Iatrogenic Water Intoxication After Intravenous Infusion of Sterile Water: A Rare and Preventable Case

Elective intravenous infusion therapies are increasingly offered in outpatient settings, often without adequate physician oversight or protocols for safety. We describe a case of accidental iatrogenic injury following an intravenous infusion at a medical spa. An elderly woman with a solitary kidney presented to the ED with chest tightness, acute shortness of breath, and headache shortly after receiving an intravenous vitamin infusion in a liter of sterile water, followed by half a liter of normal saline. She rapidly deteriorated, developing flash pulmonary edema and pulseless electrical activity arrest. Following resuscitation, she developed severe metabolic acidosis, hemoconcentration, and progressive anuric renal failure necessitating dialysis. Her hospital course was further complicated by ischemic colitis and perforation, requiring colectomy and ostomy creation. Contributing factors in the mechanism of injury included suspected hemolysis, high-dose vitamin C infusion, and diminished renal reserve. This case underscores the catastrophic impact of inappropriate intravenous fluid administration and highlights the urgent need for increased regulatory oversight in non-hospital settings.