Question: When administering a fluid bolus, are we to give the full bolus amount (i.e. 1000ml for a 50kg patient) reassessing for fluid overload or return to TKVO when the BP reaches 100mmHg or greater? Given so much fluid shifts, administering the full bolus when no fluid overload is present (either 10 or 20ml/kg), particularly with the septic or preload dependent patient would be beneficial.
This is an excellent question and highlights an area of practice that is not well defined in the directives. The topic was discussed in previous Ask MAC questions (November 04, 2013 and March 03, 2014). A research / QI project currently underway shows great variability in what paramedics are currently doing. In the study, blood pressure measurements were found to be highly variable and in some cases fluctuated wildly. Documentation of times when starting or stopping a bolus and the amount of fluid given in a bolus is often incomplete. The amount of fluid given rarely reached 20ml/kg.
There is only opinion to guide the answer. A second BP should be taken to confirm that the systolic blood pressure is below 90. If a bolus is started, then the entire bolus should be given. Checking for fluid overload after 250 ml of fluid is administered is a component of the directive. This should be done and documented. However, if the systolic blood pressure reaches 100 and is maintained for 2 readings then it would also be reasonable to decrease the fluid to a maintenance rate and continue to monitor the BP carefully. This is in keeping with the answer given in 2014 but adds that the BP should be double checked before starting or stopping a bolus.