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Osmolarity & pH in Solution
พว. วมลวลย วโรฬาร, RN, MSN คณะพยาบาลสาสตร ม. รงสต
ประธานชมรมเครอขายพยาบาลผใหสารน าแหงประเทศไทย
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Body Fluid
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Fluid in Body
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Plasma (blood) pH Osmolarity
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Human blood
• osmolarity 290 mOsm/L
• ( 285-310 mOsm/L) • pH 7.35-7.45
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Osmolarity is defined as the number of milliosmoles per liter of solution
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osmolarity
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Osmolarity & Tonicity
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Tonicity Crystalloid solution มโมเลกลเลก ซมเขาออกcell ได isotonic solution hypotonic solution hypertonic solution Colloid solution มโมเลกลใหญซมเขาออกcell ไมได
albumin
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pH pH (positive potential of the hydrogen ion) In chemistry pH is a measure of the acidity or basicity
of an aqueous solution ranges from 0 to 14
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คาสมดล pH ของเลอด: (blood gas)
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ตวอยาง คา pH
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solution (drugs,cytotoxic drugs, TPN, PPN) into blood circulation effect to blood vessel wall : phlebitis extravasation
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Solution irritation blood vessel wall: Phlebitis
osmolarity & pH
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Solutions in-through blood vessel via catheters
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ความแตกตาง ผนงเสนเลอดแดง และด า
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Line of IV: peripheral, midline, central
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Device Selection
PIV 1-3 days 2-3 cm
Midline 1-29 days 8-20 cm
Central line > 30 days 45 cm
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acidity
increases the phlebitis potential irritates venous endothelial cells over a longer
distance from the catheter tip
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What pH damages cells pH 2.3 and 11 have been shown to kill cell on contact pH moderates, the cell survive for a long time period Cell culture at pH 4 survives for 10 minutes same for pH 9 pH 5 to 8 safer
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INS Standard To prevent or reduce vascular complications,
INS standards recommend that Infusions with a pH outside the range of 5 to 9 an osmolarity greater than 600 be administered through an access device that
delivers the infusate into a blood vessel with a high rate of flow
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Why concern phlebitis
Patients pain risk to sepsis comfortable satisfaction
Nurses independent role prevent 100%
Hospital cost quality of care
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Phlebitis in vivo Animal data isolates traumatic effect of pH and
osmolarity 6 hr infusions through peripheral vessels pH 4.5 = 100% severe phlebitis changes pH 5.9 = 50% mild to moderate phlebitis pH 6.3 = 20% mild damage pH 6.5 = No significant damage
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Phlebitis in vivo Animal data isolates traumatic effect of pH
and osmolality Tolerance osmolarity of peripheral vessels in
animals 820 mOsm for 8 hr 690 mOsm for 12 hr 550 mOsm for 24 hr
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Phlebitis in humans The most cited human study of osmolarity induced
phlebitis found: the lowest risk of phlebitis occurred with solution under
450 mOsm/L moderate risk at 450-600 mOsm/L highest risk over 600 mOsm/L
Helped establish 600 mOsm/L as the outer limit of peripheral vein tolerance
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Phlebitis in humans
The INS pH range of 5-9 for peripheral veins Others factors blood flow infusion rate patient variability
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Phlebitis : was universal
Low risk less than 10% Dextrose less than 5% Protein Osmolarity <500 Medication pH 5-9 Not vesicant or caustic
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Phlebitis
Osmolarity : Low risk =< 450 mOsm/L Moderate risk = 450-600 mOsm/L High risk = > 600 mOsm/L
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PH in living systems compartment PH gastric acid 1 human skin 5.5 urine 6 pure H2O at 37OC 6.5 CSF 7.5 blood 7.35-7.45 pancreas secretions 8.1
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Drug know to have extreme pH pH
Amikacin 3.5 - 5.5 Ampicillin 8.0 – 10.0 Bactrim 10.0 Dopamine 2.5 – 4.5 Gentamycin 3.5 – 5.5 Morphine 2.5 – 6.0 Vancomycin 2.5 – 4.5
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Drug know to have extreme pH pH
Acyclovia 10.5 - 11.6 Cefotaxine 5.0 – 7.5 Ceftriaxone 6.7 Clindamycin 5.5 – 7.0 Levofloxacin 3.8 – 5.8 Meropenem 7.3 – 5.8 Metronidazole 4.5 – 7.0
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Osmolarity Calcium chloride
Calcium gluconate
Magnesium sulfate
Potassium chloride
Sodium bicarbonate
1 gm/10 ml = 2053 mOsm/L
1 gm/10 ml = 697 mOsm/L
0.5 gm/1 ml = 4057 mOsm/L
149 mg/1 ml = 4000 mOsm/L
1 meq/1 ml = 2000 mOsm/L
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Osmolarity of various sugar
Type Sucrose Glucose Sorbital dextrin
mOsm 345 637 643 70
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pH & Osmolarity
Solution / L pH mOsm/L D5W 4.3 - 4.5 250 – 253 D10W 4.3 – 4.5 505 D20W 4.0 – 4.6 1010 D50W 4.0 – 4.2 2520-2526
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pH & Osmolarity Solution /L pH mOsm/L D5LR 4.7 – 5.0 525 – 530 LR 6.2 – 6.5 273 – 275 0.9NS 5.0 – 5.6 308 – 310 D5 .9NS 4.0 – 4.4 560 – 561 3%NaCl 5 1030 Sterile water 4.5 – 7.0 0
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pH & Osmolarity
Solution /L pH mOsm/L 10%manital 5.7 549 15%manital 5.7 823 20%manital 5.7 1098
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pH & Osmolarity Solution /L pH mOsm/L 5%D/N/2 3.2-6.5 406 5% D/N/3 3.2-6.5 355 5% D/N/5 3.2-6.5 314 0.45% NSS 4.5-7 157 5%D/NSS 3.2-6.5 560 10%D/NSS 3.2-6.5 813
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PPN Peripheral line maximum glucose < 12-12.5 % amino acids < 2% osmolarity < 900 mOsm/L
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Safety for Solution Administration
No complications
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complications Local Complications
Bruising Hematoma Catheter Occlusion Cellulitis Thrombosis Infiltration extravasation Phlebitis Cellulitis
Systemic Complications Embolism
Air embolism
Fluid overload and pulmonary edema
Systemic infection
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Local Complications
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Bruising
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Hematomas
เปนภาวะทมเลอดรวออกจากหลอดเลอดไปยงเนอเยอบรเวณรอบ ๆ
สาเหต ปลายเขมทใชมความยาวมาก ท าให
ระคายเคองหลอดเลอดเสยหาย
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Hematomas A hematoma forms under the skin adjacent to the
puncture site - release the tourniquet immediately and withdraw the needle. Apply firm pressure.
Hematoma formation is a problem in older patients.
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Catheter Occlusion
การเกด “ลมเลอด” หรอภาวะตกตะกอนจากการผสมกนของยาบางชนดทใหในเวลาเดยวกน ทปลายสายสวนหลอดเลอด
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Catheter Occlusion
การแกไข ดงสายสวนใหสารน าทอดตนออก ในกรณทเปน Central line อาจตองใชยาละลายลมเลอด เพอใหใชไดอก
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Catheter Occlusion
การปองกน ถามการใหสารน าแบบเปนระยะ ควรกระตนใหมการ flush สายสวนใหสารน า อยางมประสทธภาพ ดแลใหสารน าไหลอยางตอเนอง อาจใชอปกรณชวย เชน infusion pump มคมอในการบรหารใหสารน า/สารละลาย/ยา เกยวกบ (drug incompatibility)
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Thrombosis occurs when a blood clot blocks one or more of
veins, typically in legs. Rarely, in arms or neck. The affected vein may be near the surface of
skin, or deep, causing deep vein thrombosis (DVT). Thrombophlebitis can be caused by trauma, surgery or prolonged inactivity. Superficial thrombophlebitis may occur in people with varicose veins.
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Thrombosis
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Treatment Low molecular weight heparin(LMWH)
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Cellulitis: Aseptic Technique
เปนการอกเสบของผวหนงและเนอเยอชน subcutaneous tissue เฉพาะท ณ ต าแหนงทใหสารละลาย
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Infiltration
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Extravasation
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Infiltration & Extravasation อาการ สารน าไหลชาลง หรอหยด โดยไมมการหกพบ งอ หรอกดทบ บรเวณทแทงเขมจะมอาการบวม และปวด ถาสารนามตวทระคายเคองตอเนอเยอ จะท าใหเนอเยอตายได
การแกไข หยดใหสารน าทนท เปลยนต าแหนงแทงใหม ถาสารน าไมมตวยาทระคายเคอง ประคบรอนเพอใหสารน าซมเขาสระบบ
ไหลเวยนเรวขน และยบบวม ถาสารน ามตวยาทระคายเคอง รายงานแพทย เพอพจารณาให anti-dose
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Infiltration & Extravasation การปองกน เลอกขนาดของเขม/ชดการใหสารน าทเหมาะกบขนาดของหลอดเลอดและชนด
ของสารน า หลกเลยงการแทงเขมบรเวณทมการหก พบ งอ หรอมการเคลอนไหวมาก มการยดตรงจดใหสารน าอยางเหมาะสม มความรเกยวกบสารนาหรอยาทใหอยางถกตอง ทงในสวนการผสม การบรหาร
ยา ระยะเวลา ผลขางเคยง มความระมดระวงในการประเมนสภาพผปวย (รางกาย/ผวหนง)
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Phlebitis defined as an inflammation of the vein(wall of blood vessel) Studies estimate that anywhere from 20-80 percent.
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Phlebitis การอกเสบของหลอดเลอดด า
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Phlebitis: Dopamine
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Phlebitis scale
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Why concern phlebitis? Clinical indicator Patients
pain risk to sepsis comfortable satisfaction
Nurses independent role prevent 100%
Hospital cost quality of care
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Systemic Complications
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Embolism
Air embolism Pulmonary embolism
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air embolism
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Pulmonary embolism
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Pulmonary edema
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Systemic infection: CABSI=catheter associate blood steam infection
Clinical indicator Cause of death
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peripheral line preparation: scrub
dressing; sterile , transparent, (CDC: Category 1A)
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Central line; CHG: Chlorhexidine Gluconate IV Securement Dressing
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CDC; Needleless Intravascular Catheter Systems
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Needleless Intravascular Catheter Hubs; scrub the hub 15 sec (add on devices; Systems)
needle-less system (needle-Free Connector)
needle system
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Scrub the hub before injection : 15 sec alcohol swab, site-scrub
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Scrub the Hub! Catheter Needle-less Port Decontamination
applied commercially available fluoresceine-impregnated powder (Brevis Corporation, Salt Lake City, UT)
to CVC hubs and subsequently scrubbed the hubs with 70% isopropyl alcohol pads for
0 (control), 5, 10, and 15 s. Using ultraviolet light, we exposed residual fluorescent powder on the CVC hub.
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Risk
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Risk
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Risk for infection
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Risk
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WHO & CDC
Hand hygiene: the chief culprit (ผทาความผด, ผกอเหต) ◦ No factor is more important in prevent HAI than hand hygiene
- Do you wash your hands follow guideline? - Why?
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WHO; how to hand-wash, hand-rub 2009
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World Health Organization (WHO)
hand washing: 5 Moments for Hand Hygiene
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CDC
Global Hand-washing Day, October 15th, 2013 (since 2008)
Global Hand washing Day was originally created for children and schools, but can be celebrated by anyone promoting hand washing with soap. Each year, over 200 million people are involved in celebrations in over 100 countries around the world.
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Incidence; Severity ความรนแรง ระดบตน A เหตการณซงมโอกาสทจะกอใหเกดความคลาดเคลอน B เกดความคลาดเคลอนขน แตยงไมถงผปวย C เกดความคลาดเคลอนกบผปวย แตไมท าใหผปวยไดรบอนตราย ระดบกลาง D เกดความคลาดเคลอนกบผปวย สงผลใหตองมการเฝาระวงเพอให มนใจวาไมเกดอนตรายตอผปวย E เกดความคลาดเคลอนกบผปวย สงผลใหเกดอนตรายชวคราวและตองมการ บ าบดรกษา F เกดความคลาดเคลอนกบผปวย สงผลใหเกดอนตรายชวคราว และตองนอน โรงพยาบาลหรออยโรงพยาบาลนานขน
Near miss
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Severity
ระดบรนแรง G เกดความคลาดเคลอนกบผปวย สงผลใหเกดอนตรายถาวรแกผปวย H เกดความคลาดเคลอนกบผปวย สงผลใหตองท าการชวยชวต I เกดความคลาดเคลอนกบผปวยซงอาจเปนสาเหตของการเสยชวต
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สรป
เสนเลอดเปรยบเสมอนเสนชวตของผปวย เสนเลอดตดตอกระจายทวรางกาย เปดเสนเลอดเปรยบดงเปดประตเชอโรคสรางกาย
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Patients on IV
Outcomes: no complications
- pH, osmolarity
- compatibility
- type of drugs
- IV Nurses
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Thanks You