Which fluid, when, and what it does to the cells — plus what to do when the IV goes wrong.
Hypotonic swells cells. Dangerous in head injury — it worsens cerebral edema.
Isotonic expands blood volume without shifting fluid. Your resuscitation fluid.
Hypertonic shrinks cells and pulls fluid into the vessels. Watch for overload.
Only normal saline goes with blood.
No LR in liver failure or hyperkalemia. It contains potassium and needs the liver to convert lactate.
Correct sodium slowly — no more than about 8-10 mEq/L in 24 hours.
• Fluid resuscitation and hypovolemia
• The only fluid compatible with blood products
• Hyponatremia, metabolic alkalosis
• Flushing lines, diluting medications
• DKA initial resuscitation
• Heart failure and pulmonary edema
• Renal impairment with fluid retention
• Hypernatremia
• Cirrhosis with ascites
• Fluid overload, pulmonary edema
• Hyperchloremic metabolic acidosis with large volumes
• Hypernatremia
• Peripheral edema
• Stays in the vascular space — no fluid shift
• Monitor lung sounds and daily weights
• Large volumes acidify the blood
• Fluid resuscitation, especially burns and trauma
• Surgical fluid losses, dehydration
• Mild metabolic acidosis — lactate converts to bicarbonate
• NEVER with blood products — the calcium causes clotting in the line
• Liver failure — cannot convert the lactate
• Lactic acidosis
• Hyperkalemia — LR contains potassium
• pH above 7.5
• Fluid overload
• Worsening hyperkalemia
• Metabolic alkalosis with large volumes
• Closest fluid to plasma composition
• Contains sodium, chloride, potassium, calcium and lactate
• Check potassium and liver function before large volumes
• Free water replacement, hypernatremia
• A vehicle for IV medications
• Some hypoglycemia protocols
• Provides about 170 calories per liter
• NOT for fluid resuscitation — the dextrose is metabolized and only water is left
• Head injury and increased ICP — free water worsens cerebral edema
• Uncontrolled diabetes
• Never with blood products
• Cerebral edema
• Hyperglycemia
• Dilutional hyponatremia
• Cellular swelling
• Becomes hypotonic once the dextrose is used up
• Monitor glucose and sodium
• Do not use for volume replacement
• Cellular dehydration and hypernatremia
• DKA after the initial saline resuscitation, once glucose starts falling
• Maintenance fluid when sodium is high
• Increased ICP, head injury, stroke — it shifts water into brain cells
• Burns and trauma
• Hypovolemia and hypotension
• Liver disease with third-spacing
• Cerebral edema
• Hypotension from fluid leaving the vessels
• Hyponatremia
• Cell swelling and lysis
• Fluid moves OUT of the vessels and INTO the cells
• Watch neuro status closely
• Never give fast to a hypotensive client
• Severe symptomatic hyponatremia with seizures or altered mental status
• Cerebral edema and raised ICP
• Some ICU volume protocols
• Normal or high sodium
• Heart failure and pulmonary edema
• Renal impairment
• Dehydration from cellular fluid loss
• Osmotic demyelination syndrome if sodium is corrected too fast
• Fluid overload and pulmonary edema
• Hypernatremia
• Phlebitis — it is irritating to veins
• Correct sodium no faster than about 8-10 mEq/L in 24 hours
• ICU setting, infusion pump, frequent sodium checks
• Central line preferred; watch the site closely
• Monitor lung sounds and neuro status hourly
• Maintenance fluid with some calories
• D5 ½NS with potassium is a common post-operative maintenance fluid
• Preventing ketosis while keeping up with losses
• Increased ICP
• Uncontrolled diabetes
• Fluid overload states
• Never with blood products
• Hyperglycemia
• Fluid overload
• Hypernatremia with D5NS
• Pulls fluid out of cells and into the vessels
• Check glucose regularly
• Confirm urine output before adding potassium
• Hypoglycemia, especially in neonates
• After D50 in a client who cannot eat
• Some TPN weaning protocols
• Hyperglycemia
• Intracranial bleeding
• Severe dehydration as the only fluid
• Hyperglycemia and rebound hypoglycemia
• Phlebitis at peripheral sites
• Fluid overload
• Monitor glucose frequently
• Large veins or a central line where possible
• Taper rather than stopping abruptly
• Hypovolemia when crystalloids are not enough
• Hypoalbuminemia with edema
• Large-volume paracentesis
• Burns after the first 24 hours
• Heart failure and pulmonary edema
• Severe anemia
• Known hypersensitivity
• Fluid overload and pulmonary edema
• Hypertension
• Dilutional coagulopathy
• Allergic reactions
• 25% albumin pulls roughly 3-4 times its volume into the vasculature
• Monitor lung sounds, blood pressure and urine output
• See the Blood Products page for the full card
Non-vesicant fluid leaks into the surrounding tissue
Swelling, coolness, pallor, tenderness, slowed or stopped flow, no blood return
Stop the infusion and remove the catheter. Elevate the limb. Warm compress for most fluids, cold for some. Restart in a different site and document the size of the area.
A vesicant leaks into tissue — chemotherapy, vasopressors, calcium, potassium, contrast
Burning or severe pain, blistering, blanching, later tissue necrosis
STOP but leave the catheter in and aspirate what you can, then give the antidote through it. Phentolamine for norepinephrine and dopamine. Hyaluronidase for many others. Elevate, mark the area, photograph it, notify the provider.
Vein inflammation from the catheter, the solution or an infection
Redness and warmth along the vein, a palpable cord, pain, swelling
Remove the catheter, restart on the other arm, warm compress. Culture the tip if infection is suspected. Grade it and document.
Air enters the circulation through the line or during central line removal
Sudden dyspnea, chest pain, hypotension, tachycardia, altered mental status, a churning heart murmur
Clamp the line immediately. Place the client on the LEFT side in Trendelenburg to trap air in the right atrium. High-flow oxygen. Call for help.
Too much volume, or given too fast
Dyspnea, crackles, JVD, bounding pulse, hypertension, weight gain, puffy eyelids
Slow the rate to keep-vein-open and notify the provider. Sit the client upright, give oxygen, expect a loop diuretic. Monitor daily weights and strict intake and output.
A medication or bolus infused far too rapidly
Flushing, headache, chest tightness, irregular pulse, hypotension, cardiac arrest
Stop the infusion immediately, keep the line open with normal saline, notify the provider, and be ready for resuscitation. Prevent it by always using a pump for high-alert drugs.
Organisms enter at the insertion site or through the hub
Fever, chills, redness or drainage at the site, positive blood cultures
Remove the line, culture the tip and draw blood cultures, start antibiotics. Prevent with hand hygiene, chlorhexidine, scrubbing the hub and removing lines as soon as they are not needed.
Reaction to the infusate, most often an antibiotic or contrast
Hives, wheezing, angioedema, hypotension, stridor
Stop the infusion. Epinephrine for anaphylaxis, then antihistamines, steroids, oxygen and fluids. Keep the line open with normal saline through new tubing.
| Infiltration | Extravasation | |
|---|---|---|
| What leaked | Non-vesicant fluid | Vesicant — chemo, vasopressor, calcium |
| Damage | Usually resolves | Blistering, tissue necrosis |
| Catheter | Remove it | Leave it in, aspirate, give the antidote through it |
| Antidote | None needed | Phentolamine, hyaluronidase |