What is the recommended approach for ordering fluids in a patient?

How to Order Fluids in the Emergency Department

Initial Fluid Selection

Order balanced crystalloids (Lactated Ringer's or Plasmalyte) as your first-line fluid choice rather than normal saline, as they reduce mortality and prevent hyperchloremic acidosis. 1, 2

• Balanced crystalloids like Lactated Ringer's are associated with lower 1-year mortality compared to normal saline in septic patients (adjusted hazard ratio 0.71,95% CI 0.51-0.99) 2
• Normal saline should be limited to maximum 1-1.5 L if used, due to risk of hyperchloremic metabolic acidosis 3
• Avoid hypotonic solutions like Ringer's lactate in severe head trauma patients 3

Writing the Actual Fluid Order - Essential Components

Your fluid order must specify: (1) fluid type, (2) volume per bolus, (3) rate of administration, and (4) reassessment triggers. 1

For Septic Patients:

• Order: "Lactated Ringer's 30 mL/kg IV over 3 hours, then reassess" 3, 1
• This translates to approximately 2-3 liters for average-sized adults 3
• Include specific reassessment parameters after initial bolus 1

For Non-Septic Hypotensive Patients:

• Order: "Lactated Ringer's 500-1000 mL IV bolus over 15-30 minutes, reassess after each bolus" 1
• For elderly or cardiac dysfunction: reduce to 250-500 mL boluses 1

Reassessment Parameters to Include in Order

Specify these clinical endpoints for nursing staff to monitor and report: 1

• Heart rate, blood pressure, respiratory rate 1
• Skin perfusion and capillary refill time 1
• Urine output (target >0.5 mL/kg/hr) 1
• Mental status changes 1
• Signs of fluid overload (crackles, increased work of breathing, oxygen desaturation) 1

When to Stop - Include These Parameters

Order fluids to stop when: 1

• No improvement in tissue perfusion after bolus 3
• Signs of fluid overload develop (pulmonary edema, oxygen desaturation) 3, 1
• Hemodynamic parameters stabilize (MAP ≥65 mmHg, adequate perfusion) 3, 1

Rate and Volume Specifications

For rapid resuscitation: 1

• Administer 250-1000 mL boluses over 15-30 minutes 1
• Reassess after each bolus before giving additional fluid 3, 1

Maximum daily limits: 4

• Avoid exceeding 200 mEq potassium per 24 hours if adding electrolytes 4
• Monitor serum osmolality changes (should not exceed 3 mOsm/kg/h) 3

Special Populations

Diabetic Ketoacidosis (DKA):

• Order: "0.9% Normal Saline 1 L IV over 1 hour, then 250-500 mL/hr" 3
• Switch to 0.45% saline at 4-14 mL/kg/hr once corrected sodium is normal/elevated 3
• Add potassium 20-30 mEq/L once K+ >3.3 mEq/L and urine output established 3

Pediatric Patients (<20 years):

• Order: "0.9% Normal Saline 10-20 mL/kg IV over 1 hour, maximum 50 mL/kg over first 4 hours" 3
• Slower rehydration reduces cerebral edema risk 3

Common Pitfalls to Avoid

• Never order continuous fluids without specifying reassessment intervals - this leads to fluid overload 1
• Do not use normal saline exclusively - it causes hyperchloremic acidosis and worse outcomes 3, 2
• Avoid aggressive fluid resuscitation in resource-limited settings without vasopressor/ventilator access 3
• Do not give potassium-containing fluids until urine output is established and K+ >3.3 mEq/L 3

Example Complete Order

"Lactated Ringer's 1000 mL IV bolus over 30 minutes. Reassess vital signs, urine output, and respiratory status after bolus. May repeat x2 if MAP <65 mmHg and no signs of fluid overload. Call MD if no improvement after 2 liters or if respiratory distress develops." 1