May 1, 2014

Intravenous Fluids and Alcohol Intoxication

Frequently, patients with acute alcohol intoxication are brought to the emergency department (ED) for evaluation and treatment.  Although practice patterns vary, it is not an uncommon practice to give normal saline to these patients in the hopes that the saline will cause a dilution effect on the level of alcohol helping patients sober faster and therefore having a shorter length of stay in the ED.  At the end of 2013 a study was published evaluating intravenous fluids and alcohol intoxication.

How often do physicians use intravenous fluids in alcohol intoxication? [1] [2]

  • 73 – 87% of US emergency medicine physicians use intravenous fluids to treat alcohol intoxication

Are there any studies looking at the benefit of intravenous fluids and alcohol intoxication? [2][3]

Table Modified from Best BETs

What is the most recent study evaluating the benefit of intravenous fluids and alcohol intoxication? [4]

What they did:

  • Single-blind, randomized controlled trial of 144 uncomplicated acutely intoxicated ED patients aged 18 – 50 years of age
  • Carried out in 2 EDs in Queensland, Australia
  • Single bolus of 20mL/kg intravenous 0.9% saline + observation vs observation alone
  • Uncomplicated patients = no injuries, overdose, or psychiatric conditions requiring ongoing treatment

Primary Outcomes:

  • ED Length of Stay (EDLOS) = Triage time to actual discharge time

Secondary Outcomes:

  • Treatment Time = Time from being assessed by a treating doctor or nurse, until the time patient deemed ready for discharge
  • Breath Alcohol Levels
  • Intoxication Symptom Score
  • Level of Intoxication
  • Associated Healthcare Costs

Results:

  • Baseline blood alcohol content (BAC) in two groups: 0.2% vs 0.19%
  • Baseline Intoxication Symptoms Scores: 22.0 vs 22.3
  • EDLOS: 287 vs 274 minutes (p value = 0.89)
  • Treatment Time: 244 vs 232 minutes (p value = 0.94)
  • Absolute Difference in Breath Alcohol Level at 2 Hours: -0.036 vs -0.013 (p value = 0.16)
  • Intoxication Score and Level of Intoxication were not significantly different between the two groups
  • Cost Savings $156.44 in the intravenous fluids group and $124.52 in the observation group resulting in a net $31.92 saved per patient with no intravenous fluids

Limitations:

  • No placebo in the observation group
  • Staff and patients not blinded
  • When ED volume was high, many intoxicated patients were not enrolled into study (i.e. 82 patients)
  • Not powered for secondary outcomes (i.e. Although the absolute breath alcohol level was decreased at 2 hours, because of the small numbers enrolled in this study…not statistically significant)

Conclusion: Intravenous normal saline plus observation does not decrease ED length of stay compared with observation alone in uncomplicated, alcohol intoxicated patients

Alcohol Intoxication

Take Home Message

There is no evidence that intravenous fluids will expedite sobriety in patients with acute alcohol intoxication

References:

  1. Hindmarch PN et al. Emergency Physicians’ Opinions on the Use of Intravenous fluids to Treat Patients Intoxicated with Ethanol (Alcohol): Attitudes of Emergency Medicine Physicians in the North East of England Toward the use of Intravenous fluids to Treat Individuals Intoxicated with Ethanol (Alcohol) Attending the emergency Department Compared with the Scientific Evidence. Our J Emerg Med 2012. PMID: 22134421
  2. Li J et al. Intravenous Saline has no Effect on Blood Ethanol Clearance. J Emerg Med 1999. PMID: 9950378
  3. Gershman H et al. Rate of Clearance of Ethanol from the Blood of Intoxicated patients in the emergency Department. J Emerg Med 1991. PMID: 1940231
  4. Perez SR et al. Intravenous 0.9% Sodium Chloride Therapy Does not Reduce Length of Stay of Alcohol-Intoxicated patients in the Emergency Department: A Randomized Controlled Trial. Emerg Med Australas 2013. PMID: 24308613
  5. Toups VJ et al. Blood Ethanol Clearance Rates. J Emerg Med 1992. PMID: 1430989

For more thoughts on intravenous fluids and alcohol intoxication also checkout:

Cite this article as: Salim Rezaie, "Intravenous Fluids and Alcohol Intoxication", REBEL EM blog, May 1, 2014. Available at: https://rebelem.com/intravenous-fluids-alcohol-intoxication/.
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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of R.E.B.E.L. EM
14 Comments
  • Anand Senthi
    Posted at 03:02h, 02 May Reply

    As you point out, this study appears underpowered as a real finding of reduced BAL that was present might have been significant with larger numbers. As a result this study I wouldn’t have thought would be sufficient to change practice

    • Salim Rezaie
      Posted at 06:44h, 02 May Reply

      Hello Anand,
      TY for reading and your question. Although there was a trend to have a decrease in BAL, there was no difference in ED LOS or treatment time regardless. ED LOS was powered and statistically significant. So if there is no decrease in ED LOS and you spend money and time giving IVF, why would you continue that practice? Not to mention the chances of bacteremia and thrombophlebitis from IV placement. So you have a slight decrease in BAL, but no difference in outcomes, would need to see a better study to show me statistical significance before I would start giving IVF for that endpoint. Hope this helps.

      Salim

  • Gregory Roth
    Posted at 21:18h, 02 May Reply

    EtOH is metabolized as Zero Order kinetics. IVF should not affect the rate.

    • Salim Rezaie
      Posted at 23:05h, 02 May Reply

      Hello Gregory,
      You are absolutely right, however I still see people giving IVF. Invasive (iv), costly (Normal Saline), and no benefit (No decrease in ED LOS). Especially with national shortages of IVF…why do we keep doing this? TY for reading and appreciate your comment.

      Salim

  • Moiz Khan
    Posted at 00:32h, 03 May Reply

    I think part of the story is a knee jerk reaction to start NS as the first line therapy for every one who visits the ER. This gives us the confidence that we are doing something.
    But I agree with you. After reading the above I will think twice before giving anyone fluids when they come intoxicated in my ER. Thank you for the update!

    • Salim Rezaie
      Posted at 00:36h, 03 May Reply

      Hello Moiz,
      TY for reading. Glad you found it useful. More to come.

      Salim

  • Drunk Patients and Pediatric Sepsis: The FOAMed Report | Medical Device Articles
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  • Justin Hensley
    Posted at 14:29h, 04 May Reply

    At best, 1% of alcohol is excreted in urine. Adding IVF does not increase this, but it might make them have less of a hangover the next morning.
    Sal is lucky to work in San Antonio, one of the world leaders in the concept of “sobering centers”. Maybe with enough effort we can convince the police/EMS that intoxication isn’t always an emergency, and while these people need to be supervised, it doesn’t need to be at the most expensive place in the city.

  • Jennifer C. Trybom
    Posted at 20:13h, 05 May Reply

    I understand wanting to save money is a definitive goal in healthcare, particularly around ER medicine, and that some patients with acute alcohol intoxication may be simple. However, a good percentage will be people who are suffering from far more complex health issues other than just the identified and obvious. Anyone landing in an ER due to this diagnosis is obviously struggling in some way in their life; from a young teen who’s behavior is a warning sign portending further future suffering, to an older person who’s initial diagnosis hides behind outright, and dangerous, alcohol dependence, with all of its potential and often probable unfortunate health and social outcomes. This later population requires definitive ER interventions and caution, especially when the individual is unconscious and blood alcohol level substantial.

    • Salim Rezaie
      Posted at 20:22h, 05 May Reply

      Jennifer,
      Great point. As you stated in your comment, these are patients that are: uncomplicated, not agitated, and no signs of injury/trauma I am referring to. By no means is this the majority of intoxicated patients, but still there is cost saving here with no worse outcomes. That being said, each patient should be handled in a case by case manner. I always have our social workers and case managers talk to these patients about referrals for outpatient detox, AA, etc….

      TY for reading, and truly appreciate your comment…very important to not forget the social factors leading to the patients presentation to the ER.

      Salim

  • JC: IV Fluids for alcohol intoxication. St.Emlyn's - St.Emlyn's
    Posted at 12:56h, 19 September Reply

    […] 10.1111/1742-6723.12151 [Source] 3. Intravenous Fluids and Alcohol Intoxication. rebelblog.wpengine.com. http://rebelblog.wpengine.com/intravenous-fluids-alcohol-intoxication/. Published May 2014. Accessed September 19, […]

  • Daniel Romaine
    Posted at 19:03h, 26 March Reply

    Just wondering if any of the studies include the effect of nil IV fluids in intoxicated patients in relation to dehydration due to ADH blocking? If we give NS or Hartman’s it is more to treat relating dehydration not so much the dilution of alcohol (which is not effective as the study shows). Interested to know your thoughts on this.

    • Salim Rezaie
      Posted at 01:44h, 27 March Reply

      Hello Daniel,
      IV hydration does only that…which is rehydrate the patient, but whats to say they can’t orally rehydrate themselves. We have to be careful when putting IVs in people as this takes time, and also has potential complications (i.e. infiltration, potential infection, and superficial thrombophlebitis just to name a few).

      Salim

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