Can a patient be given distilled water intravenously (IV)?

No, Distilled Water Should Never Be Given Intravenously

Distilled water (sterile water without electrolytes) should never be administered intravenously as a direct infusion because it is profoundly hypotonic and will cause severe, potentially fatal hyponatremia, hemolysis, and brain edema. 1, 2

Why Distilled Water IV is Dangerous

Mechanism of Harm

• Distilled water is maximally hypotonic (osmolarity ~0 mOsm/L compared to plasma 285 mOsm/L), causing immediate fluid shift into cells, leading to cellular swelling and hemolysis of red blood cells 3
• Severe hyponatremia develops rapidly, with documented cases showing sodium drops of 14 mEq/L within 2 days when large volumes of sterile water were inadvertently infused, resulting in seizures and coma 2
• Brain edema and hyponatremic encephalopathy occur because water moves into brain cells, causing increased intracranial pressure, confusion, seizures, respiratory depression, permanent neurological damage, and death 1, 4

Clinical Evidence of Harm

• Multiple reports document death or permanent neurological impairment from hypotonic fluid administration, with children and premenopausal women at highest risk 1, 4
• A case report describes a patient who received >6 L of esmolol formulated in sterile water over 2 days, developing seizures and severe hyponatremia requiring intensive intervention 2
• There is not a single report in the literature supporting the safety of direct IV sterile water infusion for routine use 1

What Should Be Used Instead

For Maintenance Fluids

• Isotonic crystalloids (0.9% NaCl or balanced solutions like Ringer's Lactate, Plasmalyte) are recommended for maintenance IV fluids to prevent hyponatremia 3
• The American Academy of Pediatrics strongly recommends isotonic solutions with appropriate KCl and dextrose for patients 28 days to 18 years requiring maintenance IVFs (Grade A evidence) 3
• For adults, isotonic or balanced crystalloids are preferred over hypotonic solutions for maintenance therapy 3

For Fluid Resuscitation

• Balanced crystalloids (Ringer's Lactate or Plasmalyte) are preferred over 0.9% NaCl for critically ill patients, especially when high volumes are needed, due to better acid-base balance and lower mortality 5, 6
• For sepsis-induced hypoperfusion, at least 30 mL/kg of IV crystalloid should be given within the first 3 hours 5

For Specific Conditions Requiring Free Water

If free water replacement is genuinely needed (e.g., hypernatremia correction):

• 5% dextrose in water (D5W) is the appropriate hypotonic solution, as the dextrose is metabolized, leaving free water 7
• Hypotonic fluids should only be used in specific circumstances: patients with voluminous diarrhea, severe burns, nephrogenic diabetes insipidus, or to correct established hypernatremia 3
• Enteral water supplementation is always preferred when the gastrointestinal tract is functional 3

Rare Exception: Central Line Administration for Hypernatremia

• Sterile water via central venous catheter has been described in the literature for severe hypernatremia when enteral supplementation is impossible and D5W is contraindicated (e.g., severe hyperglycemia on insulin infusion) 7
• This remains off-label, highly controversial, and requires intensive monitoring with serum sodium checks every 2-4 hours 7
• This should only be considered by experienced intensivists in ICU settings with continuous monitoring, never as routine practice 7

Critical Pitfalls to Avoid

• Never administer sterile water peripherally - the risk of hemolysis and tissue damage is immediate 7
• Avoid all hypotonic fluids in postoperative patients, those with brain injury, pulmonary disease, or on medications that stimulate AVP (antidiuretic hormone) - these patients are at highest risk for hyponatremic encephalopathy 1, 4
• Do not assume "free water" means sterile water - when free water is needed clinically, use D5W or enteral water 7
• Monitor serum sodium closely (every 4-6 hours initially) in any patient receiving hypotonic solutions, even D5W 3

Emergency Management if Hyponatremia Develops

• If symptomatic hyponatremia occurs (confusion, seizures, altered mental status), immediately administer 3% hypertonic saline (100 mL bolus over 10 minutes, can repeat up to 3 times) 1, 4
• Stop all hypotonic fluid sources immediately and switch to isotonic crystalloids 2
• Target sodium correction of 4-6 mEq/L in first 6 hours, not exceeding 8 mEq/L in 24 hours to avoid osmotic demyelination 4