Intravenous Therapy

1
Intravenous Therapy
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4
2
Thirty years ago

• Rampart, Squad 51.
• We have a 20 year old male motorcycle rider
  involved in a motor vehicle collision complaining
  of neck, back and leg pain.
• He presents with compound fractures to both
  femurs and has significant blood loss.
• We are requesting an order for two large bore
  IVs and Ringers Lactate.

3
Objectives

• Identify the reasons IV therapy is performed in
  the prehospital setting
• Identify the fluids commonly administered
• State the basis of fluid and electrolyte balance
• Identify factors affecting water loss
• Explain the recommended uses of IV solutions
• Identify common complications and reactions
• Calculate a flow rate
• Demonstrate proper skin cleansing and aseptic
  venipuncture technique
• Demonstrate proper IV cannulation technique

4
Why do we cannulate?

• Fluid administration
• Medication administration
• To maintain life (electrolytes, blood)
• Do we do them to be EHSNS protocol compliant?

5
IV fluids

• Normal saline (0.9 NS)
• Lactated Ringers (LR)
• Also known as Hartmans solution or RL
• D5W
• ½ NS
• D5 ½ NS
• D5RL (D5LR)

6
Isotonic Solutions

• Characteristics
• Same tonicity as plasma
• Osmotic pressure is the same as the inside of the
  cell
• Fluid never leaves or enters the cell
• Approximate osmolarity is 240 340 mOsm/L
• Will increase circulating volume, which may lead
  to fluid volume excess or overload.

• Solutions
• 2.5 dextrose/0.45 NaCl
• 0.9 NaCl
• Lactated Ringers
• 2.5 dextrose in ½ lactated ringers
• 6 dextan and 0.9 NaCl
• 10 dextran and 0.9 NaCl

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Normal Saline

• Most commonly administered IV fluid prehospitally
• IV fluid of choice for EHSNS protocols
• Why?

8
Lactated Ringers

• Composed of multiple electrolytes in saline
• Has fallen out of favor as one of main IV fluids
  for treatment of traumatic hypovolemia in past
  decade
• Why?

9
Hypotonic Solutions

• Characteristics
• May cause blood cells to swell and burst
• May cause changes or damage endothelial cells
• Exert less osmotic pressure than the fluid in the
  extracellular compartment
• Fluid is drawn into the cells
• Approximate osmolarity lt 240 mOsm/l

• Solutions
• 0.45 NaCl
• 10 dextran and 5 dextrose (slightly hypotonic)

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Hypertonic Solutions

• Characteristics
• May cause blood cells to shrink
• May cause dame/changes to endothelial cells
• Exert more osmotic pressure then the
  extracellular fluid
• Fluid is drawn from the cell into the vascular
  space
• Approximate osmolarity gt 340 mOsm/l

• Solutions
• 5 dextrose/0.2 NaCl
• 5 dextrose/0.9 NaCl
• D5W
• D10W
• D50W
• 5 NaHCO3
• 10, 15 and 20 Mannitol
• 6 dextran and 0.9 NaCl

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Administration Sets

• The calibration of the administration set must be
  known in order to calculate the flow of the IV
  fluids correctly.
• Macrodrip sets
• 10, 15 or 20 gtts/ml
• Microdrip (minidrip)
• 60 gtts/ml

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Where do we cannulate?

• Hand
• Forearm
• Neck
• Foot

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Equipment Required

• Solution
• Administration set
• IV cannula
• Tourniquet
• Alcohol swab
• Gloves
• Sharps bin
• Op site and gauze
• Tape
• If performing a Lock
• Lock, syringe and saline

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Catheter specifics

• Color Size Int Dia/Length Max Flow
• Grey 16 G 1.4 mm/45 mm 180 mls/min
• Green 18 G 1.0 mm/45 mm 80 mls/min
• Pink 20 G 0.8 mm/32 mm 54 mls/min
• Blue 22 G 0.6 mm/25 mm 31 mls/min
• The length and diameter will affect the amount of
  fluid able to be infused through the catheter
• Larger diameter and shorter length gives more
  fluid
• Small diameter and long length gives less fluid

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Types of catheters

• Jelco
• Cathelon
• Insyte

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Types of catheters

• Protective
• Protective Plus

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Administration Sets

• 10 gtts/ml
• 15 gtts/ml
• 60 gtts/ml
• Blood sets

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Vein Selection

• Based on
• Condition
• Palpate to confirm type of vessel
• Should be soft and spongy
• Straight with no turns or bumps
• Location
• Is the pt right or left handed
• Is the extremity injured
• Avoid joints (stabilization)
• Does the pt have a shunt (fistula)
• Purpose
• Fluid replacement, Medication route, Safety line
  (lock)
• Dictates flow rate and type of fluid to be
  infused
• Try to use large veins for large quantities of
  fluid
• Duration
• What type of patient (trauma, cardiac or
  outpatient)
• Patient comfort over long period of time
• Prolonged therapy may require multiple punctures
• For long durations use distal veins first

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Fluid Replacement

• Blood
• Replaced at a ratio of 31 of IV fluid to blood
  being replaced
• Minimum daily requirements
• 1st 10 kg 100 ml/hr
• 2nd 10 kg 50 ml/hr
• 3rd 10 kg 20 ml/hr
• 4th 10 kg 10 ml/hr
• 5th 10 kg 10 ml/hr
• Example 50 kg patient
• 100 ml/hr 50 ml/hr 20 ml/hr 10 ml/hr 10
  ml/hr 190 ml/hr

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Contraindications

• Distal to a fracture site in a limb
• Through damaged or abraded skin
• Burns may be an exception if there is no other
  accessible site
• In an arm affected by a radical mastectomy,
  edema, blood clot or infection
• In an arm with a fistula for dialysis or a
  peripherally inserted control catheter (PICC Line)

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Procedure

• Obtain consent and explain rationale for IV
  therapy
• Assess that the pt meets the criteria for the
  procedure
• Ensure that there are no contraindications for
  the procedure
• Observe universal precautions for body substance
  exposures
• Prepare all necessary equipment
• Position the patient
• Apply a tourniquet 3 5 inches above the
  selected site
• Patient may make a fist to assist in engorging
  the vein
• Select the most appropriate venipuncture site
• Condition
• Location
• Purpose
• Duration
• Prepare the pts arm using alcohol swab

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Procedure

• Insert needle through skin
• Should be at an 30 angle
• Lower angle (15)and enter vein
• Observe flashback
• Enter vein a little bit more
• Enter catheter into vein
• Release tourniquet
• Withdraw needle and discard in sharps container,
  tamponade the vein to avoid blood spill
• Attach iv tubing and open flow valve observing
  for infiltration
• Cover with Op site or other sterile dressing,
  tape in place

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IV Access
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Complications

• Local complications
• Hematomas
• Infiltration
• Necrosis
• Thrombophlebitis
• Systemic complications
• Pulmonary edema
• Speed shock
• Pyrogenic reaction
• Pulmonary embolism
• blood
• Air
• Catheter shear

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Local - Hematomas

• Causes
• Symptoms
• Preventative actions

• Punctured vein
• Bruising
• Tenderness
• Swelling
• Proper techniques

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Local - Infiltration

• Causes
• Symptoms
• Preventative actions

• Poor insertion techniques
• Improper taping
• Over active patient
• IV slows or stops
• Swelling or hardness
• Feeling of coldness
• Leaking at the site
• Armboards, proper taping
• Routine checks of IV flow and site

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Local - Necrosis

• Irritation of tissues from infiltrated drug or
  fluid
• Swelling, tenderness
• Inflammation or bruising
• Routine checks
• Report any changes

• Causes
• Symptoms
• Preventative actions

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Local - Thrombophlebitis

• Causes
• Symptoms
• Preventative actions

• Trauma to endothelium from chemical means
• Pain, redness, swelling along infected vein
• Generalized symptoms such as fever, malaise,
  rapid pulse
• Avoid insertion over joint
• Select veins with adequate blood flow for
  infusions of hypertonic solutions

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Systemic Pulmonary Edema

• Causes
• Symptoms
• Preventative actions

• Circulatory overload from too rapid infusion when
  patient has impaired renal or cardiac function
• JVD, ?BP, ?Resps, dyspnea, agitation
• Watch rate
• Oxygen, sit pt upright
• Slow IV and contact OLMC

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Systemic Speed Shock

• Causes
• Symptoms
• Preventative actions

• IV running to rapidly
• Rapid injection of a drug
• ?BP, rapid pulse
• Labored resps, cyanosis
• Faint, ?LOC
• Use controlled volume infusion set
• Upon initiation, ensure free flowing prior to
  rate adjustment

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Systemic Pyrogenic Reaction

• Causes
• Symptoms
• Preventative actions

• Contaminated IV solutions
• Symptoms generally occur after IV begun
• ?temp, chills, headache, N/V, circulatory
  collapse
• Check IV fluids for cloudiness and particles
• Use fresh open IVs

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Systemic PE (Blood/Embolus)

• Causes
• Symptoms
• Preventative actions

• Unfiltered blood
• Partially dissolved drug
• Particulate matter in IV solution
• Dyspnea, cyanosis, pain, anxiety, tachycardia,
  tachypnea
• Infuse blood through filter
• Dissolve drugs completely
• Use good judgment when syringing IVs

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Systemic PE (Air)

• Causes
• Symptoms
• Preventative actions

• Failure to clear tubing of air
• Allowing air to enter the system
• Cyanosis, ?BP, weak, tachycardia, ?LOC,
  non-specific chest or ABD pain
• Dont let IV run dry
• Clear tubing properly
• Check syringe prior to injecting
• If occurs place pt on left side and contact OLMC

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Troubleshooting

• If blood begins to flow back in the IV tubing
• Check location of the bag to insure it is in a
  gravity flow location
• Insure all valves are open
• If continues, reassess site and assure arterial
  cannulation has not occurred
• If your IV does not run
• Start at the top, work your way back to the
  patient
• Is the bag empty?
• Check the IV set clamps to insure they are open
• Check tubing for kinks
• Check site for any problems
• Blood backing up
• Infiltration
• Do you need to flush the site
• Is your tourniquet still one!

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External Jugular (EJ) cannulation
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EJs

• Often used in severe cases of shock,
  unresponsiveness and cardiac arrest since they
  are HUGE and relatively easy to cannulate.
• Why are they not commonly used in those who are
  conscious ?
• Why are they not a good choice for patients of
  multi system trauma ?

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EJ cannulation procedure

• Place patient supine / slight reverse
  Trendelenburg
• Why ???
• Turn patients head slightly to opposite side
• Cleanse with antiseptic using universal
  precautions
• Create tourniquet effect with fingers by applying
  light pressure to the inferior aspects of the EJ
  being cannulated.

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Procedure

• Aim needle towards ipsilateral nipple
• Insert needle and enter vein
• Observe flashback
• Withdraw needle and attach IV tuning
• Cover site with sterile dressing

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EJ cannulation
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Calculating flow rates
Volume to be administered (ml)
X
Drip set (gtts/ml)
Drops/min (gtts/min)

Time to be infused (min)

• Drip sets Factor
• 10 gtt/ml (macro) 10 drops 1 ml 6
• 15 gtt/ml 15 drops 1 ml 4
• 20 gtt/ml 20 drops 1 ml 3
• 60 gtt/ml (micro) 60 drops 1 ml 1

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Calculations

• Your patient is to receive 1000 ml of normal
  saline (NS) over a 12 hour period using a
  microdrip (60 gtt/ml) administration set. The
  formula will now look like this

Volume to be administered (ml)
X
Drip set (gtts/ml)
Drops/min (gtts/min)

Time to be infused (min)
1000 ml
X
60 gtts/ml
Drops/min (gtts/min)

720 min
Drops/min (gtts/min)
83.333

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Now add medications

• A physician orders 2 mg/min of Lidocaine to your
  patient. She orders 2 g of lidocaine to be added
  to 500 ml NaCL. Using a 60 gtt/ml set, calculate
  the gtt/min.

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Calculation

Mass Volume
Dose
D H
X
V


X
500 ml
2.0 g 500 ml
2 mg/min 2000 mg


2000 mg 500 ml
1000 mgml/min 2000 mg


4 mg/ml
0.5 ml/min


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Calculation
Volume to be administered (ml)
X
Drip set (gtts/ml)
Drops/min (gtts/min)

Time to be infused (min)
0.5 ml
X
60 gtts/ml
Drops/min (gtts/min)

1 min
Drops/min (gtts/min)
30

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A Variation to the Same
Volume (ml)
X
Ordered (mg/min)
Drops/min (gtts/min)
X
Drip set (gtts/ml)

On Hand (mg)
500 ml
X
2 mg/min
Drops/min (gtts/min)

X
60 gtt/ml
200 mg
Drops/min (gtts/min)
30