I have written about this before but I still see it a lot. Perhaps you have too.
A doctor orders for a fluid bag (or a set bolus of fluid) to be delivered STAT
The nurse diligently loads the bag into an infusion pump (or perhaps it was already running via a pump) and maxes up the delivery rate.
On many pumps (for example the Imed) this will be 999mls/hr. Our new Bbraun Space pumps max out at 1200mls/hr. Other pumps might allow faster delivery rates 2000 perhaps? Or 3000?
Indeed these are big numbers. But they are not STAT.
We need to be up around 11,000–12,000 mls/hr here…..conditions permitting.
The word stat comes from the Latin statim which means immediately. Right now, at once, instantly.
Unfortunately, even at full throttle an Imed pump dialled up to 999 is going to take an hour to deliver a 1L bag of fluid….which is a long way from instantly.
So here are some quick tips for delivering a fluid bolus Stat:
- Remove the drip set from the pump and open the roller clamp fully. We can then raise the IV pole as high as it will go to increase the flow.
If your rusted pre-Civil War IV pole (held at half mast with tape) wont go any higher….drop the bed height. - Look at the drip chamber. Ideally, you do not want to see drips. What you want to see is a solid ‘tube’ of fluid flowing across the chamber.
- Consider using a separate blood/fluid pump giving set to deliver the bolus. These sets have a small reservoir container built into the giving set, that allows you to hand pump in the fluids at a much greater rate. Every nurse should be familiar with how to prime and use these sorts of pump sets.
- Consider increasing the flow by using a pressure bag over the IV flask ( um…..unless of course its a glass one right?)
- If the patient is going to need rapid fluid resuscitation it is important to look at the size and state of the patients cannula. A small diameter cannula will offer greater resistance to fluid flow. And a cannula sited in some tortuously winding vein in the back of the patients thumb just wont cut it. Consider inserting a large bore cannula into a large vein (eg anti-cubital fossa), or seeing if central access is required.
- If we are delivering a set bolus of fluid (say 500mls from a 1L bag), keep a close eye on the infusion so you can throttle back once the desired volume has been administered.
So the take home message is: You cannot deliver a Stat fluid bolus via an electronic pump that has a maximum delivery rate in the vicinity of 999 mls/hr.
does the order of a stat dose mean that the nurse can put up a drip and run fluids through at 1000mls and hour or 1190 mls an hour
I’ve always been told that on a pump maxed out is better than free-flowing because of the resistance that free-flowing can’t overcome but the pump can.
You’ve given me food for thought.
Thank you Ian, and as a Nurse Practitioner told a few worried RNs one day, if we overload a patient we can give lasix, if we let her bleed to death we’ll be going to her funeral.
Stat means now, right now, do not pass go, do not collect $200, do not even go to the loo.
I am a first year Nurse student pursuing a SECHN course at Defence School of Nursing, of the Republic of Sierra Leone Armed Forces. So interesting for me with regards your topic Tips on delevering IV fluid Stat especially so when i am on preparation to enter the wards for my practice and practical exercises. Thanks for the great idea i have derived. Please send me more tips regarding treat of a patient/client.
Regards
Ibrahim F kanu
Great topic, all too often overlooked.
To add.
The vascular access device is crucial in this clinical scenario and can avoid some of the MacGyver type tips ( all necessary with an unsuitable/inappropriate device). A strict aseptic non touch technique is imperative for any manipulation of medical devices to ensure key parts are protected. Venous return check and device mgt/flushing is required.
“Stat” is an ambiguous term that lacks any quantitative figure (rate). “Stat” fluid is only as good as the device it is infused into. You want to prevent infiltration and device failure. Great point on assessing the device. Avoid ACF blind insertion as the next step, as you do not you know your flow rate will improve to STAT ? CVC may not be the answer either.
Using Ultrasound for peripheral insertion for non- vesicant/irritant medications can prevent premature device failure and prevent either failed blind peripheral attempts or placement of a CVC.
Using Ultrasound will give you vessel measurement and thus cannula diameter to vessel ratio. Based on on this information one can decide if peripheral access is suitable for appropriate STAT fluids and what power injectable devices /cannula guage will support STAT px.
Nice post.
The first thing one should do, especially a new nurse, is to ask the physician or mid-level to clarify the “bolus, stat” order. I would never write or give an order for a bolus without giving parameters for said bolus, otherwise the nurse/tech at the bedside would be expected to ask to clarification. Furthermore, if as much as a liter or more is needed and is ordered as a “bolus, stat” at the bedside I would be asking for central venous access and an arterial line while the practitioner is at the bedside.
New or timid non-critical care practitioners are often hesitant to ask for large boluses because of concerns of CHF and “fluid overload,” not recognizing the inherent deficit during the primary survey. I would ask them, “how many people have died of Acute CHF in the inpatient setting in the last 20 years?” Auscultating lung sounds might provide a decent indication that the patient is becoming fluid overloaded. Furthermore, if they are indeed ordering such a “bolus, stat” why wouldn’t the patient already be intubated or have a secure airway?
Great point about fluid overload Mike, as I mentioned below, I work in dialysis and we never worry about it when it comes to fluid resus. Usually ESRD patients only need 200ml-500ml to get their BP up to something reasonable, but I would never worry about “filling them up”. I’m reminded of one patient who came to us post fluid resus via RFDS and the ED and by the time she was stable she was nearly 10L over her IBW!!
Just because someone needs fluid resuscitation, doesn’t mean they require an artificial airway or a CVL + art line (think dehydrated toddler with gastro, burns patients, DKA etc). The fluid resus comes first and can be easily accomplished as outlined by Ian though a decent cubital fossa IV.
How quickly can fluid bolus be given to kids? (ie 20 ml kg @ ?)
As quick as you can get it in if it’s needed- i.e open the line up.
Stopcock with 20 to 60 cc syringe attached. Close to pt, fill syringe, close to iv bag, push in ASAP and repeat to 20 ml per kg for peds
I don’t believe the scenario, as outlined above, would indicate the “bolus, stat” would be given to a peds, gastro, or burn patient.
In the Burn Center that I worked at ideally the pts would come up with 2 large bore peripheral IVs and we could resuscitate them quite easily sometimes giving >2 liters/hour. We would monitor them closely,they would have alines if intubated but rarely central lines unless they had preexisting cardiac problems.
This was a while ago and I doubt the treatment plans etc are the same but I’m just commenting that we had no problems giving large boluses rapidly via largebore peripheral IVs.
You can put a 20mL syringe into a port on the giving set, then extract saline from the bag, and then injecting the bag and inject in the direction of the vein. Clamping as necessary to direct flow. Like flushing the cannula, but repeatedly. A 3 way tap would work.
Only need to do it 50 times…
In case you have a glass bottle, in an enclosed area unable to raise the bag and don’t have much choice o giving sets…
Ed, the only concerns I have about this method is that it is painful to do this in a peripheral vein and it also as the risk of causing the cannula to tissue if TOO much pressure is put on the cannula when injecting.
So, how fast is TOO fast?
Thanks KT,
If the doctor wants the bag (or bolus) over 15 minutes or 10 minutes, they should order it accordingly….but if they order it STAT, then it is as quickly as you can get it in there.
So to answer your question, TOO fast would be if it was causing great discomfort to the patient, or the IV disconnects sending them flying around the room like a rogue garden hose.
Others may have a differing opinion……
Thanks Ian. We frequently have to do fluid resus in the dialysis unit. At my unit we normally turn the pump speed down to 150-200ml/min but we have the ability to do 400+ ml/min, so I’ve always wondered if there was a point when you are giving fluid too quickly.
In my experience working in a Burn Center, the answer would be no whether or not a pt could get fluid too quickly in large TBSA burn pts(mostly >60% TBSA burns). They would arrive in shock and their very lives would depend on whether or not we could get fluid in them fast enough to avoid organ failure. Of course they would have to be monitored very closely in an ICU setting and this was done,pretty much only during the first 24 hours.
After that their fluid needs were more like any other ICU pt.
And whether or not fluid can be given too quickly certainly yes in cardiac, pediatric or otherwise compromised pts. Most young healthy pts will tolerate a quick bolus just fine.