iv fluid therapy lecture and demo pfn: sompsd03slides.jsomtc.org/sompsd03/sompsd03.pdf · jsomtc,...

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Slide 1JSOMTC, SWMG(A)

IV Fluid Therapy Lecture and DemoPFN: SOMPSD03

Hours: 2.0

Instructor:


Terminal Learning Objective

Action: Communicate knowledge of IV fluid therapy

Condition: Given a lecture and demonstration in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


References

Fluids and Electrolytes Made Incredibly Easy, 5th edition, 2011

The ICU Book, 3rd edition, 2007

AACN Essentials of Critical Care Nursing, 2006

Infusion Nursing an Evidence Based Approach, 3rd edition, 2010

PHTLS Manual, Military 7th edition, 2011

2


Reason

Hemorrhagic shock is a leading cause of death on the battlefield

Infusion of intravenous fluids and blood products will help sustain the casualty until surgical intervention occurs

IV cannulation enables providers to administer a variety of life saving drugs for both clinical and trauma scenarios


Agenda

Identify the physiology, indications, and contraindications of IV fluids

Identify the indications and considerations for a peripheral IV

Identify the peripheral IV sites

Identify the characteristics of common IV equipment


Agenda

Identify the steps for initiating and discontinuing a peripheral IV

Identify the complications of IV fluid therapy

Demonstrate initiating and discontinuing a Peripheral IV

3




IV Fluids

IV fluid bags are good for 24 hours after being spiked, IV sites/lines are good for 72 hours

Crystalloids

Inexpensive, common, non‐infectious

Lack O2 carrying/coagulation capability, and have short IV half‐life

Colloids

Greater osmotic pull

Potential reactions and storage issues


Crystalloids Solutes capable of crystallization are easily mixed and dissolved in a solution

May be electrolytes or non‐electrolytes, such as dextrose

Contain small molecules that flow easily across semi‐permeable membranes, allowing for transfer from bloodstream into cells and body tissues

May increase fluid volume in both interstitial and intravascular spaces

Useful in replenishment or dilution in the treatment of fluid and electrolyte disturbances

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Crystalloids

Distinguished by their relative tonicity (before infusion) in relation to plasma

Tonicity refers to concentration of dissolved molecules held within solution

Isotonic, Hypotonic, and Hypertonic


Isotonic Crystalloids

Dissolved particles concentration similar to plasma

Osmotic pressure constant both inside and outside cells

Fluid shift does not occur. Cells neither shrink nor swell

Distributed between intravascular and interstitial spaces, thus increasing intravascular volume

0.9% sodium chloride, lactated Ringer's, Plasmalyte, D5W


0.9% Sodium Chloride

Contains only water, sodium (154 mEq/L), and chloride (154 mEq/L)

Often called "normal saline (NS)" because percentage of NS dissolved in solution is similar to concentrations of sodium and chloride in intravascular space

Because water goes where sodium goes, 0.9% sodium chloride increases fluid volume in extracellular spaces

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0.9% Sodium Chloride Indications

Hyponatremia and hypercalcemia

Rhabdomyolysis

Medication and blood administration

Used as a vehicle for many parenteral drugs to replenish electrolytes for maintenance of deficits of extracellular fluid

Contraindications

Shock

• Large volumes of normal saline leads to hyperchloremic acidosis

Cardiac or renal disease


Lactated Ringer's

Electrolyte content is most closely related to body's blood serum and plasma

130 mEq/L Sodium

109 mEq/L Chloride

4 mEq/L Potassium ‐ 3 mEq/L Calcium

28 mEq/L Lactate

Indications

Shock/Burns ‐ Alkalization helps attenuates metabolic acidosis

Dehydration


Lactated Ringer's

Contraindications

Rhabdomyolysis

• Due to K+ content of solution

Conditions decreasing lactate metabolism and excretion

• Liver failure prevents lactate conversion into bicarbonate

• Kidney failure: Hyperkalemia risk

• PH >7.5 due to alkalinization

Not given w/blood products

• C++ can increase hypercoagulable state which results in emboli

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Plasmalyte‐148

Electrolyte content is similar to LR, with many of the same indications

140 mEq/L Sodium

98 mEq/L Chloride

27 mEq/L Acetate

23 mEq/L Gluconate

5 mEq/L Potassium

1.5 mEq/L Magnesium

Indications

Same as LR plus……


Plasmalyte‐148

Uses acetate and gluconate as buffers. May be used in liver failure pts w/caution

Approved for use in use with blood product transfusion

No calcium/citrate interaction

Contraindications

Rhabdomyolysis/ PH >7.5

Kidney failure: Hyperkalemia and Hypermagnesemia risk


D5W (Dextrose in Water)

D5W's initial tonicity comparable to intravascular fluid (isotonic). Dextrose is metabolized leaving no osmotically active particles (hypotonic)

Indications:

Moderate nutrition

Hypernatremia/Isotonic dehydration

Dilute concentrated drugs for IV infusion

Contraindications:

Shock, TBI, stroke, hyperglycemia, transfusions, corn allergy, renal failure

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Hypotonic Crystalloids

Compared with intracellular fluid, hypotonic solutions have lower concentration, or tonicity, of solutes (electrolytes)

Lowers serum osmolality within vascular space, causing fluid to shift from intravascular space to both intracellular and interstitial spaces

Solutions will hydrate cells, although their use may deplete fluid within circulatory system

0.45% NaCl, 0.33% NaCl, 0.2% NaCl, 2.5% dextrose in water


Hypotonic Crystalloids

Indications

Intracellular dehydration conditions

•Only after the initial resuscitation of DKA is complete

A SOCM will not initially use a hypotonic solution for resuscitation

Contraindications

Trauma ‐ Shock, burns

Hypotension

Increased ICP


Hypertonic Crystalloids

Hypertonic solutions have higher sodium and chloride concentrations

Solute concentration > ICS. Water drawn out of ICS, temporarily increasing fluid volume in the IVS

3% NaCl, 5% NaCl

Vasoregulatory, immunologic, and neurochemical effects can attenuate post injury complications

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Indications

Increased ICP/Cerebral edema

•Osmolarity almost identical to Mannitol w/o risks of diuresis, and subsequent hypovolemia

• Less chance of rebound in ICP

Hyponatremia

Contraindications:

Pulmonary edema

Hypertension




Complications

Central Pontine Myelinolysis

• Rapid transition from hyponatremia to hypernatremia

•Manifested clinically as lethargy and quadriplegia/paresis

Hypernatremia

Hypervolemia

Pulmonary edema


Colloids

Unlike crystalloids, colloids contain molecules too large to pass through semipermeable membranes, such as capillary walls

Remain in intravascular compartment

Expand intravascular volume by drawing fluid from interstitial spaces into intravascular compartment

• Known as volume expanders or plasma expanders

Same effect as hypertonic crystalloids of increasing intravascular volume, but have longer duration of action and require administration of less total volume

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Colloids

Blood products (SOCM fluid of choice for hemorrhagic shock)

Packed RBCs (PRBC)• Store at 33‐43 degrees F

• 2 units given w/FFP at a 1:1 ratio

Plasma (FFP)• Shelf life once thawed: 3 days at 33‐43 degrees F, 30 min room temperature

• Supplied as AB or A, RH factor is not a concern

Platelets (PLTS)

Whole blood (WB)• Equivalent of FFP, PBRC and PLTS in a 1:1:1 ratio

• 24 hours shelf life or refrigerated for 21‐42 days


Colloids

Albumin

5% solution ‐ 25% solution

One of the most commonly utilized colloid solutions

Used to maintain a normotensive state, or even a hypervolemic state in neuro trauma (Triple H therapy)

Dextrans ‐ LMWD (Dextran 40) and HMWD (Dextran 70)

Reduces erythrocyte aggregation, Factor VIII‐Ag (Von Willebrand), platelet adhesiveness, and can inhibit a‐2 anti‐plasimin

Interferes with blood cross matching/labs. Anaphylactoid risks

Hydroxyethylstarches ‐ Hespan and Hextend


Hydroxyethylstarches

Hypertonic synthetic colloids used for volume expansion

Hespan

• 6% hetastarch in normal saline

Hextend

• 6% hetastarch in Lactated Ringer’s

Effects can last 24 hours

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Current Events Regarding HextendA1


Hydroxyethylstarches

Black Box Warning

Do not use in critically ill adult patients including those with sepsis, and those admitted to the ICU

Avoid use in patients with pre‐existing renal dysfunction, or in open heart surgery w/cardiopulmonary bypass due to excess bleeding

Discontinue use at the first sign of renal injury, or coagulopathies

Need for renal replacement therapy has been reported up to 90 days after administration; monitor renal function for at least 90 days in all patients


Hextend

SOCM’s fluid of choice for treating hemorrhagic shock if blood products are unavailable

Powerful volume expander that remains in IVS longer than crystalloids, requiring less fluid needs to be carried

Indications

Shock

Contraindications

Hypertension (CHF)

Heat casualties (volume expansion does not equal hydration)

A1 LTC Riesberg want this slide to remain in power point.Author, 6/5/2017

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Hextend versus Lactated Ringer’s

Why use Hextend instead of much less expensive Lactated Ringer’s?

1000 ml of LR (2.4 lbs) will yield expansion of circulating blood volume of only 200 ml one hour after fluid is given

The other 800 ml of LR has left circulation after an hour and entered other fluid spaces in body

500 ml of Hextend (1.3 lbs) will yield expansion of intravascular volume of 600 to 800 ml

This intravascular expansion is still present 8 hours later




Peripheral IV Indications

Patient requiring infusion of:

Medications

Fluids

• Volume replacement/expansion for hemorrhagic shock

• Correction of acid/base, and electrolyte disturbances

Blood product admin/labs

Nutritional supplements

• GI dysfunction, obstruction, perforation, coma, absence

• Relieve organ workload

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Peripheral IV Considerations

Cannulation site criteria

Most distal site on extremity

Upper extremities preferred

Straight veins/free of valves

Veins not prone to rolling

Site selection troubleshooting

Pumping fist (open and close)

Gravity dependent position

Tapping/stroking site

Applying heat to the site



Sites to avoid:

Veins near joints (if so, splint the joint)

Locations with penetrating injuries

Lower extremities when abdominal trauma may have compromised the vena cava or portal circulation

Sites distal to previous insertion sites

Infiltrated/bruised areas

Burned areas may be used if no other sites are available



Choosing right diameter (or gauge) needle or catheter is important for ensuring adequate flow and patient comfort

The higher the gauge, the smaller the diameter of the needle

Small gauge catheters (14G, 16G, or 18G) w/a shorter length offer less resistance, and should be used for rapid fluid infusions

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Tactical considerations (not all casualties need IVs!)

Not required for minor wounds

IV fluids and supplies are limited

IVs take time and distract from other treatments

May unnecessarily disrupt tactical flow




Peripheral Veins

Upper extremities

Dorsal aspect of hand

Radial and ulnar veins

Antecubital (AC) vein

Median cephalic and median basilic veins

Lower extremities

Dorsal aspect of foot

Medial malleolus region

Long saphenous vein

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Peripheral Veins

Head/Scalp veins Used primarily on infants

External jugular vein Used in emergent situations

Procedure largely same as for other peripheral sites• Place patient supine (preferably in Trendelenburg)

• Increases blood flow to vein

• Aids in visualization of site

• Pressure may be put on portal system if not contraindicated

• Potential air entrainment


Alternate Infusion Methods

Hypodermoclysis: Subcutaneous infusion of fluids

Patients unable to take adequate fluids orally or when it's difficult/impractical inserting an IV

Moderately dehydrated adult patients

Animals

Rectoclysis‐ Proctoclysis: Fluids and nutrients

Intraosseuos: Same as IV (use with pressure infuser)

Endotracheal Tube: ACLS Medications (Navel/Lean)

Dosage 2‐2.5 times


Identify the Characteristics of Common IV Equipment

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IV Catheters

Hollow needle (Butterfly)

• Used for peds or other patients w/tiny‐delicate veins

• No Teflon tube, needle left in vein, and must be secured

• Some hollow have wings for guidance and securing

Over the needle catheter (Angiocath)

• Over the needle catheter comprises a semi‐flexible catheter enclosing a sharp metal stylet (needle) that is hollow and beveled at distal end

•Most common ‐ Quick and easy to use

•More comfortable for patient


Over the Needle Catheter

Components Needle

• Permits easy puncturing

• Blood flows from needle to flashback chamber

Teflon catheter • Slides over needle into punctured vein

Flashback chamber • Visualize blood after needle has punctured vein

• Allows you to confirm initial placement in vein

Hub • Located at back of catheter

• Connects to IV tubing, or saline lock


Catheter Flow Characteristics

The flow of fluids through an IV catheter can be described by Poiseuille’s Law.

It states that the flow (Q) of fluid is related to a number of factors: the viscosity (n) of the fluid, the pressure gradient across the tubing (P), and the length (L) and the diameter (r) of the tubing.

The smaller the gauge the larger the diameter

Doubling the diameter of a catheter increases the flow rate by 16 fold.

Shorter/larger catheter = Faster fluid flow rate

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Catheter Flow Characteristics

Increasing viscosity decreases flow through a catheter

Warming viscous fluids (blood products) prior to administration increases flow rate

Increasing pressure further maximizes flow rate.


Catheter Diameter and Length

Catheters come in different lengths and gauges

22 to 26 gauge ‐ Pediatrics

18 to 20 gauge ‐ TKO lines, non‐acute fluid resuscitation

14‐16 gauge ‐ Rapid fluid replacement, blood products

Which catheters would you use on adult trauma patients?

14‐16 gauge

What catheters would you use for med admin?

18‐20 gauge


Catheter Diameter and Length

18 gauge 1 ¼ inch is the catheter of choice for a trauma patient in a tactical environment

Ease of cannulation (higher success rate)

Rapid administration of crystalloids and colloids

14G 1 ¼”

16G 2”

18G 1¼”

20G 1 ¼”

22G 1 ¼”

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IV Administration Set

Clear plastic tubing for detection of air bubbles

One end connects to catheter

Other end connects to IV fluid or bag

Drip chambers are either Micro or Macro meaning that X # of drops = 1 ml


IV Administration Set

MICRO ‐ Small bore drip chamber

Used on medical and pediatric emergencies

Easy to titrate

Avoids fluid overload

MACRO ‐ Large bore drip chamber

Used on trauma patients

Allows for rapid fluid replacement/boluses


IV Accessories

IV Pressure Infuser Bag

Used in field for rapid fluid replacement

Also used when IV pole is not available

Required for I/O fluid administration

Saline Lock (PRN adapter or med port)

Used when IV medication or fluid bolus is required, but not a continuous infusion

Flushed every hour to keep open

Conserves IV fluid and supplies

Do not put needle in needless port

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Identify the Steps for Initiating and Discontinuing a Peripheral IV


Both techniques will be taught during your SOCM course training

You will be expected to be proficient at both

If you can perform a Ranger IV, you will be able to perform a traditional IV

During lecture, Ranger IV specific steps and equipment will be in orange font

Traditional IV versus Ranger IV


Traditional IV versus Ranger IV

Traditional IV

Used in hospitals, and ambulances

Quicker to initiate

Less equipment required

With multiple casualties it could equal more equipment

Faster flow rate

Ranger IV

Tactical option for IV fluid therapy

Designed by Rangers

Also referred to as a “Ruggedized IV”

More versatile than traditional IV

More resistant to accidental or deliberate DC

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IV Equipment IV fluid

IV catheter

IV administration set

Tape and OpSite

2x2s

Alcohol/betadine swabs

Constriction band

Gloves and eye protection

10 ml syringe

18G needles

Saline lock


Prepare Equipment

Select and inspect IV fluid

Color, clarity and expiration date

Select and inspect admin set

Connect administration set to IV bag

Clamp line

Fill drip chamber

Flush tubing

Apply 18G needle

Pre‐fill 10 ml syringe with 5 ml of IV fluid

Leave 18G needle attached

Tear tape

Open saline lock packets

Open alcohol, betadine swab and OpSite

Take BSI precautions

Gloves

Eye protection


Select Site

Apply constriction band

Used to halt venous return not arterial flow as in tourniquets

Best to use a quick release

Palpate vein

Clean site with alcohol and betadine

Select and inspect catheter

Catheter moves freely over needle

Use free hand to pull skin taut stabilizing vein

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Cannulate Vein

Approach vein at 20 to 30 degrees

From side of vein or over vein insuring needle bevel is up

Once you see “flash” or feel a “pop” reduce your angle and ease catheter and needle approximately ¼ inch


Cannulate Vein and Connect IV Tubing

Advance catheter over needle

Maintain manual control of hub until IV is secured by tape strips

Occlude vein proximally to staunch flow

Withdraw needle while stabilizing catheter , and immediately place directly into Sharps container

W/the traditional IV, connect IV tubing to catheter hub, then check IV patency


Verify IV Flow

Release constricting band

Start flow

Check patency

Drop the bag

Pinch and prime

Proximal occlusion

Apply OpSite

Adjust flow rate as appropriate

Double up/S‐fold tubing and tape down

Splint extremity if site is on joint

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Document

Label IV site

Date

Time

Catheter gauge and length

Document the procedure

Same info as above

Fluid type and amount

MIST Report (MOI, injuries sustained, S/S, treatments provided

Combat Casualty card


Ranger IV Saline Lock

For the Ranger IV, connect a saline lock instead of the direct IV line

Cleanse lock or port w/alcohol

Verify Saline Lock Patency

Attach syringe and aspirate blood

Flush saline lock with 1‐3 ml of fluid

Secure Saline Lock

Wipe away any blood

Apply OpSite


Connect IV Tubing to Saline Lock

Clean OpSite area over saline lock with alcohol

Insert needle through OpSite into saline lock until resistance is felt

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Discontinue an IV

Verify order and/or indication for discontinuation of IV

Explain procedure to patient

Shut off IV flow

While holding catheter with fingers and thumb, remove tape and OpSite

Place gauze over site

Withdraw catheter and apply pressure

Place catheter in appropriate container

Place gauze “wad” over first gauze

Secure gauze with tape or Coban

Document procedure


Identify the Complications of IV Fluid Therapy


Complications of IV Fluid Therapy

Divided into two categories

Local

Hematoma

Infiltration

Infection

Phlebitis and thrombophlebitis

Extravasation

Arterial cannulation

Systemic

Circulatory (fluid) overload

Catheter related sepsis

Pyrogenic reaction

Catheter embolism

Air embolism

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Hematoma

Blood leaks from vessel into surrounding soft tissue

IV catheter penetrates both walls of vessel

Not applying pressure to site when catheter is removed

Signs and symptoms

Swelling at site, pain, and ecchymosis

This is not awesome


Hematoma

Treatment

Remove catheter

Apply direct pressure to site

Reattempt at another site

Prevention

Utilize proper technique when initiating or discontinuing IV

Sub-Optimal


Infiltration

IV fluid leaks from vein into surrounding tissue

IV catheter becomes dislodged from vein

Signs symptoms

Pain, swelling, coolness and leakage at insertion site

Sluggish or stopped IV fluid flow

Still not good

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Infiltration

Treatment

Stop infusion, elevate affected extremity, remove catheter, and restart infusion in another site

Apply warm packs initially to site, after 24 hours cold packs can be apply

Prevention

Avoid IV placement in joint areas

Properly secure catheter

Closely monitor insertion site

Nope


Infection

Puncture for venous access disrupts integrity of skin, body's barrier to infection

Signs and symptoms

Drainage, pain, redness, swelling, and warmth at IV site

Hardness on palpation

Fever, chills, and elevated WBC count

Treatment

Remove catheter and monitor patient's vital signs

Swab site for culture and initiate anti‐microbial therapy


Infection

Prevention

Properly clean intended insertion site with antiseptic solution

Maintain sterile technique during catheter insertion and when performing IV site care

Rotate peripheral IV catheter sites every 72 hours

Try again NO!!

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Phlebitis and Thrombophlebitis

Both can result from poor insertion technique, use of solution or drug with inappropriate pH or osmolality, or IV catheter remaining in place too long

Phlebitis

Inflammation of vein

Mechanical, chemical, or bacterial

Thrombophlebitis

Irritation of vein with clot formationHeavy sigh…



Signs and symptoms

Pain (more severe in thrombophlebitis), redness, swelling, or induration at site

Red line streaking along vein

Sluggish flow of infusion solution

Fever

Edema

Mild joint pain Come on!



Treatment

Remove catheter

Apply warm soaks to site

Elevate extremity

Monitor patient's vital signs

Prevention

Choose large veins

Change IV catheter every 72 hours

For pity’s sake!

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Extravasation

Vesicant drug leaks into surrounding tissue at IV site

Can cause severe local tissue damage

Signs and symptoms

Pain and swelling at site

Delayed healing at site

Infection at site

Tissue necrosis and disfigurement

Loss of function/amputationREALLY!!!


Extravasation

Treatment

Remove catheter

Elevate extremity

Apply warm or cold packs depending on drug

Monitor site closely

Prevention

Use large, intact vein with good blood flow


Arterial Cannulation

IV catheter introduced into artery instead of vein

Signs and symptoms

Large amount of bright red, pulsating blood in flashback chamber of catheter

Blood will usually backflow into tubing if IV administration set is connected

• Due to arterial pressure

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Arterial Cannulation

Treatment

Remove catheter

Apply direct pressure for 10 minutes

Elevate extremity

Apply pressure dressing

Prevention

Avoid using IV sites near arteries


Circulatory (Fluid) Overload

Infusing excessive amounts of solutions too rapidly, especially in patient compromised by cardio, pulmonary or renal disease

Signs and symptoms

Increased BP and JVD

Increased respirations and shortness of breath

Crackles on auscultation and cough


Circulatory (Fluid) Overload

Treatment

Slow IV infusion rate and, monitor patient's vital signs, keep patient warm, elevate head of bed, and give supplemental oxygen

Prevention

Monitor IV infusion

Identify conditions which can be exacerbated by high volume infusions

28


Catheter Related Sepsis

Improper technique in catheter insertion, infusion of contaminated solution, multiple line violation and manipulation, or skin colonization adjacent to catheter site


Catheter Related Sepsis

Signs and symptoms

Temperature of > 38C or < 36C

Respiratory Rate of > 20 per minute

Heart Rate of > 90 bpm

WBC count > 12,000uL or < 4,000uL or 10% immature forms

Treatment

Remove catheter and administer antibiotic therapy

Prevention

Provide strict adherence to aseptic technique during line insertion, line manipulation and catheter care


Pyrogenic Reaction

Febrile phenomenon caused by infusion of pyrogenic organisms, toxins, or chemicals

Reaction can occur during or after infusion (as quickly as 30 seconds)

Signs and symptoms

Sudden rise in temperature (100‐106⁰F)

Nausea and vomiting

Tachycardia

Headache, backache, chills and malaise

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Pyrogenic Reaction

Treatment

Remove catheter

Administer antipyretic and antihistamine

Monitor patient’s vital signs

Prevention

Inspect IV solution and equipment for expiration dates and contamination

Ensure strict adherence to aseptic technique


Catheter Embolism

Piece of catheter breaks off and travels through vascular system to lungs

Signs and symptoms

Sharp sudden pain at IV site

Minimal blood return during IV patency check

Rough and uneven catheter noted on removal

Cyanosis, chest pain, tachycardia, and hypotension


Catheter Embolism

Treatment

Immediately place patient in left lateral decubitus w/the head down

Administer high flow oxygen

Evacuate for surgical removal of catheter tip

Prevention

Once you pull needle out of IV catheter, never re‐insert it

30


Air Embolism

Large volume of air enters blood stream via IV administration set

Death may occur if large bubble of gas becomes lodged in heart stopping blood from flowing from right ventricle to lungs

20 ml of air may show symptoms and 70 to 150 ml of air can be fatal


Air Embolism

Signs and symptoms

Anxiety, dyspnea, tachypnea, chest pain, agitation or disorientation, shortness of breath, cyanosis, sudden loss of consciousness, and circulatory shock or sudden death

Treatment

Immediately place patient in left lateral decubitus w/the head down

Administer high flow oxygen

Prevention

Prime and monitor IV administration set


Demonstrate Initiating and discontinuing a peripheral IV

31


Questions?


Agenda




Identify the characteristics of common IV equipment


Agenda

Identify the steps for initiating and discontinuing a peripheral IV

Identify the complications of IV fluid therapy

Demonstrate initiating and discontinuing a Peripheral IV

32


Reason

Hemorrhagic shock is a leading cause of death on the battlefield

Infusion of intravenous fluids and blood products will help sustain the casualty until surgical intervention occurs


References

Fluids and Electrolytes Made Incredibly Easy, 5th edition, 2011

The ICU Book, 3rd edition, 2007

AACN Essentials of Critical Care Nursing, 2006

Infusion Nursing an Evidence Based Approach, 3rd edition, 2010

PHTLS Manual, Military 7th edition, 2011


Terminal Learning Objective

Action: Communicate knowledge of IV fluid therapy

Condition: Given a lecture and demonstration in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards

33


IV Fluid Therapy Lecture and DemoPFN: SOMPSD03

Hours: 2.0

Instructor:

iv fluid therapy lecture and demo pfn: sompsd03slides.jsomtc.org/sompsd03/sompsd03.pdf · jsomtc,...

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