What are the guidelines for initiating and managing IV therapy in patients?

Guidelines for Initiating and Managing IV Therapy

Balanced crystalloid solutions such as Ringer's Lactate or Plasmalyte are preferred over 0.9% NaCl for IV rescue hydration, especially when high volumes are needed, as they are associated with better acid-base balance and potentially lower mortality. 1

Patient Assessment Before IV Therapy

• Evaluate the patient's clinical status including vital signs, mental status, skin perfusion, urine output, and laboratory values to determine the need for IV therapy 2
• Assess for underlying conditions that may affect fluid management such as heart failure, renal failure, or electrolyte disturbances 2
• Check capillary blood glucose immediately in patients with suspected stroke, as hypoglycemia (glucose below 60 mg/dL or 3.3 mmol/L) should be treated with IV dextrose 2

Fluid Selection

• Balanced crystalloids are recommended as first-line IV fluids for most patients due to their physiologic composition and lower risk of metabolic complications 1
• Avoid synthetic colloids due to increased risk of renal failure and hemostasis disorders 1
• Albumin is generally not recommended for routine IV hydration due to higher cost without demonstrated benefit over crystalloids 1
• Hypertonic saline solutions should not be used as first-line treatment for rescue hydration except in specific situations such as traumatic brain injury with focal neurological signs 1

IV Access and Administration

• Select appropriate IV catheter size based on the purpose of therapy, expected duration, and patient's vascular condition 2
• For sepsis-induced hypoperfusion, administer at least 30 ml/kg of IV crystalloid fluid within the first 3 hours 2, 1
• In patients eligible for IV thrombolysis, ensure blood pressure is lowered below 185/110 mmHg before initiating therapy 2
• For IV iron administration, monitor patients for at least 15 minutes after infusion and be prepared to manage potential infusion reactions 2

Monitoring During IV Therapy

• Perform regular reassessment including clinical examination and evaluation of physiologic variables (heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, urine output) 1
• Use dynamic variables such as pulse pressure variation and stroke volume variation over static variables like central venous pressure to predict fluid responsiveness where available 1
• Target a mean arterial pressure of 65 mmHg in patients requiring vasopressors 1
• Monitor for normalization of lactate levels as a resuscitation goal in patients with elevated lactate as a marker of tissue hypoperfusion 1

Special Considerations

Sepsis Management

• Initiate IV antimicrobials as soon as possible after recognition and within one hour for both sepsis and septic shock 2
• Use empiric broad-spectrum therapy with one or more antimicrobials to cover all likely pathogens 2
• Narrow antimicrobial therapy once pathogen identification and sensitivities are established 2

Stroke Management

• Maintain oxygen saturation ≥94% in patients with suspected stroke 2
• Correct hypotension and hypovolemia to maintain systemic perfusion levels necessary to support organ function 2
• Perform emergency treatment of hypertension only if there is concomitant acute myocardial ischemia, aortic dissection, or preeclampsia/eclampsia 2

Heart Failure Management

• In acute heart failure with hypoperfusion, consider non-vasodilating inotropes or vasopressors and right-heart catheterization 2
• For patients with inadequate urine output (<20 mL/h), consider increasing diuretic dose, using combination diuretics, or adding low-dose dopamine 2

Common Pitfalls to Avoid

• Avoid fluid overload, which is associated with worse outcomes and increased mortality 1, 3
• Do not wait for hemodynamic worsening before initiating fluid resuscitation 1
• Avoid hypotonic fluids in pediatric patients due to risk of iatrogenic hyponatremia 4
• Consider patient-specific factors such as age, weight, and pre-existing renal and/or cardiac conditions when determining fluid volume 1, 3

Management of IV Therapy Complications

Infusion Reactions

• For mild reactions (flushing, urticaria, chest tightness): stop infusion, maintain IV access with normal saline at keep-vein-open rate, and monitor for ≥15 minutes 2
• For moderate reactions (transient cough, shortness of breath, tachycardia, hypotension): consider IV corticosteroids and H2 antagonists 2
• For severe reactions (loss of consciousness, hypotension, angioedema): immediately call emergency services, administer epinephrine, and provide supportive care 2

Electrolyte Disturbances

• Monitor serum electrolytes regularly, especially sodium, to prevent derangements that could lead to neurological injury 3
• Be aware that large volumes of isotonic saline may lead to hyperchloremic metabolic acidosis 5

By following these guidelines, healthcare providers can optimize IV therapy while minimizing potential complications, ultimately improving patient outcomes.