when do you give saline?

paradoqs said:
I dont even think this lpn was the pt's nurse. She gave me a packet with the pt's labs and walked off. No report. I had to follow and ask what was going on. she said "abnormal labs." She didnt even tell me the pt had a bag hanging which my partner dc'ed and told me it was saline. Turns out it was a med and he forgot the name. Pt had a picc line which i cant use so i could either start an iv and give fluids or wait until the ed so they can use the picc and not need to stick her again. Pt was at around 102 sbp the whole trip. Bp was stable but low. ll other vitals stable and wnl so i chose not to stick her again.

My original question restated is, where is that line between needs fluid rescusitation, and doesnt. (for hypovolemia)
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So it's your job to prod for more info. I don't know why you wanted to "save her a stick", with a history of "failure to thrive" and some sort of a bag already hanging, those are indicators that she could possibly be dehydrated. Granted I'm not going to be dumping fluids into this lady, but I'm also not going to base my IV therapy off of just a set of numbers.

I will restate the answers of others, there's no clear line, you use your own clinical judgement to make that decision. Everyone is different and you must combine ALL of your tools to determine whether or not someone needs fluids.


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paradoqs said:
My original question restated is, where is that line between needs fluid rescusitation, and doesnt. (for hypovolemia)
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Unfortunately, the answer remains the same. There is no magic number that says "She needs a bolus!!" It is still very driven by cumulative assessment findings, not a check list.
 
paradoqs said:
So my partner is always telling me to give saline when my pt is hypotensive, say 100 systolic. Im like, Im going to treat my pt, not the bp cuff. If my patient is running alittle low but has no other indications of hypoperfusion, such as tach or pallor or agitation or dehydration then I am not going to give saline. My question is, what are the key indicators for saline administration that you more experienced folks look for? In a sense, how bad off does a pt need to be to warrant a fluid challenge or even a tko'd bag?
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You're starting to futz around with the right concepts... but you've not quite grasped it.
JPINFV said:
...and I stopped reading. How are you going to determine the patient is hypotensive in the first place? Drop an arterial line for a little IAB?
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OOOOhh.... I'm liking that idea.. ;) IABP FTW!! :rofl: Just kidding.
NVRob said:
That's like saying treat the patient not the monitor. We don't use these tools for fun. We use them in conjunction with each other and a good physical exam to form a differential diagnosis and treatment plan. Look at the whole picture, not just the patient, and not just the BP/ECG yadda yadda. Now if something doesn't make sense at all for the presentation go back and look for why it doesn't make sense.
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Uhm... That's exactly like saying "treat the patient not the monitor". for the OP: What makes more sense to me is "treat the patient, not just the monitor. Those devices can give you glimpses into what's going on, but it takes consideration of the whole patient, as best as you can ascertain, to come up with an appropriate treatment plan to address those problems that your patient has.

Out here, our protocols are basically somewhere between a guideline and a cookbook. If you're a cookbook type, you'll dismiss those other indications that trouble is brewing because they don't fit neatly into "the recipe." The clinician in me looks for what the problem is, as best as I can determine, and come up with a plan of care to suit that... and if that plan basically says: use xyz protocol, I can verbalize why I selected that protocol vs coming up with a whole new plan that I'd have to call in to get approval to do it.

But the point of all this is that I can't really make that decision without taking into consideration the patient's entire situation/condition including what the monitors are telling me.
 
Oh, you had labs? Was the patient hypernatremic?

F'ing electrolytes, how do they work.
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DV_EMT said:
If they have fluid in their lungs but they're a little hypotensive, you may consider holding off on giving fluids and may opt for placing them trandelenberg.
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Actually, you would be better off doing a fluid challenge of, say, 250cc and re-checking, and going from there.

Few CHF patients have pulmonary edema due to hypervolemia. Infact, most CHF patients are actually HYPOvolemic. Giving some fluid will hopefully bring up that BP a bit, 'priming the pump' to kick in Starling law, and keep more fluid from backing up due to inadequate contractile force. That fails and we move on to inotropes such as Dopamine.


And good luck laying a CHFer flat on their back / trendelenberg.
 
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Akulahawk; But the point of all this is that I can't really make that decision without taking into consideration the patient's entire situation/condition [I said:
including[/I] what the monitors are telling me.
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.

That is my point. The only abnormal finding I got was a stable but low bp and I decided the pt did not need fluids. If the pt had been tachy and dehydrated i would have given fluids. I understand there is no checklist but I was just wondering if the posters here had any advice. But it seems like the advice is just keep doing what I am doing i.e. using good judgment and not just treating numbers.
 
paradoqs said:
. If the pt had been tachy and dehydrated i would have given fluids
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How do you know they werent dehydrated?

Why rely on tachycardia as a sign? For one, tachycardia can relate to MANY different conditions, even with 'hypotension'.

On top of that, did the patient have any cardiac meds, such as beta blockers, which would artificially lower the HR despite BP changes?
 
JPINFV said:
Oh, you had labs? Was the patient hypernatremic?

F'ing electrolytes, how do they work.
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If i remember correctly it was low potassium and elevated wbc. No signs of any infection though.
 
Linuss said:
How do you know they werent dehydrated?

Why rely on tachycardia as a sign? For one, tachycardia can relate to MANY different conditions, even with 'hypotension'.

On top of that, did the patient have any cardiac meds, such as beta blockers, which would artificially lower the HR despite BP changes?
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Tach was an example of a finding that would be abnormal. Pt had no signs of dehydration, turgor, conjunctiva, mucous membranes etc were all fine.
 
Linuss said:
And good luck laying a CHFer flat on their back / trendelenberg.
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Pfft, you can put the feet up and the head up at the same time. An RN told me that, so it must be true.
 
paradoqs said:
There were no other signs aside from the elevated wbc
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You mean besides the elevated WBC count, borderline hypotension, and what sounds like an altered patient (poor historian)? The elderly or immunocompromised aren't always going to spike a fever.
 
paradoqs said:
There were no other signs aside from the elevated wbc
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The body tends to not spike it's WBC for no reason, be it an infection, what it perceives as an infection, or another disease process. Elderly don't always have a fever when they're sick, as their immune system is, well, crappy. 100 systolic can be normal, or can be low, depending on the patients body type and normal BP.



If you took a look at the patients BGL, I'd be willing to bet it was slightly elevated as well. Do you happen to remember the value? What about the pts HR? RR?


Could very possibly be SIRS.
 
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JPINFV said:
You mean besides the elevated WBC count, borderline hypotension, and what sounds like an altered patient (poor historian)? The elderly or immunocompromised aren't always going to spike a fever.
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Pt didnt seem to be altered, just apathetic about her tx. Sure, she could have had an infection starting and I considered that but as a basic I am going to leave that to the md, because those findings arent significant enough for me to initiate saline infusion.
 
Linuss said:
The body tends to not spike it's WBC for no reason, be it an infection, what it perceives as an infection, or another disease process. Elderly don't always have a fever when they're sick, as their immune system is, well, crappy. 100 systolic can be normal, or can be low, depending on the patients body type and normal BP.



If you took a look at the patients BGL, I'd be willing to bet it was slightly elevated as well. Do you happen to remember the value? What about the pts HR? RR?


Could very possibly be SIRS.
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Didnt get a bgl as it was not indicated. Pulse and rr normal. This wasnt a 911 call it was a BLS non emergent to the ed. The pt didnt have much going on except for the low bp and labs. Anyway, time for bed. I will come up with a different question for tomorow.;)
 
Not indicated?

::twitch::

/inbeforeJP
 
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