Fitness Health Medicine Wellness
Katie Wiskar
Katie Wiskar

@katiewiskar

12 tweets 12 reads Jan 11, 2025
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Suggested New Year's Resolution: more mindful prescribing of IV fluids 🫧
Far too often I see IV fluids thrown around with minimal consideration; meanwhile, we'll deliberate for hours about a dose of lasix πŸ€¦β€β™€οΈ
Here are the 10 most common fluid prescription mistakes I see 🧡
Suggested New Year's Resolution: more mindful prescribing of IV fluids 🫧 Far too often I see IV flu...
1. Confusing maintenance fluids with resuscitation fluids
These are two very distinct indications for IV fluids and should be in separate mental buckets; each with their own considerations.
Be very clear about the reason for which you are prescribing IV fluids πŸ’‰
2. Prescribing maintenance fluids for *most* ward/ICU patients
Most patients just don't need maintenance fluids πŸ€·β€β™€οΈ
Most ward patients are eating/drinking sufficiently that they can meet their needs.
Most ICU patients are getting enough infusions from other sources (vasoactive meds, antibiotics, etc).
There are some patients who truly will need maintenance fluids, but they are a lot less common than you might think!
3. Prescribing maintenance fluid with no stop date/time
IF you really think your patient deserves maintenance fluids: please πŸ™ include a stop date/time in your order.
I find this is especially problematic with EHRs nowadays, where orders can sometimes slip by for days unnoticed.
4. Prolonged saline administration
There have been a plethora of RCTs and meta-analyses looking at this recently; and the results have been somewhat underwhelming.
For small amounts of fluid (<2L), the difference is likely negligible.
However - if you are going to give prolonged fluids (think carefully about whether you need to do this!) - why would you chose to give your patient a hyperchloremic non-anion gap metabolic acidosis?
5. Avoiding balanced crystalloids (Ringer's lactate, etc) in hyperkalemia
There have been many excellent tweetorials over the years about this from people far smarter than I. The blog post below is over 10 years old!!
RL is safe in hyperK; and actually superior to NS.
emcrit.org
emcrit.org

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6. Prescribing fluids for "a low JVP" or "a flat IVC"
This is a common soap box of mine, but I'll say it again louder for the people in the back: πŸŽ™οΈ
The job of the right heart is to keep Central Venous Pressure LOW.
A normal JVP/CVP/IVC is a non-elevated or non-plethoric one.
This alone is not an indication for IV fluid!!!
7. Failure to consider the pathophysiology of the underlying problem
Sepsis - one of the most common conditions for which fluids are administered - is NOT typically a volume depleted state.
Beyond the first couple litres, MOST septic patients are not excessively volume deplete such that they require litres and litres of IVF.
Vasodilation is NOT the same thing as volume depletion.
8. Failure to consider the potential harms of fluid administration
Fluid tolerance - the potential for fluids to cause additional harm - is JUST as important, if not more so, than fluid responsiveness.
Strong data tells us that excessive fluids lead to worse outcomes ☠️
9. Chasing arbitrary markers
If you are giving fluids endlessly just to try to correct a rising lactate/a falling urine output/a tachyarrhythmia....just....stop πŸ€¦β€β™€οΈ
10. Failure to just stop and think πŸ›‘
Fluids are medications. We need to treat them as such!! They have very real harms alongside potential benefits.
We should be considering our fluid prescriptions with the amount of mental energy that we use for any other medication.
Thanks for reading! Drop your #IVFluid tips and tricks (and pet peeves!) here ⬇️
#MedTwitter #volumestatus #fluidtherapy
Ping @ross_prager @NephroP @ArgaizR @FH_Verbrugge @ThinkingCC @PulmCrit @msiuba

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