Stability of warmed and cooled intravenous fluids used in Emergency Room
We would like to share with you and the scientific community our concern about some anecdotal practices in some emergency rooms. Intravenous solutions are used daily for different emergency conditions. Depending on the indications, these solutions can be either cooled before administration, such as in post-cardiac arrest [1], or warmed and given as treatment to patients suffering from hypothermia, shock or any other condition necessitating replacement of fluids warmer than room temperature [2], [3]. Most of the manufacturers recommend keeping the solutions at or below 25 degrees, but there is no specification on the label as to how low this can be and no mention of warming. Cooling, warming and storage at certain temperatures may compromise the neutrality of the packing plastic and affect the stability of the infusion solutions (pH, sterility, osmolality) [4].Three majors observations can be made throughout emergency rooms in South Africa whether private or state institutions:
Cooling
Guidelines for cardiopulmonary resuscitation recommend the use of a cold intravenous sodium chloride solution in the treatment of cardiac arrest. Treatment is carried out by infusing a cooled (4 degrees) sodium chloride solution. No storage or designated cooling device is used. Should there be a need for fluid with a much lower temperature, NaCl 0.9% is put into a cooler bag with ice cubes. The fluid is used when the temperature is around 4 degrees Celsius. Does this cooling affect the stability of the solution? How long can the solution be stored at 4 degrees, and if not used, can it be taken back to the manufacturer’s storage conditions? Can it be warmed? No evidence is available in this regard [5].
Warming
If the method of warming is the same, the duration and the disposal of IVI warmed fluids differ significantly, depending on the medical institution. In some state hospitals, infusions are kept in the warmer as long as they have not expired. In private, the fluids are kept in the warmer for a period of 7–14 days, depending on the discretion of the nursing staff.
Lack of information and knowledge
There is a clear discrepancy in the way the fluids are handled, without any logical, evidence-based medicine, which may be due to lack of knowledge. A review of the published literature showed very scanty information on the stability and sterility of such solutions when cooled or heated and stored for an extended period of time [5]. In addition, the recent article published by Enrique Puertos received a lot of criticism [4], [5]. This lack of knowledge and information puts patients at risk and can be a source of litigation.