Question: I'm a PCP with autonomous IV. It states that a contraindication for a fluid bolus is "signs of fluid overload". I realize the obvious one is pulmonary edema as that is the example that is always brought up in this scenario. What about a pt that has a clear chest with no fluid accumulation in the lungs, but has peripheral edema in the legs or abdomen? I've also had pt's with hypotension that are on dialysis and have stated that they cannot receive large amounts of fluid due to kidney failure. Do we just document their condition? I've heard different answers from everyone and would appreciate some clarification.
Thank you for your question. The purpose of the IV fluid therapy directive is to provide fluid resuscitation to hypotensive patients. Patients who have peripheral edema and those that require dialysis can require fluid resuscitation due to a variety of pathological processes causing them to be hypotensive. If these patients are hypotensive and have a clear chest on auscultation then they would benefit from IV fluid. You are correct in your concern that those who are dialysis dependent and those who have peripheral edema and/or ascites may be more sensitive to IV fluids than those who do not have these conditions. As per the directive, this is why frequent reassessments (i.e. chest auscultation) every 250mL of fluid therapy is required to determine whether or not the patient is tolerating the fluids or is developing pulmonary edema. This acts as a built in safety mechanism to help prevent continued fluid therapy in a patient who may go on to develop pulmonary edema (such as in the types of patients you have correctly identified who may be more sensitive to IV fluid).