IV therapy for POTS

The following criteria may help determine whether IV fluid administration should be considered for POTS:

Unstable advanced dehydration that cannot be controlled by oral drinking;
Continuous low blood volume that progresses and cannot be controlled by oral drinking;
Frequently feeling unwell and often fainting, forcing the patient to lie down almost continuously (severe POTS symptoms);
Severe deconditioning;
Malnutrition due to other conditions such as gastroparesis or other gastrointestinal disorders involving tube feeding or artificial feeding;
Other reasons why the necessary fluids and salts cannot be taken orally with any other option.

Available options regarding the regularity of intravenous fluid administration:
The doctor determines the frequency of administration once he/she is willing to do or try this and also the duration.

There are few scientific articles available that support the positive effect of intravenous fluid administration in POTS patients and are mainly based on the positivity in POTS patients themselves.

The possible frequency of administration may vary and depends on the severity of the patient's complaints and his/her personal overall medical file (possibly with multiple conditions).

In case of severe symptoms such as advanced dehydration, very low blood pressure, chest pain and/or certain concerns about your health condition, it is advisable to go to the emergency room or contact a doctor as soon as possible!
A single administration of 1 liter of NaCl in an emergency room or hospital can relieve the acute symptoms of POTS in a short period of time.

The doctor may decide to admit the POTS patient to the hospital for a certain period of time to administer additional fluid intravenously until the complaints have stabilized and the patient has significantly improved symptomatically.

The doctor may opt to administer fluids in the hospital several times a week via a normal small IV that is then placed in the arm.
The patient is then given 1 liter of NaCl 0.9% with a lead-in time of a few hours.
This treatment can be paused when the patient is stable with dehydration/blood volume or shows symptomatic stability and has recovered sufficiently.
This therapy can be restarted if the patient deteriorates again and repeated.

The doctor may choose to provide infusion therapy of 1 to a maximum of 2 liters of fluid several times a week via home administration and calling in home nurses with close monitoring (also with regular consultations with the GP with blood samples).

Finally, the doctor may also choose to give the patient fluids of 1 to a maximum of 2 liters per day on a daily basis via home administration with the assistance of home nurses with close monitoring (also with regular consultations with the GP with blood samples).
This is an extremely rare method.

What intravenous administration options are there?

There are different types of venous access options:

PICC: a central line placed on the underside of the upper arm and fixed with a statlock. This is a minor operation involving day hospitalization under local anesthesia. This central line can be removed at any time by a doctor or nurse. This line can remain in place for 6-12 months.
PAC: port catheter under the collarbone, which is placed subcutaneously and can remain in place for up to 6-8 years. This is a surgical procedure involving day hospitalization under general anesthesia.
The port catheter is mainly placed in patients for chemotherapy treatment.
Hickmann: the same as a PICC line but under the collarbone.

The possible reasons why most doctors do not use intravenous fluid administration:

There is insufficient scientific literature available about POTS and the treatment method.
POTS syndrome cannot have life-threatening consequences.
POTS is NOT life-threatening provided there are NO underlying (heart) conditions!
Dehydration and low blood volume (caused by POTS) can lead to a shock condition and become life-threatening.
The risks of having a central line such as getting infections at the insertion point or sepsis (blood poisoning) and formation of blood clots.
The risks of the fluid administration itself, which must always be carefully treated by a nurse, for example air in the pipe that can subsequently enter the body, can also be life-threatening (embolism).
The doctor does not want to run the risk of being held liable for this if one of the above occurs in a condition that is still relatively unknown and does not fall under the regular condition for which the infusion therapy protocol is initiated.

Available scientific articles about POTS and IV therapy:

These articles contain one and the same statement:
The beneficial effects of IV therapy have not been scientifically proven and are based solely on the positive experiences of POTS patients, stated percentage in one study.
Intravenous fluid administration is not included in the literature as a possible treatment method.

If nonpharmacologic approaches are not completely effective, pharmacologic therapies may be targeted at specific problems. Patients who are known to or are strongly suspected of having hypovolemia should drink at least 2–3 L of water per day, and dietary salt intake should be increased to approximately 10–12 g/day, if tolerated, using salt tablets, if necessary.

Fludrocortisone might be useful for boosting sodium retention and expanding the plasma volume, although these pharmacody- namic effects might last only 1–2 days, and its effectiveness has not been tested in randomized clinical trials. Midodrine is metabolized to a peripheral alpha-1 agonist that constricts veins and arteries and might be useful for increasing venous return.

Midodrine significantly reduces orthostatic tachycardia but to a lesser degree than intravenous saline. Midodrine has a rapid onset with only brief effects and should be administered 3 times daily. The drug should only be administered during daytime hours as it can cause supine hypertension.
A related strategy is to augment blood volume with intravenous saline. Expert centers report anecdotally that 1 L of normal saline infused over 1 hour decreases orthostatic tachycardia and improves symptoms for several hours to 2 days. Although it has not yet been assessed in a clinical trial, this approach is recommended as rescue therapy for patients who are clinically decompensated and whose symptoms have worsened significantly.
This approach could also prevent hospitalizations.
Long-term infusions of intra- venous saline are not recommended for routine care, because they usually require the insertion of a chronic central venous catheter, with its attendant complications.

Source: Sheldon et al HRS Expert Consensus Document on POT/IST/VVS

Study about intravenous saline infusions with patients (+ schedule):
http://standinguptopots.org/resources/iv-saline