Can Distilled Water Be Given Intravenously?
No, distilled water (sterile water) should never be administered intravenously as a routine fluid therapy because it is profoundly hypotonic and causes severe, potentially fatal complications including hemolysis, hyponatremia, seizures, cerebral edema, and death. 1
Why Sterile Water IV Is Dangerous
Sterile water is essentially free water with zero osmolarity, making it extremely hypotonic compared to plasma (normal osmolarity ~285 mOsm/L). When infused intravenously, it causes:
- Acute hemolysis - Red blood cells rupture due to osmotic gradient, releasing hemoglobin into circulation 1
- Severe hyponatremia - Rapid dilution of serum sodium can drop levels to dangerous ranges (<120 mEq/L) within hours 1, 2
- Cerebral edema and herniation - Brain cells swell from water influx, potentially causing seizures, coma, respiratory arrest, and death 1, 3
- Neurological devastation - Permanent brain damage or death has been repeatedly documented 1
The Only Exception: Central Line Administration for Hypernatremia
Sterile water can be administered via central venous catheter only in highly specific circumstances when treating severe hypernatremia and other options are not feasible 4. This requires:
- Central line access mandatory - Never through peripheral IV due to immediate hemolysis risk 4
- Severe hypernatremia present (serum sodium >150 mEq/L and rising) 4
- Enteral route impossible - Patient cannot receive water orally or via feeding tube 4
- Isotonic alternatives contraindicated - Such as 5% dextrose in water being inappropriate (e.g., severe hyperglycemia) 4
- Intensive monitoring required - Frequent sodium checks, neurological assessments 4
Even in this narrow indication, sterile water remains controversial and off-label, with minimal supporting evidence 4.
What Should Be Used Instead
Current guidelines universally recommend isotonic crystalloid solutions for IV fluid therapy:
For Maintenance Fluids
- Isotonic balanced solutions (Plasmalyte, Ringer's Lactate) are first-line for hospitalized children and adults 5
- 0.9% sodium chloride is acceptable when balanced solutions unavailable 5
- These prevent hyponatremia while maintaining physiologic electrolyte balance 5
For Volume Resuscitation
- Balanced crystalloids preferred over normal saline to reduce hyperchloremic acidosis and acute kidney injury 5, 6
- Isotonic solutions mandatory - osmolarity 280-310 mOsm/L 5
Clinical Pitfalls to Avoid
Be aware that some medications are formulated in sterile water, which can inadvertently deliver large volumes of free water:
- Esmolol in sterile water - A documented case showed >6L of esmolol formulated in sterile water caused seizures from acute hyponatremia (sodium dropped 14 mEq/L in 2 days) 2
- Check all medication formulations - Verify diluents and excipients, especially for continuous infusions 2
- Calculate total free water intake - Include all IV sources, not just maintenance fluids 2
Hypotonic fluids of any kind are dangerous in hospitalized patients because most have impaired free water excretion from elevated antidiuretic hormone (ADH) due to pain, nausea, surgery, medications, or illness 1, 3. The traditional practice of using hypotonic maintenance fluids was established before this physiology was understood and has caused numerous preventable deaths 1.
For treating dehydration or volume depletion, isotonic fluids should be used via oral, nasogastric, subcutaneous, or intravenous routes 5. Even in geriatric patients with severe dehydration, isotonic solutions are recommended 5.