IV infusions — reference & ordering sequence

Order an IV the way pharmacy reads it.

An IV order isn't a fluid — it's a fluid plus a rate, a duration, a route, and a monitoring plan. This page walks the correct ordering sequence and gives you a dense, scannable reference for every solution you'll meet on the inpatient ward.

01 — The 9-step sequence

What every complete IV order contains

1
Indication
Start with WHY. Resuscitation, maintenance, replacement of ongoing losses, KVO (keep-vein-open), drug-delivery vehicle, blood-product replacement — each has different rates and end-points.
2
Solution + additives
Generic name of the bag (0.9% NaCl, LR, D5W, etc.) plus every additive in mEq or mg. Never abbreviate KCl as 'K' — always write 'potassium chloride' and the mEq.
3
Volume
Total volume per bag (e.g., 1000 mL) — separate from the rate. Pharmacy needs this to dispense the right size bag.
4
Rate
mL/hr for continuous infusions OR total mL over total time for bolus / replacement (e.g., '1 L over 1 h'). Drips dosed per kg/min get a calculated mL/hr.
5
Duration / endpoint
Defined stop criterion: 'x 24 h', 'until MAP ≥ 65', 'until UOP ≥ 0.5 mL/kg/hr', '× 3 boluses then reassess', or 'until d/c'. Never open-ended.
6
Line / compatibility
Peripheral vs central. Some drips (NE > 10 mcg/min sustained, K+ > 10 mEq/hr, vesicants, hyperosmolar TPN) require a central line. Check Y-site compatibility against existing infusions.
7
Monitoring
Specify frequency: VS q15min × 4 then q1h, BMP q6h, ECG continuous, MAP/CVP targets. Without a frequency, nursing won't capture data — and you won't titrate appropriately.
8
Hold / titration parameters
For drips: titrate to MAP / HR / RASS / aPTT / glucose; specify the increments and the maximum dose. For boluses: hold for SBP > 160, S3 gallop, rales, etc.
9
Adjuncts / orders linked to the fluid
Foley for strict I&Os, daily weights, baseline + scheduled labs, the antidote / reversal agent if applicable (calcium for hyperK, glucagon for β-blocker drips, naloxone for opioids).

02 — Crystalloids

Every bag on the floor — composition, indication, contraindication

Solution	Osm	Na	K	Cl	Other	Tonicity
0.9% NaCl (NS)	308	154	0	154	—	Isotonic
Lactated Ringer's (LR)	273	130	4	109	Ca 3, lactate 28	Isotonic
Plasma-Lyte A	294	140	5	98	Mg 3, acetate 27, gluconate 23	Isotonic
0.45% NaCl (½ NS)	154	77	0	77	—	Hypotonic
3% NaCl	1027	513	0	513	—	Hypertonic
D5W (5% dextrose in water)	252	0	0	0	Dextrose 50 g/L	Isotonic in bag → hypotonic in body
D5 ½ NS	406	77	0	77	Dextrose 50 g/L	Hypertonic in bag, ~isotonic effect
D5 NS	560	154	0	154	Dextrose 50 g/L	Hypertonic
D10W	505	0	0	0	Dextrose 100 g/L	Hypertonic

Units: osmolarity mOsm/L · electrolytes mEq/L. Dextrose where present 50 g/L (D5) or 100 g/L (D10).

0.9% NaCl (NS)

UseResuscitation, vehicle for blood products, hyponatremia (slow), DKA after initial bolus.

AvoidLarge-volume → hyperchloremic acidosis. CHF/edema. ESRD with hyperkalemia: actually fine (no K).

Lactated Ringer's (LR)

UseResuscitation, surgical / trauma, balanced fluid of choice for most adult resuscitation per recent trials.

AvoidSevere liver failure (impaired lactate metabolism). Hypercalcemia. With ceftriaxone (Ca precipitation) — never co-infuse.

Plasma-Lyte A

UseBalanced crystalloid; lactate-free (use when LR is contraindicated, e.g., liver failure).

AvoidHyperkalemia. Hypermagnesemia (rare).

0.45% NaCl (½ NS)

UseHypernatremia correction (slowly), maintenance fluid in some peds protocols.

AvoidResuscitation (will not stay in vascular space). Hyponatremia. Suspected raised ICP — can worsen cerebral edema.

3% NaCl

UseSymptomatic severe hyponatremia (Na <120 with seizures / obtundation). Refractory raised ICP.

AvoidPeripheral line (vesicant — central preferred for sustained infusion). Heart failure. Correct Na ≤ 8–10 mEq/L per 24 h to avoid osmotic demyelination.

D5W (5% dextrose in water)

UseFree-water replacement for hypernatremia. Vehicle for some drips (amiodarone, nicardipine).

AvoidResuscitation (no Na, distributes to total body water). Hyperglycemia. Active CVA / TBI.

D5 ½ NS

UseStandard maintenance fluid in adults without contraindications.

AvoidHyperglycemia, hypernatremia. Add K (typically 20 mEq/L) if patient is NPO and making urine.

D5 NS

UseSpecific replacement strategies; rarely first-line maintenance.

AvoidHeart failure, hypernatremia, hyperglycemia.

D10W

UseHypoglycemia in continuous infusion (esp. neonates, sulfonylurea overdose). Insulin overdose.

AvoidPeripheral line for prolonged infusion (irritant). Hyperglycemia.

03 — Colloids & blood products

When the bag needs to be more than salt + water

Albumin 5%

UseIntravascular volume expansion in SBP/large-volume paracentesis, hepatorenal syndrome, post-liver transplant, sepsis (selective).

DoseTypical bolus 250–500 mL. SBP: 1.5 g/kg D1, 1 g/kg D3.

AvoidSevere heart failure, fluid overload, prior reaction.

Albumin 25%

UseOncotic support without large volume. Cerebral edema (selective), refractory ascites + diuretic resistance.

Dose50–100 mL slow IV; aliquots driven by oncotic / volume target.

AvoidPulmonary edema (volume shift into vascular space). Anemic patients without volume need.

Packed RBCs

UseSymptomatic anemia or Hb < 7 (or < 8 in active cardiac ischemia). Hemorrhage with hemodynamic instability.

Dose1 unit ~ 250–300 mL, raises Hb ~1 g/dL. Infuse over 1.5–4 h; faster only in active hemorrhage.

AvoidY-site with anything other than 0.9% NaCl (calcium-containing fluids → clotting; D5W → hemolysis).

Fresh frozen plasma (FFP)

UseActive bleeding with coagulopathy (INR > 1.5), warfarin reversal when 4-factor PCC unavailable, massive-transfusion protocol.

Dose10–15 mL/kg. ABO compatibility required. Thaw 20–30 min lead time.

AvoidAsymptomatic INR elevation — not a vitamin K replacement. TRALI/TACO risk.

Platelets

UsePlt < 10 prophylactic, < 20 with fever/sepsis, < 50 with active bleeding or pre-procedure, < 100 with CNS bleed or neurosurgery.

Dose1 apheresis unit raises plt ~30–50 K. Infuse over 30–60 min.

AvoidTTP / HIT — platelets are contraindicated (worsen microvascular thrombosis).

Cryoprecipitate

UseFibrinogen replacement (< 150 in active bleed, < 100 with DIC), hemophilia A / vWD when factor concentrates unavailable.

Dose1 unit per 10 kg raises fibrinogen ~50 mg/dL.

AvoidGeneric 'INR correction' — cryo is fibrinogen-specific.

04 — Continuous infusions

Drip reference: concentration, dose, line, monitoring

Norepinephrine
Epinephrine
Phenylephrine
Vasopressin
Dobutamine
Nitroglycerin
Nicardipine
Diltiazem
Amiodarone
Heparin (UFH)
Insulin (regular)
Propofol
Dexmedetomidine
Fentanyl
Magnesium sulfate
Potassium chloride

Norepinephrine

Standard concentration

4 mg / 250 mL D5W (16 mcg/mL) or 8 mg / 250 mL (32 mcg/mL) high-concentration

Dose

Start 0.05 mcg/kg/min, titrate q5–15 min to MAP ≥ 65. Typical 0.05–0.5; refractory ≤ 3.

Line

Central preferred for sustained doses > 0.05–0.1 mcg/kg/min; peripheral OK short-term with extravasation plan (phentolamine local infiltration if extrav).

Monitoring

Continuous BP/MAP (arterial line if titrating), HR, UOP q1h, lactate q2–6h, glucose.

05 — Septic shock

The Hour-1 bundle (Surviving Sepsis Campaign)

Septic shock is sepsis-induced hypotension persisting despite adequate fluid resuscitation AND lactate ≥ 2 mmol/L. Every step below has a time target. Each hour of delay in antibiotics raises mortality ~7% — start them after cultures but never let cultures delay the dose more than 45 minutes.

Measure lactate

Within 1 h

Initial level — repeat at 2 h if first ≥ 2 mmol/L. Trend guides resuscitation success; failure to clear ≥ 10% suggests ongoing tissue hypoxia.

Lactate STAT, repeat in 2 h

Obtain blood cultures

Before antibiotics (must not delay them > 45 min)

Two sets from two separate sites. If patient already on antibiotics, draw immediately before next dose. Adding fungal / AFB cultures when clinically indicated.

Blood culture × 2 sets (peripheral + line if present), STAT

Broad-spectrum antibiotics

Within 1 h of recognition

Empiric coverage based on suspected source. Each hour of delay increases mortality ~7%. Reassess at 48–72 h with culture data for de-escalation.

Piperacillin-tazobactam 4.5 g IV q8h (extended infusion 4 h) — empiric Gm-neg + anaerobe coverage
+ Vancomycin 25–30 mg/kg IV load, then per pharmacy nomogram — MRSA coverage
± Consider antifungal (e.g., micafungin 100 mg IV q24h) if at-risk host

Rapid crystalloid resuscitation

Within 3 h

30 mL/kg ideal-body-weight balanced crystalloid (LR or Plasma-Lyte preferred over NS) for MAP < 65 or lactate ≥ 4. Reassess after each litre — dynamic measures (PLR, pulse-pressure variation, IVC US) > static (CVP).

Lactated Ringer's 30 mL/kg IV over 1–3 h (= ~2 L for 70 kg)
Reassess MAP, UOP, JVP / IVC, lactate after each bolus

Start vasopressors if MAP < 65

During or after fluid resuscitation

Norepinephrine first-line. Target MAP ≥ 65 (consider 80–85 if chronic HTN). Add vasopressin 0.03 units/min at NE > 0.25 mcg/kg/min as catecholamine-sparing. Epinephrine third-line.

Norepinephrine 4 mg / 250 mL D5W:
   start 0.05 mcg/kg/min, titrate q5 min to MAP ≥ 65
   max 1 mcg/kg/min — call MD if approached
± Vasopressin 0.03 units/min fixed if NE > 0.25 mcg/kg/min
Central line if NE sustained > 0.1 mcg/kg/min for > 1 h
Arterial line for continuous MAP

Resuscitation targets at 6 h

MAP

≥ 65 mmHg

UOP

≥ 0.5 mL/kg/hr

Lactate

↓ ≥ 10% / 2 h or normalising

ScvO₂

≥ 70% (if central access)

Adjuncts (beyond the bundle, often within 24 h)

Steroids

Hydrocortisone 200 mg/day (50 mg IV q6h OR 200 mg/day continuous) if vasopressor-dependent after adequate fluid + NE. Continue until off pressors.

Source control

Imaging within 6 h to identify drainable foci. Drainage / debridement / device removal within 6–12 h if anatomically possible.

Glycemic control

Insulin drip for sustained BG > 180 mg/dL. Target 140–180 (not tight control — increases hypoglycemia + mortality).

Stress-dose & VTE

PPI for stress-ulcer prophylaxis if mechanically ventilated > 48 h or coagulopathic. Mechanical VTE prophylaxis day 1; chemical when bleeding risk acceptable.

Lung-protective vent

If intubated: tidal volume 6 mL/kg IBW, plateau pressure < 30, PEEP titrated to FiO2 / ARDSnet table.

When to re-image / re-culture

Persistent fever or rising lactate at 48–72 h → repeat imaging of suspected source, repeat cultures off antibiotics if possible, infectious-disease consult.

06 — Common pitfalls

Where IV orders go wrong

Pitfall

Ordering a bolus without a rate

'500 mL NS bolus' is incomplete — pharmacy and nursing infer rate, which can mean 30 min or 4 h. Write '500 mL NS over 30 min'.

Pitfall

Co-infusing LR with ceftriaxone

Calcium in LR precipitates with ceftriaxone → fatal pulmonary embolism. Never on the same line, ever. Use NS as carrier for ceftriaxone.

Pitfall

Peripheral KCl > 10 mEq/hr

Severe burning + phlebitis. Central line OR slow the rate. Always order on a pump, never run K wide-open.

Pitfall

Rapid Na correction in chronic hyponatremia

Max 8–10 mEq/L per 24 h. Faster → osmotic demyelination syndrome. Use D5W to slow correction if you're going too fast.

Pitfall

D5W resuscitation

Distributes to total body water — does NOT stay in the vascular space. Useless for shock. Use a balanced crystalloid.

Pitfall

Forgetting compatibility on a single line

When the patient has 2 peripheral IVs and 4 drips, somebody runs them together. Check every Y-site pair against the institutional compatibility tool.

Pitfall

Heparin without baseline labs

Need CBC, aPTT, INR, SCr before starting. HIT requires a baseline platelet count. Renal failure changes anti-Xa monitoring strategy.

Pitfall

Open-ended vasopressor orders

'Titrate to MAP ≥ 65' is necessary but not sufficient — add a max dose, a re-eval interval, and the next-line drug if you exceed it.

07 — Side by side

Septic shock resuscitation, written two ways

A 72-year-old with sepsis, MAP 56 despite 2 L crystalloid, lactate 4.2.

Incorrect

start levo and give some fluids

Brand name 'levo' for norepinephrine.
No fluid type, volume, or rate.
No starting drip rate or titration target.
No line plan, no monitoring frequency, no max dose.

Correct

1) Lactated Ringer's 30 mL/kg IV (= 2 L for 67 kg) over 1 h
2) Norepinephrine 4 mg / 250 mL D5W:
   start 0.05 mcg/kg/min, titrate q5 min to MAP ≥ 65
   max 1 mcg/kg/min — call MD if exceeded
3) Central line if NE > 0.1 mcg/kg/min sustained > 1 h
4) Arterial line for continuous MAP
5) Lactate q2h × 3, BMP q6h, CBC q12h
6) UOP q1h, target ≥ 0.5 mL/kg/hr
7) Indication: septic shock

Bolus dose, type, and rate all specified.
Pressor with concentration, starting dose, titration interval, target, and max.
Line plan + arterial monitoring tied to the drip.
Lab and urine output endpoints make titration possible.
Indication anchors the order to the patient's problem list.

Order an IV the way pharmacy reads it.

What every complete IV order contains

Indication

Solution + additives

Volume

Rate

Duration / endpoint

Line / compatibility

Monitoring

Hold / titration parameters

Adjuncts / orders linked to the fluid

Every bag on the floor — composition, indication, contraindication

When the bag needs to be more than salt + water

Albumin 5%

Albumin 25%

Packed RBCs

Fresh frozen plasma (FFP)

Platelets

Cryoprecipitate

Drip reference: concentration, dose, line, monitoring

Norepinephrine

The Hour-1 bundle (Surviving Sepsis Campaign)

Measure lactate

Obtain blood cultures

Broad-spectrum antibiotics

Rapid crystalloid resuscitation

Start vasopressors if MAP < 65

Steroids

Source control

Glycemic control

Stress-dose & VTE

Lung-protective vent

When to re-image / re-culture

Where IV orders go wrong

Ordering a bolus without a rate

Co-infusing LR with ceftriaxone

Peripheral KCl > 10 mEq/hr

Rapid Na correction in chronic hyponatremia

D5W resuscitation

Forgetting compatibility on a single line

Heparin without baseline labs

Open-ended vasopressor orders

Septic shock resuscitation, written two ways