What are the indications for starting an intravenous (IV) drip?

Indications for Starting an Intravenous (IV) Drip

The primary indications for starting an intravenous (IV) drip are hypovolemia, septic shock, hemorrhagic shock, and situations requiring fluid resuscitation to restore hemodynamic stability. 1

Primary Indications

1. Hypovolemia and Shock States

• Septic shock: Administer IV antimicrobials within 1 hour of recognition, along with fluid resuscitation of at least 30 mL/kg of crystalloids in the first 3 hours 1
• Hemorrhagic shock: Use balanced crystalloids rather than 0.9% NaCl as first-line fluid therapy to reduce mortality and adverse renal events 2
• Hypovolemic shock: Administer isotonic crystalloids at 10-20 mL/kg as a fluid bolus, followed by reassessment of hemodynamic parameters 1

2. Hemodynamic Targets

• Mean arterial pressure (MAP) ≥65 mmHg
• Central venous pressure of 8-12 mmHg
• Urine output >0.5 mL/kg/hour 1

Fluid Selection

1. Crystalloids

• First-line therapy: Balanced crystalloids are preferred over 0.9% NaCl for most situations 2
• Initial bolus: 10-20 mL/kg of isotonic crystalloids, with reassessment after each bolus 1
• Avoid hypotonic solutions like Ringer's lactate in patients with traumatic brain injury 2

2. Colloids

• Not recommended as first-line: Synthetic colloids (hydroxyethyl starch, gelatin) are not recommended in first-line treatment due to increased risk of renal failure and coagulation disorders 2
• Albumin: Generally not recommended for patients with hemorrhagic shock 2

3. Hypertonic Solutions

• Not recommended: 3% or 7.5% hypertonic solutions are not recommended in first-line treatment for hemorrhagic shock to reduce mortality 2
• Exception: May be considered in situations combining hemorrhagic shock with severe head trauma and focal neurological signs 2

Administration Guidelines

1. Initial Approach

• Start with 10-20 mL/kg of isotonic crystalloids as a fluid bolus 1
• For sepsis: Administer at least 30 mL/kg within first 3 hours 1
• Titrate to clinical response (improved blood pressure, urine output, peripheral perfusion) 1

2. Monitoring Response

• Reassess hemodynamic parameters after each fluid bolus
• Monitor for signs of fluid overload (increased jugular venous pressure, pulmonary crackles, peripheral edema, decreased oxygen saturation) 1
• Consider echocardiography to guide ongoing management and fluid titration 1

3. Avoiding Complications

• Limit total volume of crystalloids to 2.6L to reduce risk of congestive heart failure 1
• Reduce infusion rate or suspend fluid administration if signs of fluid overload appear 1
• Insert IV cannula through non-lesional skin in patients with skin conditions like Stevens-Johnson syndrome/toxic epidermal necrolysis 2

Special Considerations

1. Acute Pancreatitis

• More conservative intravenous fluid resuscitation protocols are suggested to reduce fluid-related complication risk 2

2. Trauma Patients

• Aggressive resuscitation techniques may be detrimental for trauma patients 2
• Early large-volume crystalloid administration is associated with increased risk of secondary abdominal compartment syndrome 2
• Incidence of coagulopathy increases with increasing volume of IV fluids administered pre-clinically 2

3. Elderly and Patients with Chronic Conditions

• Permissive hypotension should be carefully considered in elderly patients
• May be contraindicated if the patient suffers from chronic arterial hypertension 2

When to Start Vasopressors

• Begin peripheral inotropic support if patients remain hemodynamically unstable despite adequate fluid resuscitation 1
• For septic shock: Consider epinephrine at an intravenous infusion rate of 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve desired mean arterial pressure 3

Cautions and Pitfalls

• Fluid overload: Excessive fluid administration is associated with poorer outcomes and is an independent predictor for morbidity and mortality 4
• Coagulopathy risk: Large volumes of IV fluids (>2,000 ml) are associated with increased risk of coagulopathy 2
• Renal injury: Chloride-rich solutions like 0.9% NaCl may increase risk of acute kidney injury compared to balanced solutions 2
• Extravasation: Avoid extravasation into tissues, which can cause local necrosis, particularly with vasopressors 3

Remember that fluids are drugs and should be prescribed with careful consideration of the patient's condition, with the goal of achieving zero fluid accumulation whenever possible 4.