What intravenous (IV) fluid is administered to a patient with hypotension in the Emergency Room (ER)?

From the Guidelines

For a hypotensive patient in the Emergency Room, the recommended initial intravenous fluid is Normal Saline, administered at a rate of 5 to 10 mL/kg in the first 5 minutes, as it is the most effective fluid for rapid volume expansion and restoration of blood pressure 1.

Key Considerations

• The choice of fluid may depend on the patient's underlying condition, but Normal Saline is generally preferred due to its isotonic properties and ability to rapidly expand intravascular volume.
• Lactated Ringer's solution may be considered as an alternative, but it may potentially contribute to metabolic acidosis, and its use should be cautious in patients with certain underlying conditions.
• The goal of fluid administration is to restore intravascular volume quickly and improve blood pressure and tissue perfusion.

Administration Guidelines

• Initial bolus administration typically involves 1 to 2 liters of Normal Saline given rapidly (over 5 to 10 minutes) for adults, with reassessment after each bolus.
• For children, the recommended dose is up to 30 mL/kg in the first hour.
• Patients with congestive heart failure or chronic renal disease should be observed cautiously to prevent volume overload.

Additional Considerations

• For patients who remain hypotensive despite adequate fluid resuscitation, vasopressors should be considered, and more specific interventions may be needed based on the underlying cause of hypotension.
• Continuous hemodynamic monitoring is essential in patients receiving vasopressors or other advanced interventions.
• The use of other fluids, such as dextrose or colloid solutions, may be considered in specific situations, but Normal Saline remains the first-line choice for initial fluid resuscitation 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Norepinephrine Bitartrate Injection is a concentrated, potent drug which must be diluted in dextrose containing solutions prior to infusion. Diluent: LEVOPHED should be diluted in 5 percent dextrose injection or 5 percent dextrose and sodium chloride injections. Administration in saline solution alone is not recommended Average Dosage: Add the content of the vial (4 mg/4 mL) of LEVOPHED to 1,000 mL of a 5 percent dextrose containing solution.

The intravenous (IV) fluid administered to a patient with hypotension is 5 percent dextrose injection or 5 percent dextrose and sodium chloride injections containing the drug norepinephrine, as stated in the drug label 2.

Alternatively, for epinephrine, the IV fluid is also 5 percent dextrose solution or 5 percent dextrose and sodium chloride solution 3.

• Key points:
  • The IV fluid used is a dextrose containing solution.
  • Administration in saline solution alone is not recommended.
  • Whole blood or plasma, if indicated, should be administered separately.

From the Research

Intravenous Fluid Administration for Hypotension

• The choice of intravenous (IV) fluid for administering to a patient with hypotension in the Emergency Room (ER) can vary depending on the underlying cause of hypotension and the patient's condition 4, 5, 6, 7, 8.
• For patients with sepsis-induced hypotension, lactated Ringer's solution may be associated with improved survival compared to 0.9% saline 4.
• In trauma patients, the optimal fluid for resuscitation is still unknown, but some studies suggest that restricting fluid administration prior to definitive hemorrhage control may be beneficial 5.
• Hypertonic saline has been studied as a potential treatment for hypotensive trauma patients, but the current evidence does not support its use over isotonic fluids 6.
• Colloids such as Hespan and Hextend may be more effective than crystalloids like lactated Ringer's in improving vascular responsiveness to norepinephrine in hemorrhaged patients 7.
• In the perioperative setting, evidence-based recommendations for fluid resuscitation and vasopressor use are still being debated, but a balanced approach using a combination of fluid administration and vasoactive pharmacological support may be the most effective strategy 8.

Types of IV Fluids

• Lactated Ringer's solution: a balanced salt solution that may be associated with improved survival in patients with sepsis-induced hypotension 4.
• 0.9% saline: an isotonic fluid that is commonly used for fluid resuscitation, but may not be as effective as lactated Ringer's in certain situations 4, 5, 6.
• Hypertonic saline: a concentrated salt solution that has been studied as a potential treatment for hypotensive trauma patients, but is not currently recommended for use in this setting 6.
• Colloids (e.g. Hespan, Hextend): solutions that contain large molecules that can help to expand plasma volume and improve vascular responsiveness to norepinephrine 7.