What is the alternative treatment for correcting volume status in the absence of Intravenous (IV) saline?

Alternative Routes for Volume Resuscitation When IV Access is Unavailable

When intravenous saline is not available, use oral rehydration solution (ORS) as first-line for mild-to-moderate dehydration, subcutaneous isotonic fluids for moderate-to-severe dehydration (especially in geriatric patients), or nasogastric isotonic fluids for patients unable to drink but without IV access. 1, 2

Oral Rehydration Solution (First-Line for Mild-to-Moderate Dehydration)

• ORS is the preferred initial treatment for isotonic dehydration when patients can tolerate oral intake, with high-quality evidence supporting its effectiveness across all age groups. 2, 3

• Use glucose-containing reduced osmolarity WHO ORS formulations rather than sports drinks, juice, or soft drinks, which lack appropriate electrolyte composition. 3

• ORS can effectively replace lost water and electrolytes in volume depletion from vomiting, diarrhea, or other causes when the patient is alert and able to drink. 2

• For patients with ketonemia or severe nausea, a brief period of alternative hydration may be needed before oral intake becomes tolerable. 2

Subcutaneous Fluid Administration (Hypodermoclysis)

• Subcutaneous isotonic fluids are an effective alternative to IV therapy for moderate-to-severe volume depletion, particularly in geriatric patients, with similar efficacy and fewer complications than IV access. 4

• Use appropriate electrolyte-containing solutions such as half-normal saline with 5% dextrose, or two-thirds 5% glucose with one-third normal saline, rather than electrolyte-free or hypertonic solutions which cause more adverse effects. 4

• Subcutaneous rehydration has lower financial costs and comparable adverse effect rates to IV administration, making it particularly valuable in resource-limited settings or when IV access is difficult. 4

• For older adults with measured serum osmolality >300 mOsm/kg who appear unwell, subcutaneous fluids should be offered alongside encouraging oral intake. 4

Nasogastric/Enteral Fluid Administration

• Isotonic fluids can be administered via nasogastric tube for patients unable to drink but who have intact gastrointestinal function. 4, 1

• This route is appropriate for mild, moderate, or severe volume depletion when oral intake is not feasible but IV access cannot be obtained. 4

• Enteral fluid administration should be prioritized over IV when possible, as it maintains gut function and has fewer complications than parenteral routes. 4

Fluid Selection and Dosing

• Use isotonic fluids (balanced crystalloids like lactated Ringer's or solutions with sodium, potassium, and glucose concentrations similar to body fluids) regardless of administration route. 4, 1

• For adults requiring aggressive rehydration, target 15-20 mL/kg/hour (1-1.5 liters) during the first hour when using any parenteral route. 4, 1, 2

• In geriatric patients, subcutaneous administration rates should be adjusted based on tolerance, typically slower than IV rates. 4

Clinical Assessment to Guide Route Selection

Assess severity of volume depletion to determine appropriate route:

• For excessive blood loss: Look for postural pulse change ≥30 beats/minute or severe postural dizziness preventing standing (97% sensitive, 98% specific for ≥630 mL blood loss). 4

• For vomiting/diarrhea losses: Presence of ≥4 of these 7 signs indicates moderate-to-severe depletion requiring parenteral therapy: confusion, non-fluent speech, extremity weakness, dry mucous membranes, dry tongue, furrowed tongue, sunken eyes. 4

• Severe dehydration, shock, or altered mental status mandates immediate parenteral fluid administration via whatever route is available (subcutaneous or nasogastric if IV unavailable). 2

Critical Pitfalls to Avoid

• Do not use oral fluids alone in patients at high risk or with severe dehydration—parenteral routes (subcutaneous or nasogastric) are necessary when IV is unavailable. 4

• Avoid using 0.9% normal saline when balanced crystalloids are available, as normal saline increases risk of hyperchloremic acidosis and potential kidney injury. 4, 1

• Do not delay resuscitation due to lack of IV access—subcutaneous and nasogastric routes provide effective alternatives that can be life-saving. 1

• Monitor for fluid overload even with non-IV routes, particularly in patients with cardiac or renal compromise, as excessive fluid administration worsens outcomes regardless of route. 1, 2