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Basic Basic Intravenous Intravenous

TherapyTherapy

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90-95% of patients in the 90-95% of patients in the

hospital receive some type hospital receive some type

of intravenous therapyof intravenous therapy

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Veins are unlike arteries in Veins are unlike arteries in that they are that they are 1)superficial, 1)superficial, 2) display dark red blood at 2) display dark red blood at

skin surface and skin surface and 3) have no pulsation 3) have no pulsation

Vein AnatomyVein Anatomy

- - Tunica AdventitiaTunica Adventitia - Tunica Media- Tunica Media - Tunica Intima- Tunica Intima - Valves- Valves

Vein Anatomy and Vein Anatomy and PhysiologyPhysiology

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Tunica AdventitiaTunica Adventitiathe outer layer of the vesselthe outer layer of the vessel

Connective Connective tissuetissue

Contains the Contains the arteries and arteries and veins veins supplying supplying blood to blood to vessel wallvessel wall

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Tunica MediaTunica Mediathe middle layer of the vesselthe middle layer of the vessel

Contains nerve Contains nerve endings and endings and muscle fibersmuscle fibers

The The vasoconstrictive vasoconstrictive response occurs response occurs at this layerat this layer

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Tunica IntimaTunica Intimathe inner layer of the vesselthe inner layer of the vessel

One layer of endothelialOne layer of endothelial

No nerve endingsNo nerve endings

Surface for platelet Surface for platelet aggregation w/trauma and aggregation w/trauma and recognition of foreign recognition of foreign object at this levelobject at this level

PHLEBITIS begins herePHLEBITIS begins here

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ValvesValvespresent in MOST veinspresent in MOST veins

Prevent backflow Prevent backflow and pooling and pooling

More in lower More in lower extremities and extremities and longer vesselslonger vessels

Vein dilates at Vein dilates at valve attachmentvalve attachment

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Veins of the Upper Veins of the Upper ExtremitiesExtremities

Digital VesselsDigital Vessels

-Along lateral aspects fingers, infiltrate easily, painful, difficult to immobilize and should be your LAST RESORT

Metacarpal VesselsMetacarpal Vessels

-Located between joints and metacarpal bones (act as natural splint)

-Formed by union of digital veins

-Geriatric patients often lack enough connective / adipose tissue and skin turgor to use this area successfully

Digital

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Veins of the Upper ExtremitiesVeins of the Upper Extremities

Cephalic (Intern’s Vein)Cephalic (Intern’s Vein) -Starts at radial aspect of wrist -Access anywhere along entire

length (BEWARE of radial artery/nerve)

Medial Cephalic (“On ramp” Medial Cephalic (“On ramp” to Cephalic Vein)to Cephalic Vein)

-Joins the Cephalic below the elbow bend

-Accepts larger gauge catheters, but may be a difficult angle to hit and maintain

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Veins of the Upper ExtremitiesVeins of the Upper Extremities

BasilicBasilic

- Originates from the ulnar side of the metacarpal veins and runs along the medial aspect of the arm. It is often overlooked because of its location on the “back” of the arm, but flexing the elbow/bending the arm brings this vein into view

Medial BasilicMedial Basilic - Empties into the Basilic vein

running parallel to tendons, so it is not always well defined. Accepts larger gauge catheters.

- BEWARE of Brachial Artery/Nerve

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Fluid IntakeFluid Intake

Water from beverages:1600 ml (64%)

Water from food:700 ml (28%)

Water from metabolism:200 ml (8%)

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Fluid OutputFluid Output

Water from skin:550 ml (25%)

Water from feces:150 ml (5%)

Water from lungs: 300 ml (11%)

Water from urine: 1500 ml (59%)

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IV Infusion . . .

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IV Infusion . . .

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IV Infusion . . .

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IV Infusion . . .

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IV Infusion . . .

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IV Infusion . . .

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Affects of Hypotonic Solution Affects of Hypotonic Solution on Cellon Cell

CellSwelling

Cell

SwollenCell

RupturedRupturedCellCell

The [solute] outside The [solute] outside the cell is lower the cell is lower than inside. than inside.

Water moves from Water moves from low [solute] to high low [solute] to high [solute].[solute].

The cell swells and The cell swells and eventually bursts!eventually bursts!

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IV Infusion . . .

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Affects of Hypertonic Affects of Hypertonic Solution on CellSolution on Cell

Cell

The [solute] outside The [solute] outside the cell is higher the cell is higher than inside. than inside.

Water moves from Water moves from low [solute] to high low [solute] to high [solute].[solute].

The cell shrinks!The cell shrinks!

ShrinkingCell

ShrunkenCell

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IV Infusion . . .

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Infusion of Infusion of hypertonic hypertonic solution into veinssolution into veins

Infusion of Infusion of hypertonic hypertonic solution into veinssolution into veins

No fluid No fluid movementmovement

No fluid No fluid movementmovement

Fluid Fluid movement movement into veinsinto veins

Fluid Fluid movement movement into veinsinto veins

Fluid Fluid movement movement out of veinsout of veins

Fluid Fluid movement movement out of veinsout of veins

Infusion of Infusion of isotonic solution isotonic solution into veinsinto veins

Infusion of Infusion of isotonic solution isotonic solution into veinsinto veins

Infusion of Infusion of hypotonic solution hypotonic solution into veinsinto veins

Infusion of Infusion of hypotonic solution hypotonic solution into veinsinto veins

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Saline SolutionsSaline Solutions(1) 0.9% Normal Saline – Think of it as ‘Salt and water’(1) 0.9% Normal Saline – Think of it as ‘Salt and water’ Principal fluid used for intravascular resuscitation and replacement of salt loss Principal fluid used for intravascular resuscitation and replacement of salt loss

e.g diarrhoea and vomitinge.g diarrhoea and vomiting Distribution: Stays almost entirely in the Extracellular spaceDistribution: Stays almost entirely in the Extracellular space

Of 1 litre – 750ml Extra cellular fluid; 250ml intravacular fluidOf 1 litre – 750ml Extra cellular fluid; 250ml intravacular fluid So for 100ml blood loss – need to give 400ml N.saline [only 25% remains So for 100ml blood loss – need to give 400ml N.saline [only 25% remains

intravascular]intravascular]

(2) 0.45% Normal saline = ‘Half’ Normal Saline = (2) 0.45% Normal saline = ‘Half’ Normal Saline = HYPOtonic salineHYPOtonic saline

Reserved for severe hyperosmolar states E.g. severe dehydrationReserved for severe hyperosmolar states E.g. severe dehydration Leads to HYPOnatraemia if plasma sodium is normalLeads to HYPOnatraemia if plasma sodium is normal May cause rapid reduction in serum sodium if used in excess or infused too May cause rapid reduction in serum sodium if used in excess or infused too

rapidly. rapidly.

(3) 1.8, 3.0, 7.0, 7.5 and 10% Saline = HYPERtonic saline(3) 1.8, 3.0, 7.0, 7.5 and 10% Saline = HYPERtonic saline Reserved for plasma expansion with colloidsReserved for plasma expansion with colloids In practice rarely used in general wards; Reserved for high dependency, In practice rarely used in general wards; Reserved for high dependency,

specialist areasspecialist areas Distributed almost entirely in the ECF and intravascular space. This leads to an Distributed almost entirely in the ECF and intravascular space. This leads to an

osmotic gradient between the ECF and ICF, causing passage of fluid into the EC osmotic gradient between the ECF and ICF, causing passage of fluid into the EC space. This fluid distributes itself evenly across the ECF and intravascular space, space. This fluid distributes itself evenly across the ECF and intravascular space, in turn leading to intravascular repletion. in turn leading to intravascular repletion.

Large volumes will cause HYPERnatraemia and IC dehydration.Large volumes will cause HYPERnatraemia and IC dehydration.

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Dextrose solutionsDextrose solutions(1) 5% Dextrose (often written D5W) – Think of it as ‘Sugar and Water’(1) 5% Dextrose (often written D5W) – Think of it as ‘Sugar and Water’ Primarily used to maintain water balance in patients who are not able to take Primarily used to maintain water balance in patients who are not able to take

anything by mouth; Commonly used post-operatively in conjuction with salt anything by mouth; Commonly used post-operatively in conjuction with salt retaining fluids ie saline; Physiological replacement’ of water and Na+ losses]retaining fluids ie saline; Physiological replacement’ of water and Na+ losses]

Regarded as ‘electrolyte free’ – contains NO Sodium, Potassium, Chloride or Regarded as ‘electrolyte free’ – contains NO Sodium, Potassium, Chloride or CalciumCalcium

Distribution: <10% Intravascular; > 66% intracellularDistribution: <10% Intravascular; > 66% intracellular When infused is rapidly redistributed into the intracellular space; Less than When infused is rapidly redistributed into the intracellular space; Less than

10% stays in the intravascular space therefore it is of limited use in fluid 10% stays in the intravascular space therefore it is of limited use in fluid resuscitation. resuscitation.

For every 100ml blood loss – need 1000ml dextrose replacement 10% For every 100ml blood loss – need 1000ml dextrose replacement 10% retained in intravascular spaceretained in intravascular space

Common cause of iatrogenic hyponatraemia in surgical patientCommon cause of iatrogenic hyponatraemia in surgical patient

(2) Dextrose saline – Think of it as ‘a bit of salt and sugar’(2) Dextrose saline – Think of it as ‘a bit of salt and sugar’ Similar indications to 5% dextrose; Similar indications to 5% dextrose; Primarily used to replace water losses post-operativelyPrimarily used to replace water losses post-operatively Limited indications outside of post-operative replacement – ‘Neither really Limited indications outside of post-operative replacement – ‘Neither really

saline or dextrose’; Advantage – doesn’t commonly cause water or salt saline or dextrose’; Advantage – doesn’t commonly cause water or salt overload.overload.

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IV Infusion . . .

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IV Infusion . . .

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IV Infusion . . .

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Needle GaugeNeedle Gauge

VioletViolet= Newborn= 26G= Newborn= 26G YellowYellow= Pedia= 24G (Introcath)= Pedia= 24G (Introcath) BlueBlue= Adult= 22G= Adult= 22G GreenGreen= OB/OR (Adult)= 20G= OB/OR (Adult)= 20G PinkPink= BT/OR= 18G= BT/OR= 18G

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PARTS OF IV TUBINGPARTS OF IV TUBING

Protector capProtector cap Spike ConnectorSpike Connector Connector to IV cathConnector to IV cath Drip chamberDrip chamber ClampClamp Secondary PortSecondary Port

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IV Infusion . . .

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IV Infusion . . .

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IV Infusion . . .

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IV Infusion . . .

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IV Infusion . . .

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Venipuncture Procedure: Venipuncture Procedure: TipsTips

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IV Infusion . . .

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IV Infusion . . .

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IV Infusion . . .

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IV Infusion . . .

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IV Infusion . . .

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Demonstration & PracticeDemonstration & Practice

Questions?Questions?

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The Fluid chartThe Fluid chart

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The Fluid ChartThe Fluid Chart

You need to fill in all the areas of the chart, just You need to fill in all the areas of the chart, just like a drug chart.like a drug chart.

Useful to record the patient’s weight if known; Useful to record the patient’s weight if known; Guestimate and record it if not.Guestimate and record it if not.

You will note there is a drop rate advised at the You will note there is a drop rate advised at the bottom of the chart shown in the previous slidebottom of the chart shown in the previous slide

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Using one of the blank charts supplied - Please write up 3 x 1litre of normal saline with 20 mmol/l of KCl in each litre – to run at 1litre/ 8 hourly; Patient is Mr Ali Khan Number 326587, DOB 13/09/81, weight 81Kg. Consultant Ms Cuttem; Ward B3

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Your fluid chart should look something like this. (I Your fluid chart should look something like this. (I have written it out twice as I was unconvinced of have written it out twice as I was unconvinced of my first attempt)my first attempt)

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Infiltration/ExtravasationInfiltration/Extravasation

The most common cause is damage to the wall during insertion or angle of placement.

STOP INFUSION and treat as indicated by Pharmacy, Medication package insert or drug reference book.

Notify MD and document

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Phlebitis/ThrombophlebitisPhlebitis/Thrombophlebitis

Chemical

- Infusate chemically erodes internal layers. Warm compresses may help while the infusate is stopped/changed. Anti-inflammatory and analgesic medications are often used no matter what the cause Mechanical

- Caused by irritation to internal lumen of vein during insertion of vascular access device and usually appears shortly after insertion. The device may need to be removed and warm compresses applied

Bacterial

- Caused by introduction of bacteria into the vein. Remove the device immediately and treat w/antibiotics. The arm will be painful, red and warm; edema may accompany

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CellulitisCellulitis

Inflammation of loose connective tissue around insertion site.

- Caused by poor insertion technique

- Red swollen area spreads from insertion site outwardly in a diffuse circular pattern

- Treated w/antibiotics

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Septicemia/Pulmonary Edema/Septicemia/Pulmonary Edema/EmbolismEmbolism

Septicemia

- Severe infection that occurs to a system or entire body

- Most often caused by poor insertion technique or poor site care

- Discontinue device immediately, culture and treat appropriately Pulmonary edema- caused by rapid infusion

Pulmonary embolism - Caused by any free floating substances that require thrombolytic therapy for several months. Increased risk w/lower ext.

Air embolism- caused by air injected into IV system. Keep insertion site below level of heart

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Vascular access device will not flush/can’t draw blood- Evaluate for kink in tubing or catheter tip against vein wall.

Vascular access device (VAD) leaking when flushed - Verify that hub access cap is connected correctly

Patient complains of pain while VAD being flushed- Assess for infiltration

VAD broken- PICC’s may be repaired. All other devices must be replaced

Call IV therapy team member for any concerns or questions.

TroubleshootingTroubleshooting