INTRAVENOUS THERAPY

1. Infusion systems
   1. Plastic bag:
      1. Contains no vacuum - needs no air to replace fluid as it flows from container.
      2. Medication can be added with syringe through a resealable latex port.
         1. During infusion, administration set should be completely clamped before medications are added
         2. Prevents undiluted, and perhaps toxic, dose from entering administration set.
   2. Closed system:
      1. Requires partial vacuum - however, only filtered air enters container.
      2. Medication may be added during infusion through air vent in administration set.
   3. Administration sets:
      1. Standard sets - deliver 10-15 drops/mL
      2. Pediatric or niinidrop sets - deliver 60 drops/ mL.
      3. Controlled-volume sets - permit accurate infusion of measured volumes of fluids.
         1. Particularly valuable when piggybacked into primary infusion.
         2. Solutions containing drugs can then be administered intermittently.
      4. Y-type administration sets - allow for simultaneous or alternate infusion of two fluids.
         1. May contain filter and pressure unit for blood transfusions.
         2. Air embolism significant hazard with this type of administration set.
      5. Positive-pressure sets - designed for rapid infusion of replacement fluids.
         1. In emergency, built-in pressure chamber increases rate of blood administration.
         2. Pump chamber must be filled at all times to avoid air embolism.
         3. Application of positive pressure to infusion fluids is responsibility of physician.
      6. Infusion pumps - used to deliver small volumes of fluid or doses of high-potency drugs.
         1. Used primarily in neonatal, pediatric, and adult intensive care units.
         2. Have increased the safety of parenteral therapy and reduced nursing time


2. Fluid administration
   1. Factors influencing rate:
      1. Patient’s size
      2. Patient’s physical condition.
      3. Age of patient.
      4. Type of fluid
      5. Patient’s tolerance to fluid
      6. Patient’s position.
   2. Flow rates for parenteral infusions can be computed using the following formula:
      
      

      gtt/mL of given set 60 min/hr

      X

      total volume/hr = gtt/min

      
      
      E.g., if 1000 mL is to be infused in an 8 hours (125 mL/hr) period and the administration set delivers 15 gtt/mL, the rate is 32 gtt/min:

      15 60

      X 125 =

      1 4

      X 125 = 32 gtt/min

   3. Generally the type of fluid administration set determines its rate of flow.
      1. Fluid administration sets - approximately 15 gtt/min.
      2. Blood administration sets - approximately 10 gtt/min.
      3. Pediatric administration sets - approximately 60 gtt/min.
      4. Always check information on the administration set box to determine the number of gtt/mL before calculating; varies with manufacturer.
   4. Factors influencing flow rates:
      1. Gravity - a change in the height of the infusion bottle will increase or decrease the rate of flow; for example, raising the bottle higher will increase the rate of flow, and vice vers
      2. Blood clot in needle - stopping the infusion for any reason or an increase in venous pressure may result in partial or total obstruction of needle by clot due to:
         1. Delay in changing infusion bottl
         2. Blood pressure cuff on, or restraints on or above infusion needle
         3. Patient lying on arm in which infusion is being mad
      3. Change in needle position - against or away from vein wall.
      4. Venous spasm - due to cold blood or irritating solution.
      5. Plugged vent - causes infusion to stop.


3. Fluid and electrolyte therapy
1. Types of therapy:
   1. Maintenance therapy - provides water, electrolytes, glucose, vitamins, and in some instances protein to meet daily requirements.
   2. Restoration of deficits - in addition to maintenance therapy, fluid and electrolytes are added to replace previous losses.
   3. Replacement therapy - infusions to replace current losses in fluid and electrolytes.




Commonly Used Intravenous Fluids

IV Solution Na (mEq/L) K (mEq/L) Ca (mEq/L) Cl (mEq/L) Lactate (mEq/L) Calories/L 0,9% NaCl (NS) 154 0 0 154 0 0 5% Dextrose (D SW) 0 0 0 0 0 170 5% Dextrose + 0.9% NaCl (D5 1/2 NS) 154 0 0 154 0 170 5% Dextrose + 0.45% NaCl (D5 1/2 NS) 77 0 0 77 0 170 Lactated Ringer’s solution 130 3 3 109 28 9 3% NaCl 462 0 0 462 0 0 5% NaCl 770 0 0 770 0 0 0.45% NaCl 69.3 0 0 69.3 0 0 10% Dextrose (D wW) 0 0 0 0 0 340




2. Types of intravenous fluids
1. Isotonic solutions - fluids that approximate the osmolarity (280-300 mOsm/L) of normal blood plasma
1. Sodium chloride (0.9%) - normal salin
   1. Indications:
      1. Extracellular fluid replacement when Cl^- loss is equal to or greater than Na ⁺ loss.
      2. Treatment of metabolic alkalosis.
      3. Na ⁺ depletion.
      4. Initiating and terminating blood transfusions.
   2. Possible side effects:
      1. Hypernatremi
      2. Acidosis.
      3. Hypokalemi
      4. Circulatory overloa
2. Five percent dextrose in water (D ₅W).
   1. Provides calories for energy, sparing body protein and preventing ketosis resulting from fat breakdown.
      1. 75 calories are provided per gram of glucos
      2. USP standards require use of monohydrated glucose, so only 91% is actually glucos
      3. D ₅W yields 170.6 calories; D _SW means 5 g glucose/100 mL water.
         
         50 X 75 = 187.5 calories/L
         0.91 X 187.5 = 170.6 calories/L
   2. Indications:
      1. Dehydration.
      2. Hypernatremi
      3. Drug administration.
   3. Possible side effects:
      1. Hypokalemi
      2. Osmotic diuresis - dehydration.
      3. Transient hyperinsulinism.
      4. Water intoxication.
3. Five percent dextrose in normal salin
   1. Prevents ketone formation and loss of potassium and intracellular water.
   2. Indications:
      1. Hypovolemic shock - temporary measure
      2. Burns.
      3. Acute adrenocortical insufficiency.
   3. Same side effects as normal salin
4. Isotonic multiple-electrolyte fluids - used for replacement therapy; ionic composition approximates blood plasm
   1. Types - Plasmanate, Polysol, and lactated Ringer’s.
   2. Indicated in: vomiting, diarrhea, excessive diuresis, and burns.
   3. Possible side effect - circulatory overloa
   4. Lactated Ringers is contraindicated tn severe metabolic acidosis and/or alkalosis and liver diseas
   5. Same side effects as normal saline
2. Hypertonic solutions - fluids with an osmolarity much higher than 310 mOsm (+50 mOsm); increase osmotic pressure of blood plasma, thereby drawing fluid from the cells.
   1. Ten percent dextrose in normal salin
      1. Administered in large vein to dilute and prevent venous traum
      2. Used for nutrition and to replenish Na ⁺ and Cl".
      3. Possible side effects:
         1. Hypernatremia (excess Na ' ).
         2. Acidosis (excess Cl").
         3. Circulatory overloa
   2. Sodium chloride solutions, 3% and 5%.
      1. Slow administration essential to prevent overload (100 mL/hr).
      2. Indicated in water intoxication and severe sodium depletion.
3. Hypotonic solutions - fluids whose osmolarity is significantly less than that of blood plasma ( - 50 mOsm); these fluids lower plasma osmotic pressures, causing fluid to enter cells.
   1. 0.45% sodium chloride - used for replacement when requirement for Na ⁺ use is questionabl
   2. 5% dextrose in 0.45% saline, also 5% D in 0.2% NaCI - common rehydrating solution.
      1. Indications:
         1. Fluid replacement when some Na ⁺ replacement is also necessary.
         2. Encourage diuresis in patients who are dehydrate
         3. Evaluate kidney status before instituting electrolyte infusions.
      2. Possible side effects:
         1. Hypernatremi
         2. Circulatory overloa
         3. Use with caution in edematous patients with cardiac, renal, or hepatic diseas
         4. After adequate renal function is established, appropriate electrolytes should be given to avoid hypokalemi
4. Alkalizing agents - fluids used in the treatment of metabolic acidosis:
   1. Ringer’s:
      1. Administration - rate usually not more than 300 mL/hr.
      2. Side effects - observe carefully for signs of alkalosis.
   2. Sodium bicarbonate:
      1. Indications:
         1. Replace excessive loss of bicarbonate ion.
         2. Emergency treatment of lifethreatening acidosis.
      2. Administration:
         1. Depends on patient’s weight, condition, and carbon dioxide level.
         2. Usual dose is 500 mL of a 5% solution (89 mEq).
      3. Side effects:
         1. Alkalosis.
         2. Hypocalcemic tetany.
         3. Rapid infusion may induce cellular acidity and deat
5. Acidifying solutions - fluids used in treatment of metabolic alkalosis.
   1. Types:
      1. Normal saline
      2. Ammonium chloride
   2. Administration - dosage depends on patient’s condition and serum lab values.
   3. Side effects:
      1. Hepatic encephalopathy in presence of decreased liver function because ammonia is metabolized by liver.
      2. Toxic effects of irregular respirations, twitching, and bradycardi
      3. Contraindicated with renal failur
6. Blood and blood products
   1. Indications:
      1. Maintenance of blood volum
      2. Supply red blood cells to maintain oxygen-carrying capacity.
      3. Supply clotting factors to maintain coagulation properties.
      4. Exchange transfusion.


4. Intravenous cancer chemotherapy
   1. Usual sites: forearm, dorsum of hand, wrist, antecubital foss
   2. Procedure:
      1. Normal saline infusion usually started first, to verify vein patency, position of needl Chemotherapy “piggybacked” into IV line that is runnin
      2. Rate: usually 1 mL/min. Running slowly decreases nausea, vomiting, and the degree of vein damag
      3. Check vein patency every 3-5 minutes.
      4. If more than one drug is to be infused, normal saline should be infused between drugs.
      5. Never infuse against resistanc
      6. Stop treatment if patient reports pain at needle sit Extravasation (infiltration of toxic drugs into tissue surrounding vessel) may be present.
      7. If extravasation present, begin protocol appropriate to drug administered (, flushing of line with saline, applying ice or heat, local injection of site with antidote drugs, topical application of steroid creams).
      8. Once treatment is completed, remove needle, apply Band-Aid, exert pressure to prevent hematoma formation.

Transfusion with Blood or Blood Products