Intravenous Therapy

Advanced Care Paramedicine

Module: 7 Session: 4

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 IV’s and Ringer’s Lactate.

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

Why do we cannulate?

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

IV fluids

      Normal saline (0.9% NS) Lactated Ringer’s (LR)  Also known as Hartman’s solution or RL D 5 W ½ NS D 5 D 5 ½ NS RL (D 5 LR)

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

Normal Saline

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

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?

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 < 240 mOsm/l   Solutions 0.45% NaCl 10% dextran and 5% dextrose (slightly hypotonic)

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 > 340 mOsm/l         Solutions 5% dextrose/0.2% NaCl 5% dextrose/0.9% NaCl D 5 W D 10 W D 50 W 5% NaHCO 3 10%, 15% and 20% Mannitol 6% dextran and 0.9% NaCl

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

Where do we cannulate?

    Hand Forearm Neck Foot

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

Catheter specifics

Color

Grey Green Pink Blue

Size

16 G 18 G 20 G 22 G

Int Dia/Length

1.4 mm/45 mm 1.0 mm/45 mm 0.8 mm/32 mm 0.6 mm/25 mm

Max Flow

180 mls/min 80 mls/min 54 mls/min 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

Types of catheters

 Jelco  Cathelon  Insyte

Types of catheters

 Protective  Protective Plus

Administration Sets

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

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

Fluid Replacement

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

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)

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 pt’s arm using alcohol swab

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

IV Access

Complications

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

Local - Hematomas

 Causes:  Punctured vein  Symptoms:  Preventative actions:    Bruising Tenderness Swelling  Proper techniques

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

Local - Necrosis

 Causes:  Symptoms:  Preventative actions:  Irritation of tissues from infiltrated drug or fluid   Swelling, tenderness Inflammation or bruising   Routine checks Report any changes

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

Systemic – Pulmonary Edema

 Causes:  Symptoms:  Circulatory overload from too rapid infusion when patient has impaired renal or cardiac function  JVD, ↑ BP, ↑Resps, dyspnea, agitation  Preventative actions:    Watch rate Oxygen, sit pt upright Slow IV and contact OLMC

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

Systemic – Pyrogenic Reaction

 Causes:  Contaminated IV solutions  Symptoms:  Preventative actions:   Symptoms generally occur after IV begun ↑temp, chills, headache, N/V, circulatory collapse   Check IV fluids for cloudiness and particles Use fresh open IV’s

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 IV’s

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     Don’t let IV run dry Clear tubing properly Check syringe prior to injecting If occurs place pt on left side and contact OLMC

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!

External Jugular (EJ) cannulation

EJ’s

  Why are they not commonly used in those who are conscious ?

 Often used in severe cases of shock, unresponsiveness and cardiac arrest since they are

HUGE

and relatively easy to cannulate.

Why are they not a good choice for patients of multi system trauma ?

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.

Procedure

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

EJ cannulation

Calculating flow rates

Volume to be administered (ml) X Drip set (gtts/ml) = Time to be infused (min) Drops/min (gtts/min) Drip sets 10 gtt/ml (macro) 15 gtt/ml 20 gtt/ml 60 gtt/ml (micro) 10 drops = 1 ml 15 drops = 1 ml 20 drops = 1 ml 60 drops = 1 ml Factor 6 4 3 1

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) = Time to be infused (min) 1000 ml X 60 gtts/ml = 720 min Drops/min (gtts/min) Drops/min (gtts/min) 83.333

= Drops/min (gtts/min)

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.

Calculation

[ ] = = Mass Volume 2.0 g 500 ml = = 2000 mg 500 ml 4 mg/ml Dose = = D H X V 2 mg/min X 2000 mg 500 ml = = 1000 mgml/min 2000 mg 0.5 ml/min

Calculation

Volume to be administered (ml) X Drip set (gtts/ml) = Time to be infused (min) 0.5 ml X 60 gtts/ml = 1 min Drops/min (gtts/min) Drops/min (gtts/min)

30

= Drops/min (gtts/min)

A Variation to the Same

Volume (ml) X Ordered (mg/min) X On Hand (mg) Drip set (gtts/ml) = 500 ml X 200 mg 2 mg/min X 60 gtt/ml = Drops/min (gtts/min) Drops/min (gtts/min)

30

= Drops/min (gtts/min)