus on the fact that it can't really harm and makes the pt think more is being done? Or is the cost to the patient a factor at all?

I ask this out of curiosity. I'm an MS3 who has been planning on going into EM since applying to med school. I would like an attending's take on how the media and ACA have influenced medical decision making in the ED.

Personally, doesn't factor in a majority of the time. I'm concerned about speed, safety, and the highest patient care possible within the realm of emergent care.
Low acuity complaints require low acuity care (typicaly) and a lot of times a few moments of a sympathetic ear and oral meds do wonders. I don't care about cost unless I'm over doing minor things. No healthy 23 yo w a grade 1 ankle sprain needs IV meds... In that vein, if someone is sick, I treat them. I order appropriate labs and medications regardless of cost. Patient care will trump cost.

The problem we find, is that people come to the ED with unrealistic expectations. And you're right, patient experience factors in... That said, the job is to identify and stabilize an emergent condition.... We just happen to consistently go above and beyond thay

 

[e30ftw]

For the ED attendings, I am curious as to how the cost to the patient/insurer of an IV factors into decision making for you. The way medicine seems to be moving is towards (as someone already mentioned above) a customer satisfaction based system. And giving an IV for placebo effect could help customer satisfaction. However, there is a lot in the media regarding ED charges, especially the out-of-network billing issues.

So, outside of the good/bad medicine conversation, how do you, as an attending, approach that decision? Is the focus on the fact that it can't really harm and makes the pt think more is being done? Or is the cost to the patient a factor at all?

I ask this out of curiosity. I'm an MS3 who has been planning on going into EM since applying to med school. I would like an attending's take on how the media and ACA have influenced medical decision making in the ED.

After seeing a few thousand patients you get a feeling of their expectations during the first few seconds of the encounter.

I never look at payer status prior to seeing the patient, but reading triage/visit history combined with a quick visual scan of the room and you can quickly figure out what the patient wants. Immediately figuring out why the patient is there is one of the most important aspects of Emergency Medicine.

The basic premise of this discussion (cost vs medical need vs satisfaction) implies that the patient does not have evidence of emergent disease. If I believe someone needs an expensive imaging study or a work-up/admit, I do everything I can to encourage them to do it, regardless of their ability to pay. This discussion will be about those whom you are ~95% certain have nothing wrong with them (notice that this is not quite the 98% standard to which we are held..)

Sometimes it's really obvious that someone wants a specific treatment, for example, the 30 y/o healthy male in khakis/polo shirt brought by wife with a big rock on her finger and mother for 1 day of n/v/d with a HR of 70 and a RR 12 who is putting on a show, grimacing in the room, states "I've been throwing up everything for the past 1 day" while having moist mucus membranes, etc. This person would be totally fine with Zofran ODT RX and discharge as long as abd soft/benign etc however in the vast majority of EDs will get 1L NS and cmp/cbc/ua as well as IV zofran. Total cost is probably thousands of dollars, for what could easily just be a Rx for Zofran from a pharmacy. This is a patient I see every shift. If the family is acting concerned I follow suit and do the whole "This is likely a self-limiting virus but we are going to check your electrolytes to rule out a life-threatening imbalance and tank you up with fluids and IV meds." cue family members nodding in agreement. On reeval prior to DC they feel much better, everyone is happy, yada yada.

In the same scenario, if it's a normal looking guy w/o insurance who comes in alone, grease on his hands, blue collar has a job, might be worried about money, etc with the same Hx/VS/exam (soft abd most important) I have the discussion, "This sounds like a self-limiting viral illness. If we can give you oral rehydration therapy in the ED (ie, gatorade) I would be comfortable giving you an Rx for antiemetics and letting you heal up at home as long as there are people who can check on you and bring you back if you can't tolerate fluids by mouth." Cost out of pocket for 30 zofran ODT w/ goodrx coupon = $20. I try not to overwork these guys because this is someone who might actually endure financial hardship due to unnecessary medical expenses.

Another category is the self-pay frequent ED user who will never attempt to pay his bills, calls EMS for 1 day of n/v/d, arrives, c/o severe abd pain, winces on exam, has tachycardia secondary to meth use, and ends up with a CT abd/pelvis and after it's all negative, requests admit for pain control.

 

[alpinism]

Personally, doesn't factor in a majority of the time. I'm concerned about speed, safety, and the highest patient care possible within the realm of emergent care.
Low acuity complaints require low acuity care (typicaly) and a lot of times a few moments of a sympathetic ear and oral meds do wonders. I don't care about cost unless I'm over doing minor things. No healthy 23 yo w a grade 1 ankle sprain needs IV meds... In that vein, if someone is sick, I treat them. I order appropriate labs and medications regardless of cost. Patient care will trump cost.

The problem we find, is that people come to the ED with unrealistic expectations. And you're right, patient experience factors in... That said, the job is to identify and stabilize an emergent condition.... We just happen to consistently go above and beyond thay

Which only feeds their unrealistic expectations and causes them to keep coming back again and again for non emergent complaints.

Its one of the biggest problems with EM in America today.

 

[deleted245139]

Which only feeds their unrealistic expectations and causes them to keep coming back again and again for non emergent complaints.

Its one of the biggest problems with EM in America today.

I definitely don't disagree. At all

 

[@Hazel-rah]

I have a couple things I tell patients, "we are going to give you this medicine together with a liter of fluid because it helps the medicines to be absorbed and processed in your body." I also say, "The IV fluids will help your body to be hydrated, which will make you feel better." I have NO IDEA if that is right, but most people nod in agreement... Anyone reading this who thinks that sounds crazy, feel free to correct me

When giving PO meds, I tell people to drink a full glass of water with it, so running fluids in with IV meds seems similar It sounds good, and like the others are saying, a lot of patients just want to feel like they are being heard and cared for---getting some level of care that they couldn't have gotten if they went to PCP or urgent care.

I have to disagree with anyone who says a bag of fluid is cheap, though. Our clerk is really hard on us nurses to document stop times on fluids because we collect about $1500 for each L of fluid given. It has greatly increased our revenue for nurses to be on top of documenting infusions.

Another reason I know we pre-emptively tank up with fluids on anyone with a potential OR destiny is because surgeons like the patients to be "tanked up", since they lose fluid during procedures.

If you feel that you shouldn't be giving fluids and the patient is not NPO, you can educate the patient into declining them.... I've done that a few times. "Would it be okay with you if we give you some IV fluid, or would you rather just drink a few cups of water?" Try it, and you'll see: people think the fluid is magic and they will want it!

 

[lymphocyte]

IV fluids are overused and kill more people than they help. Ask Paul Marik.

Sent from my SM-N910P using SDN mobile

Not sure if subtle troll or the most under-appreciated post of this entire thread.

IV fluids are tremendously overused, risk all kinds of iatrogenic injury, and cost patients hundreds of dollars out of pocket. Not at all benign. If you don't have a reason behind an intervention (and no, placebo and "patient satisfaction" don't count), you simply shouldn't be doing it.

Now back to the real world...

 

[cbrons]

I have a couple things I tell patients, "we are going to give you this medicine together with a liter of fluid because it helps the medicines to be absorbed and processed in your body."

no

 

[deleted245139]

Not sure if subtle troll or the most under-appreciated post of this entire thread.

IV fluids are tremendously overused, risk all kinds of iatrogenic injury, and cost patients hundreds of dollars out of pocket. Not at all benign. If you don't have a reason behind an intervention (and no, placebo and "patient satisfaction" don't count), you simply shouldn't be doing it.

Now back to the real world...

You're really over stating your position. Yes, of course there are risks associated with all interventions, but, true risk for 500cc of saline? We're talking MINIMAL. Even in the ESRD patient or CHF pt. If you excersize common sense, you're not slamming the wrong patients with fluids.
And cost... (recent shortage aside... I find THAT to be a bigger issue and more reason for pause)... We are talking IVF in the scheme of an ED visit. Its cost within the broader visit is minimal. Staff, facilities, imaging, labs, meds etc.... 500 cc of fluid is a drop in the bucket (pun intended)

Is it overused? Absolutly. But let's not pretend it's breaking the medical bank or risking all sorts of danger to the patient.

 

[Taddy Mason]

My wife reviews and approves/declines Medicare and Medicaid claims and a number of her co-workers were recently reassigned to just review claims for IVF during ER vists due to over usage and inappropriate usage. So it definitely is an issue...

 

[lymphocyte]

You're really over stating your position. Is it overused? Absolutely. But let's not pretend it's breaking the medical bank or risking all sorts of danger to the patient.

1. It is tremendously overused, and it does risk iatrogenic injury. But in what context? That's the point I was making about "the real world" and the original post being a "subtle troll." Marik is an intensivist; intensivists clean up the mess from fluid resuscitation. And he and other intensivists have made a strong case that we're simply pushing fluids too hard, mostly in response to Guideline Driven Medicine (like EGDT).

We've all been on the wet-versus-dry-in-sepsis merry-go-round since forever, but the more we learn about the microcirculation, the more we develop longitudinal datasets for fluid resuscitation, and the more we appreciate the dangers of supra-physiological doses of chloride, the more the evidence seems to fall on the side of neither wet nor dry but too damn much (FEAST, ARISE, PROCESS, etc.). Given the data on chloride, I'm starting to think too damn much in general. There's surely a meaningful number-needed-to-harm here, and it probably doesn't exceed the number-needed-to-treat for some yet-unappreciated low-risk patient subgroups.

But Marik is also hilariously opinionated. That's why @cbrons' post was so funny to me. Because there's no way NS kills more than it saves--generally speaking (but again, in what context).

2. It's not at all a drop in the bucket for many patients. A bag of salt water can cost over $200 out-of-pocket. $200 is a lot for some people. As many attendings and residents have noted in this thread: placebo effect and patient satisfaction. That's the same argument a chiropractor can make. Not good enough.


Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308(15):1566-72.

 

[deleted245139]

1. It is tremendously overused, and it does risk iatrogenic injury. But in what context? That's the point I was making about "the real world" and the original post being a "subtle troll." Marik is an intensivist; intensivists clean up the mess from fluid resuscitation. And he and other intensivists have made a strong case that we're simply pushing fluids too hard, mostly in response to Guideline Driven Medicine (like EGDT).

We've all been on the wet-versus-dry-in-sepsis merry-go-round since forever, but the more we learn about the microcirculation, the more we develop longitudinal datasets for fluid resuscitation, and the more we appreciate the dangers of supra-physiological doses of chloride, the more the evidence seems to fall on the side of neither wet nor dry but too damn much (FEAST, ARISE, PROCESS, etc.). Given the data on chloride, I'm starting to think too damn much in general. There's surely a number-needed-to-harm here, and it probably exceeds the number-needed-to-treat for such low-risk patients.

But Marik is also hilariously opinionated. That's why @cbrons' post was so funny to me. Because there's no way NS kills more than it saves--generally speaking (but again, in what context).

2. It's not at all a drop in the bucket for many patients. A bag of salt water can cost over $200 out-of-pocket. $200 is a lot for some people. As many attendings and residents have noted in this thread: placebo effect and patient satisfaction. That's the same argument a chiropractor can make. Not good enough.

3. @e30ftw's posts should be read by everybody twice.

Marik PE. Iatrogenic salt water drowning and the hazards of a high central venous pressure. Ann Intensive Care. 2014;4:21.

Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA. 2012;308(15):1566-72.

(1)
Again - way out side the scope of the initial question.
Not debating fluid recussitation and level of agression with sepsis (Well aware of Merik's work, well aware of the PROMISE, ARISE, PROCESS Trials, iatrogenic acidemia after NS, etc).
The debate/question was IVF for a low acuity complaint.
You will NOT see acidosis from a 500cc bolus.
You will RARELY see flash pulm edema after a 500cc bolus (would depend on their CO, pre-existing fluid status, etc)
I am not disagreeing with you, I agree it's over-used in a lot of arenas (we may have some disagreement on sepsis, but out of the per-view of the initial question posed).

(2)
Cost is bundled. As much as we talk about itemization of medical care, people aren't walking out of the ED with an itemized bill. Those that ARE, are in the hole for hundreds to thousands of dollars. A CT Head for low risk head injury in the ED is a waste of money, and MUCH more monetarily detrimental if we are discussing cost to patient and cost to system. The 500 cc bolus factors in, sure, but pound for pound, carries less weight.

I believe in RESPONSIBLE care for the patient.
I believe in APPROPRIATE lab testing, medications, referrals, consults, and imaging.
I DO think IVF is over utilized, and I'm personally not a fan of patient appeasement for the sake of it, however to argue that a small bolus is cost prohibitive and deadly for the patient is ridiculous.

 

[lymphocyte]

I believe in RESPONSIBLE care for the patient.
I believe in APPROPRIATE lab testing, medications, referrals, consults, and imaging.
I DO think IVF is over utilized, and I'm personally not a fan of patient appeasement for the sake of it, however to argue that a small bolus is cost prohibitive and deadly for the patient is ridiculous.

Who said anything about deadly? And it is indeed cost prohibitive for some. $200+ is a lot.

Also, you missed the main point I was trying to make about sepsis (and frankly ATLS): "Given the data on chloride, I'm starting to think too damn much in general. There's surely a meaningful number-needed-to-harm here, and it probably doesn't exceed the number-needed-to-treat for some yet-unappreciated low-risk patient subgroups."

The simple fact is neither you nor I know what harm is being done, because there are no longitudinal data. When the data are equivocal or absent, you have to reason from first principles, clinical judgement, and clinical experience. When you (or anybody's) clinical experience doesn't include longitudinal care, it's easy to value the benefit of short-term interventions over long-term harm.

 

[deleted245139]

Please forward your concerns on to CMS and the surviving sepsis guidelines as they mandate 30cc/kg bolus regardless of pre existing conditions.

Whatever. I don't think we are sayings different things. But keep on keepin on

 

[lymphocyte]

Please forward your concerns on to CMS and the surviving sepsis guidelines as they mandate 30cc/kg bolus regardless of pre existing conditions.

Whatever. I don't think we are sayings different things. But keep on keepin on

I think we are saying different things. But will do.

 

[Raryn]

In my experience (which is mostly on the IM side with just a couple EM rotations over my training), not all ED patients get an IV, but most get one placed when they have any bloodwork drawn. Why poke the patient twice when you can poke them once and kill two birds with one stone?

Then, when they get one, most get some amount of IV fluids. Why? Well, "so the patient feels like we did something" is a reason, but that's not the only one. There's a lot of other common reasons: People who aren't feeling well (which includes many or most ED patients) don't feel like eating as much, and would likely legitimately feel better with some fluids. In addition, tons and tons of patients may eventually need contrasted IV studies: saline prehydration has been legitimately shown to decrease the risk of any renal injury in someone who will eventually get contrast. I can think of a half dozen other indications.

And the "cost" of saline to the hospital is approximately a dollar a liter. Add in the nursing time to administer it and all, but the only people actually being charged $200+ with an expectation to pay it are the uninsured. Every single insurance company has bundled payments and while they may get a bill for $X00 for a saline infusion, they aren't paying anywhere close to that. So yes, for a patient who isn't uninsured, the cost of fluid administration is bupkis. And yes, the uninsured get boned. Welcome to America.

Finally, the argument above about the risks of saline is absurd. Yes, in septic patients who get 10-12 liters of hyperchloremic fluids you can lead to a significant acidosis that has some preliminary but nowhere near conclusive evidence that it might worsen the chance of renal injury, but most people are using chloride balanced fluids (and a more restrictive strategy) in those situations. Marik has some excellent articles on decompensated heart failure management and a few other critical care topics and is a hell of a writer, but the hyperbole is a bit on the high side sometime. Unless you have ESRD or advanced CHF (systolic or diastolic, doesn't super matter), you will be able to handle a couple liters (whether of saline or a more-expensive balanced fluid) just fine.

 

[lymphocyte]

In my experience (which is mostly on the IM side with just a couple EM rotations over my training), not all ED patients get an IV, but most get one placed when they have any bloodwork drawn. Why poke the patient twice when you can poke them once and kill two birds with one stone?

Then, when they get one, most get some amount of IV fluids. Why? Well, "so the patient feels like we did something" is a reason, but that's not the only one. There's a lot of other common reasons: People who aren't feeling well (which includes many or most ED patients) don't feel like eating as much, and would likely legitimately feel better with some fluids. In addition, tons and tons of patients may eventually need contrasted IV studies: saline prehydration has been legitimately shown to decrease the risk of any renal injury in someone who will eventually get contrast. I can think of a half dozen other indications.

And the "cost" of saline to the hospital is approximately a dollar a liter. Add in the nursing time to administer it and all, but the only people actually being charged $200+ with an expectation to pay it are the uninsured. Every single insurance company has bundled payments and while they may get a bill for $X00 for a saline infusion, they aren't paying anywhere close to that. So yes, for a patient who isn't uninsured, the cost of fluid administration is bupkis. And yes, the uninsured get boned. Welcome to America.

Finally, the argument above about the risks of saline is absurd. Yes, in septic patients who get 10-12 liters of hyperchloremic fluids you can lead to a significant acidosis that has some preliminary but nowhere near conclusive evidence that it might worsen the chance of renal injury, but most people are using chloride balanced fluids (and a more restrictive strategy) in those situations. Marik has some excellent articles on decompensated heart failure management and a few other critical care topics and is a hell of a writer, but the hyperbole is a bit on the high side sometime. Unless you have ESRD or advanced CHF (systolic or diastolic, doesn't super matter), you will be able to handle a couple liters (whether of saline or a more-expensive balanced fluid) just fine.

Bolus 500mL NS all you want. If you have a reason, great. But maybe it's doing more for you than the patient. And the risk of chloride loading seems real and dose-dependent, so balance that against your reason too. Everything contradicting the routine and received wisdom is absurd until maybe it isn't.

This is a fair-minded debate on both sides of the issue: https://www.acep.org/Content.aspx?ID=101488. It's limited to potentially sicker patients, but mostly because there are few data for the less-acute. And even then, early interventions matter, so your "not feeling well" patient who ends up going septic might not appreciate all the extra chloride.

Shaw AD, Raghunathan K, Peyerl FW, Munson SH, Paluszkiewicz SM, Schermer CR. Association between intravenous chloride load during resuscitation and in-hospital mortality among patients with SIRS. Intensive Care Med. 2014;40(12):1897-905.

 

[TooMuchResearch]

My wife reviews and approves/declines Medicare and Medicaid claims and a number of her co-workers were recently reassigned to just review claims for IVF during ER vists due to over usage and inappropriate usage. So it definitely is an issue...

I think you meant due to Medicare not wanting to pay for it.

 

[Raryn]

Bolus 500mL NS all you want. If you have a reason, great. But maybe it's doing more for you than the patient. And the risk of chloride loading seems real and dose-dependent, so balance that against your reason too. Everything contradicting the routine and received wisdom is absurd until maybe it isn't.

This is a fair-minded debate on both sides of the issue: https://www.acep.org/Content.aspx?ID=101488. It's limited to potentially sicker patients, but mostly because there are few data for the less-acute. And even then, early interventions matter, so your "not feeling well" patient who ends up going septic might not appreciate all the extra chloride.

Shaw AD, Raghunathan K, Peyerl FW, Munson SH, Paluszkiewicz SM, Schermer CR. Association between intravenous chloride load during resuscitation and in-hospital mortality among patients with SIRS. Intensive Care Med. 2014;40(12):1897-905.

I was one of the more conservative residents in using a greater proportion of balanced as opposed to chloride-rich fluids and even reviewed the literature on the subject last time I was in the ICU. Basically, the only high quality evidence we have in people is that using NS as opposed to a balanced fluid will worsen a NAGMA on your chem panel. It will make the numbers worse.

Otherwise, there's some observational data that it may also worsen the risk of short term renal injury (but not dialysis)... and other observational data that it doesn't. That's why there's debate on it.

And even still, this thread is about your routine patients. Not all the critically ill ones destined to go to the ICU. Anyone with a reasonably normal physiology can handle a few liters of saline just fine, and it may improve their sx through a variety of mechanisms... and it may protect them from renal injury if they get contrast, etc.

 

[lymphocyte]

I was one of the more conservative residents in using a greater proportion of balanced as opposed to chloride-rich fluids and even reviewed the literature on the subject last time I was in the ICU. Basically, the only high quality evidence we have in people is that using NS as opposed to a balanced fluid will worsen a NAGMA on your chem panel. It will make the numbers worse.

Otherwise, there's some observational data that it may also worsen the risk of short term renal injury (but not dialysis)... and other observational data that it doesn't. That's why there's debate on it.

And even still, this thread is about your routine patients. Not all the critically ill ones destined to go to the ICU. Anyone with a reasonably normal physiology can handle a few liters of saline just fine, and it may improve their sx through a variety of mechanisms... and it may protect them from renal injury if they get contrast, etc.

I hear you. Though I think we're over-confident about who has a normal physiology, especially with no longitudinal data. How many patients even attend follow-up? (Again, I'm not talking about most patients, just perhaps an under-recognised few who are low-acuity.) And the absence of data is not data in support of absence; it's just a call to be mindful and open to more research

To be clear, recent observational research does indicate severity-adjusted, volume-corrected, dose-dependent mortality risk (among other things).

No intervention in medicine is routine (even if it is routine in practice).

 

[Taddy Mason]

I think you meant due to Medicare not wanting to pay for it.

...or because there have been enough incidences of IVF being overused or inappropriately given in the ER setting to raise concern...

They only have to do this for ER pts. - not observation, floor, ICU, etc.