Systematic intravenous infusion: from a therapeutic reflex to an avoidable risk of serious complications and sudden death
For reasoned prescribing, evidence-based medicine and better patient safety in Senegal.
Infusing is not always healing
In many healthcare structures, intravenous infusion has sometimes become a therapeutic reflex in the face of fever, fatigue, vomiting, pain or a deterioration in general condition. For some patients, it even symbolizes more serious medical care than oral treatment.
However, infusion is not a universal treatment. It constitutes a route of administration of liquids, electrolytes or medications, the indication of which must be based on a precise clinical evaluation.
A question therefore deserves to be asked: is the infusion prescribed because the patient really needs it, or because it has become a prescribing habit?
This question goes beyond medical practice alone. It concerns patient safety, quality of care, training of professionals and the efficient use of health resources.
Intravenous infusion: a useful treatment, but not trivial
Infusion is essential in several situations: circulatory shock, severe dehydration, significant fluid losses, inability to use the oral route or administration of medications requiring intravenous access.
However, in a stable patient, capable of drinking and whose fluid needs are met, systematic infusion does not necessarily provide additional benefit.
Recommendations from the National Institute for Health and Care Excellence (NICE) recommend reserving intravenous fluids for patients whose needs cannot be met orally or enterally, with regular reassessment and discontinuation as soon as possible.
The prescription must specify the nature of the solute, the volume, the flow rate and the monitoring methods.
How can inadequate perfusion cause fatal complications?
Fluid overload and acute lung edema
Administering too much or too quickly fluids can increase cardiac filling pressures and cause pulmonary congestion.
The risk is particularly high in patients with heart failure, kidney failure, valvular disease or advanced age.
Significant overload can cause acute respiratory distress, sometimes fatal.
Electrolyte disorders and arrhythmias
The composition of the solutes, the volumes administered and the renal state of the patient influence the hydroelectrolyte balance.
Severe sodium or potassium abnormalities can cause neurological disorders or cardiac arrhythmias which may lead to cardiac arrest.
Worsening of a pre-existing illness
Inadequate perfusion can precipitate decompensation in a fragile patient. The risk depends in particular on the initial pathology, the type of liquid, the quantity administered and the speed of administration.
It is nevertheless necessary to distinguish a complication directly caused by the infusion from an event which simply occurs during it. Any sudden death in this context requires rigorous clinical analysis before concluding causal responsibility.
The real issue: abandoning automatic prescription
The quality of care is not measured by the number of infusions performed, but by the relevance of therapeutic decisions and the results obtained.
Before any prescription, the healthcare professional must answer five questions:
1. What is the precise indication for the infusion?
2. Can the patient meet his or her needs orally or enterally?
3. Is there cardiac or renal insufficiency or another relative contraindication?
4. What solute, volume and flow rate are appropriate?
5. How and when will response to treatment be reassessed?
This approach helps prevent unnecessary prescriptions and reduces avoidable complications.
What responsibilities for health professionals and structures?
Preventing infusion-related accidents is based on shared responsibility.
* The prescriber must justify the indication, adapt the prescription to the patient and organize monitoring.
*Administrative personnel must verify the prescription, respect the flow rate and promptly report any anomalies.
* The health facility must have written protocols, appropriate monitoring equipment, trained staff and an adverse event reporting system.
* Health authorities and professional organizations must promote continuing education, practice audits and a culture of healthcare safety.
Legal liability cannot be inferred solely from the occurrence of a complication. It depends on the circumstances, the applicable professional obligations, the causal link and the elements established by the investigation.
What concrete measures for Senegal?
A policy for the proper use of infusions could be structured around six measures:
1. Develop or disseminate national protocols for prescribing and monitoring intravenous fluids.
2. Train doctors, nurses and other relevant professionals in assessing hydration status and recognizing fluid overload.
3. Make a traceable prescription mandatory specifying the solute, volume, flow rate and indication.
4. Implement monitoring adapted to the patient’s risk level, with particular attention to the elderly and cardiac or renal patients.
5. Organize regular audits of prescriptions and analyze serious complications.
6. Raise public awareness of the fact that an injection or infusion is not systematically synonymous with the best treatment.
These measures must apply to both public establishments and private structures, taking into account their resources and their level of care.
Patient safety must take precedence over habits.
Intravenous infusion saves lives when indicated, correctly prescribed and properly monitored. But its automatic use can expose some patients to serious complications, including fluid overload or electrolyte disorders.
True medical progress does not consist of multiplying technical procedures, but of choosing the right treatment, for the right patient, at the right time.
In Senegal, promoting the rational prescription of infusions should become a concrete objective for improving the quality and safety of care.
Dr. Serigne Falilou Samb
(Louis Pasteur Polyclinic)
