howard griffiths, shs hazards of iv therapy n aim: to raise awareness of hazards n learning...

Howard Griffiths, SHS

Hazards of IV therapyHazards of IV therapy

Aim:To raise awareness of hazards

Learning outcomes: Recall the role of the nurse in IV therapy

List the main risk factors of IV therapy

List complications to the patient of IV therapy


Underpinning knowledge

Basic anatomy and physiology of the cardiovascular system

Principles of asepsis Pharmaceutical knowledge of

different fluids Drip factors and different giving

sets, their purpose Technical knowledge of

different pumps that may be used


Role of the nurse Identifying and verifying prescription Checking for contamination and faults The 5 R,s of drug administration Controlling the prescribed flow rate Monitoring and reporting patient’s

condition Ensuring that IV device remains patent Inspecting the insertion site, reporting any

abnormalities Maintaining records


Nursing interventions Good hand washing and universal

precautions Drug administration calculation Vital signs measurement during

therapy (BP, pulse, respiration, temperature)

Degree of consciousness of the patient Observe urinary output and maintain

fluid balance chart Report blood results of urea and

electrolytes to doctor Observe for local signs of infection at

the cannula site


Methods of administration

– Intermittent fluids – Continuous fluids– Parenteral nutrition– IV bolus medication– IV intermittent injection of

medication


Managing Risks

Infection control

Drug interactions

Correct use of syringe and infusion equipment

Correct checking procedures for drug administration


Therapeutic use of Intravenous fluids

To maintain hydration To correct fluid and

electrolyte balance To administer bolus IV

systemic medication, such as prescribed antibiotics

To maintain haemodynamic stability during surgery, and or maintain stability during pathological crisis, e.g shock


Factors to consider when administrating drugs

Does it require reconstitution storage stability expiry date drug action and side-effects what is it incompatible with physiological considerations, serum levels? is protective clothing required?


Drug interactions

inadequate mixing of drugs fluid may have an affect on the stability of the

drug

drug degradation through light (frusemide, nitroprusside, vitamin A and K)

inadequate mixing of drug additives specific gravity of the added drug may be different

from fluid used, resulting in layering


Patient related factors in drug administration

The 5 R’s allergies body mass vital signs informed consent clinical status do they understand the side-effects is the device patent?


IV administration sets Use aseptic technique when handling Latex bungs and injection ports, clean

with 70% alcohol, and allow to dry before administrating drugs

Clear fluids/ stored plasma/ drug infusion should have:– standard administration sets (5-15

micron filter, 20 drops per ml).– Burette or buretol (15 micron filter, 60

drops/ml)


Transfusions– blood administration sets (15 drops/ml) should

be used for blood and fresh frozen plasma (FFP)

– Albumin Solution, Hetastarch and Haemacell can be given through clear fluid sets, as they contain no cells

– Platelets and Cryoprecipitate is administered through a platelet set (15 drops/ ml)


Factors affecting flow rates Fluid composition, viscosity and concentration of fluid Height of fluid container will alter the hydrostatic pressure of

fluid Change in the position of the client’s access site Administration sets

– distortion of tubing may render the clamp ineffective

– diameter of the lumen

– inclusion of in line devices such as filters Vascular access

– condition and size of vein

– cannula gauge

– occlusion

– pressure


Infusion devices

Medical Device Agency has identified one of the most serious of medication errors involve the use of infusion pumps

One of the main areas where human error occurs is in drug calculation

The MDA has categorised infusion devices in terms of risk:


– Neonatal risk infusionrequires high accuracy and consistency of flow, used in neonatal intensive care and paediatric services

– High-risk infusion similar to above but not as accurate over the short term (within 1 hour). More suitable for older children

and adults.

– Low-risk infusion infusion of simple electrolytes, antibiotics and total parenteral nutrition. Devices will not need to have accurate or consistent output, only rudimentary alarm and safety systems

– Ambulatory infusioninfusion devices worn to allow normal activities

during infusion, often battery powered


Infusion device checklist

Uncontrolled flow– occur from gravity drips, volumetric and syringe

pumps

Selecting the right infusion pump for transfer– is it necessary to take all infusion devices, does

the pump meet the risk classification?, is the operator trained to use it

Changing the infusion during transit– avoid, calculate infusion requirements and

prepare so that the infusion will last the journey

Security and safety– ensure that all devices are fixed or clamped

secured


Flushing and maintaining patency

Ensures that the whole drug is given

Ensures that the device remains patent

0.9% NaCl is effective in maintaining patency in peripheral devices

Flushing should be undertaken after each dose or at least every 24 hours


Issues of infection control Transparent film dressings over catheter or cannula site

Change local dressings according to local protocols

Keep change of IV infusion bags, giving sets, disconnection or interruption to a minimum

Hand washing and asepsis should be maintained before manipulating the IV system

With minimal breaks in IV circuit, change administration sets every 72 hours.

With frequent breaks in IV circuit, change administration set every 24-48 hours. For blood products change after infusion.


Fluid and blood product administration

DO NOT ADD DRUGS TO:– blood products– mannitol– sodium bicarbonate– parenteral nutrition

Ensure individual drugs and solutions are given by the optimal route


Chemistry of body fluids

Electrolytes– it is common to measure

electrolytes in ECF, chiefly the plasma.

– The term ‘plasma’ and ‘serum’ are used interchangeably

– Na+ is the main cation in ECF and controls the volume of fluid in ECF

– K+ is the main concentration of ICF.


Intravenous fluids

Correcting and maintaining fluid and electrolyte balance– isotonic fluids are prescribed fluids that

do not alter the osmotic movement of water across cell membranes.

0.9% Sodium chloride is used to sustain extra cellular fluid volume by compensating for volume lost be – dehydration– urinary excretion of sodium– fluid drains following surgery


Hypertonic fluids are fluids that expand intravascular volume by moving endothelial and intracellar water into the intravascular space

These fluids contain a high concentration of particles when compared to plasma, has potential therefore to cause fluid overload.

These fluids also has the potential to irritate peripheral veins, administration should be slow


Hypotonic saline (0.45%) is used to replenish electrolytes. Complications can include over hydration, sodium overload and potassium defecit.

Hypotonic fluids drive fluid from the plasma into the interstitial space, and therefore are used to re-hydrate the cells


Potassium electrolyte infusion is used for patients with severe hypokaelaemia.

Conditions leading to hypokalaemia are- – vomiting, diarrhoea, use of potent diuretics,

malnutrition, some forms of renal diseases and metabolic acidosis

Careful infusion is required in order to avoid cardiac arrhythmias and death.


Peripheral site complications

Phlebitis– caused by mechanical rubbing of cannula, or

chemical irritation from fluid, or through contamination through poor hand washing by the nurse

Occlusion– caused by incorrect flushing, empty bags, kinking

of line, precipitation, poor cannula site

Infiltration– a none blistering drug leaks into the surrounding

tissue

Extravasation– blistering drug that leaks into surrounding tissue


Potential systemic complications of IV therapy

Circulatory overload Systemic infection Air embolism Allergic reaction


Types of central venous access

Peripherally inserted catheters (PICCs)- for patients requiring several weeks of IV access

Short term tunnelled catheters- days to several weeks of IV access

tunnelled cuffed catheters- for long term intermittent continuous or daily IV access

Implanted venous access- for long term, intermittent, continuous or daily IV access


Immediate Complications of central venous catheters

venous air embolism tamponade catheter embolus/rupture arterial puncture dysrhythmias pneumothorax


Delayed complications of central venous catheters

Infection of tunnel infection within catheter occlusion drug precipitation thrombosis air embolism anaphylaxis broken hub, broken clamp, split

catheter catheter pulled or fallen out


Safety issues in Critical Care Labelling of sets

– Functions of different sets must be clearly labelled– above will help prevent mal-administration of drugs

and avoid haemodynamic monitoring sets

Identify both proximal and distal end of a giving set Use uninterrupted tubing, free of junctions and access

ports Only use high pressure tubing for haemodynamic

measurements If stopcocks have to be used on administration sets,

clean with 70% alcohol beforehand


Blood products Whole blood transfusion Packed RBC Platelets- Fresh frozen plasma Cryoprecipitated antihemophilic

factor Granulocytes Serum albumin and plasma

protein fraction (PPF)


Therapeutic use of blood products

Whole blood transfusion – for massive blood loss in neonates

Packed RBC– for inadequate oxygen carrying capacity

Platelets– for treatment of thrombocytopenia, acute lukaemia,

and marrow aplasia, and to restore platelet count preoperatively inpatients with a count of <100,000/mm3 or less


Fresh frozen plasma– for expansion of plasma volume, treat post-op

haemorrhage or shock and correct coagulation factor deficiencies

Cryoprecipitated antihaemophilic factor– for haemophilia A, von Wilerbrand’s

disease, hypofibrinogenemia Granulocytes

– for severe gram negative infection or severe neutropenia unresponsive to routine forms of therapy in immunosuppressed patient. Also

indicated in severe granulocyte dysfunction. Serum albumin and plasma protein

fraction – in hypovolaemia and hypoproteinemia (burns)


Managing Clinical Risk Human error has been recognised as a

cause of transfusion fatality for several decades (BMJ 1953)

Errors can occur :

– time of blood sample collection (incorrect labelling, blood taken from the wrong patient)

– within the laboratory (use of incorrect sample or patient record; release of wrong unit from the store)

– practice settings (administration to the wrong patient)


Managing Clinical Risk There is no mandatory reporting

system in the U.K.

A voluntary system operates through Serious Hazard of Transfusion (SHOT) initiative

Anyone can report a blood transfusion error, adverse incident or error to SHOT


Good Practice required for blood transfusions All blood products should be correctly prescribed

by the doctor:– specify quantity and note any allergies– duration of the transfusion, special requirements of the blood or

blood product and precautions– reason for transfusion should be documented in the medical

notes

Other methods should be considered:– autologous blood transfusion– intra-operative blood salvage

No formal consent is required in the UK but information provided should cover:– reasons for transfusion– details of the benefit and risks of such treatment


Good Practice required for blood transfusions

Follow local policy when collecting blood:– compatability reports filed in the patient’s notes– signatures of authorized staff collecting the blood

– time of collection– storage of blood should be in a refrigerator at -2.6c

– blood transfusion should commence within 30 minutes of its removal

– blood transfusion should be completed within 5 hours (proliferation of bacteria in blood components)


Good Practice required for blood transfusions BCSH 1999 guidelines state that a single

practitioner (midwife, nurse or doctor) can verify details at the bedside, in order to reduce risk of errors.

Pre-transfusion checks should include:– expiry date– leakage– unusual colour (brown or red plasma indicates haemolysis)– patients details, and ABO and Rhesus group– unique donation number

The blood unit details should be checked against the doctor’s prescription, compatibility report and identification number


Good Practice required for blood transfusions Patients should have an I.D. band containing accurate

information The bag should be gently squeezed for leaks, and gently

rocked to mix the contents

A standard 19 gauge IV cannula and a blood giving set should be set up which has filter to prevent small clots entering the blood stream.

Administration of platelets should be through a platelet giving set, not a blood transfusion set (special paediatric sets are for infants).

Giving sets should be primed only with N/Saline



A blood warmer is indicated:– a flow rate of >50mL / Kg / hour in adults

– a flow rate of 15 mL/ Kg/ hour in children

– exchange transfusions in infants

– transfusing patients with clinically significant cold agglutins

No other drug or fluids should be added to the transfusion set which may cause red cells to clot or lyse

The giving set should be changed:– after 12 hours

– if another infusion is to continue after the transfusion



Nursing observation required according to BCSH guideline 1999 are:– baseline observations to include temperature, pulse and BP

– pulse and temperature are additionally observed within 15 minutes of the start of each unit of blood.

– nurse all patients receiving blood in a location where they can readily be observed

– additional observations are only necessary when a patient is unwell or noted to have deteriorated.

– observe urinary output and maintain fluid balance chart



– observe patient’s behaviour during transfusion

– observe the appearance of the patient during transfusion

– check cannula for signs of infection

– adverse reactions should be reported immediately

– acute haemolytic reactions, transfusion must be stopped and further assessments carried out.

After completion of transfusion:– the transfusion should be disposed of according to local policy

for disposal of clinical waste.

– Retention of blood bags for 48 hour period as been recommended by BCSH 1990, in case there may be a severe reaction some hours after discontinuation


Potential complications of blood transfusions

Infection

Febrile reaction

Allergic reaction

Transfusion hypothermia

Fluid overload


Adverse reaction

Increase in temperature Hypotension Tachycardia Headaches Rashes Swelling around cannula site Pain in abdomen or chest Patient feeling agitated or unduly apprehensive

STOP TRANSFUSION, CONTACT DOCTOR AND FILL DOCUMENTATION


Reporting adverse incident recheck the blood against the patient’s notes check the patient’s urine for blood

blood needs to be cross matched again

all equipment (blood bag, giving set and urine ) should be sent to the lab for testing

keep the iv line open with 0.9% normal saline complete the employer’s adverse clinical incident

form, and document in care plan


Conclusion IV therapy must be prescribed by a medical

practitioner

Cannulation and insertion of catheters, together with administrating IV medication is regarded as extended Professional Scope of Practice.

Always check that equipment, the fluids and the flow rate with another R.N.


The bedside check is the final opportunity to

prevent a mis-transfusion

Each hospital will have a formal policy which must be followed for blood transfusion

Every patient should have an uniquely identified wristband

Each R.N must ensure responsibility regarding their competency .


REFERENCES British Committee for Standards in Haemotology, Blood

Transfusion Task Force (1999) The administration of blood and blood components and the management of transfused patients; Transfusion Medicine 9:227-238

Jane Mallet and Lisa Dougherty (2000) Manual of Clinical Nursing Procedures (5th edition); Blackwell Science, London

Fox, Nick (2000) Managing risks posed by intravenous therapy; Nursing Times Vol.96 (30), pp37-39

R.C.N. ( ) Guidance for Nurses Giving Intravenous Therapy Serious Hazards of Transfusion (SHOT) Annual Report 1999-

2000:Availavble from; htpp://www.shot.demon.co.uk/ Quinn, C. (2000)Infusion devices: risks, functions and

management; Nursing Standard Vol. 14 (26):35-41 Wilkinson, J. (2001) Administration of blood transfusions to

adults in general hospital settings: a review of the literature; Journal of Clinical Nursing Vol. 10 (10):161-172

howard griffiths, shs hazards of iv therapy n aim: to raise awareness of hazards n learning...

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