1 Reason Hemorrhagic shock is a leading cause of death on the - - PDF document

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Slide 1 JSOMTC, SWMG(A)

IV Fluid Therapy Lecture and Demo PFN: SOMPSD03

Hours: 2.0 Instructor:

Slide 2

JSOMTC, SWMG(A)

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

Slide 3

JSOMTC, SWMG(A)

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

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Slide 4

JSOMTC, SWMG(A)

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

Slide 5

JSOMTC, SWMG(A)

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

Slide 6

JSOMTC, SWMG(A)

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

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Slide 7 JSOMTC, SWMG(A)

Identify the physiology, indications, and contraindications of IV fluids

Slide 8

JSOMTC, SWMG(A)

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

Slide 9

JSOMTC, SWMG(A)

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
• f fluid and electrolyte disturbances

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Slide 10

JSOMTC, SWMG(A)

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

Slide 11

JSOMTC, SWMG(A)

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

Slide 12

JSOMTC, SWMG(A)

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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Slide 13

JSOMTC, SWMG(A)

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

Slide 14

JSOMTC, SWMG(A)

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

Slide 15

JSOMTC, SWMG(A)

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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Slide 16

JSOMTC, SWMG(A)

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……

Slide 17

JSOMTC, SWMG(A)

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

Slide 18

JSOMTC, SWMG(A)

D5W (Dextrose in Water)

 D5W's initial tonicity comparable to intravascular

fluid (isotonic). Dextrose is metabolized leaving no

• smotically 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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Slide 19

JSOMTC, SWMG(A)

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

Slide 20

JSOMTC, SWMG(A)

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

Slide 21

JSOMTC, SWMG(A)

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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Slide 22

JSOMTC, SWMG(A)

 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

Hypertonic Crystalloids

Slide 23

JSOMTC, SWMG(A)

Hypertonic Crystalloids

 Complications

• Central Pontine Myelinolysis
• Rapid transition from hyponatremia to hypernatremia
• Manifested clinically as lethargy and quadriplegia/paresis
• Hypernatremia
• Hypervolemia
• Pulmonary edema

Slide 24

JSOMTC, SWMG(A)

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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Slide 25

JSOMTC, SWMG(A)

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

Slide 26

JSOMTC, SWMG(A)

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

Slide 27

JSOMTC, SWMG(A)

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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Slide 28

JSOMTC, SWMG(A)

Current Events Regarding Hextend

A1

Slide 29

JSOMTC, SWMG(A)

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,
• r 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

Slide 30

JSOMTC, SWMG(A)

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)



Slide 28 A1 LTC Riesberg want this slide to remain in power point.

Author, 6/5/2017

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Slide 31

JSOMTC, SWMG(A)

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

Slide 32 JSOMTC, SWMG(A)

Identify the indications and considerations for a peripheral IV

Slide 33

JSOMTC, SWMG(A)

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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Slide 34

JSOMTC, SWMG(A)

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

Slide 35

JSOMTC, SWMG(A)

Peripheral IV Considerations

 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

Slide 36

JSOMTC, SWMG(A)

Peripheral IV Considerations

 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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Slide 37

JSOMTC, SWMG(A)

Peripheral IV Considerations

 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

Slide 38 JSOMTC, SWMG(A)

Identify the peripheral IV sites

Slide 39

JSOMTC, SWMG(A)

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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Slide 40

JSOMTC, SWMG(A)

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

Slide 41

JSOMTC, SWMG(A)

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

Slide 42 JSOMTC, SWMG(A)

Identify the Characteristics of Common IV Equipment

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Slide 43 JSOMTC, SWMG(A)

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

Slide 44

JSOMTC, SWMG(A)

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

Slide 45

JSOMTC, SWMG(A)

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
• f 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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Slide 46

JSOMTC, SWMG(A)

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.

Slide 47

JSOMTC, SWMG(A)

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

Slide 48

JSOMTC, SWMG(A)

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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Slide 49

JSOMTC, SWMG(A)

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

Slide 50

JSOMTC, SWMG(A)

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

Slide 51

JSOMTC, SWMG(A)

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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Slide 52 JSOMTC, SWMG(A)

Identify the Steps for Initiating and Discontinuing a Peripheral IV

Slide 53

JSOMTC, SWMG(A)

 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

• range font

Traditional IV versus Ranger IV

Slide 54

JSOMTC, SWMG(A)

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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Slide 55

JSOMTC, SWMG(A)

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

Slide 56

JSOMTC, SWMG(A)

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

Slide 57

JSOMTC, SWMG(A)

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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Slide 58

JSOMTC, SWMG(A)

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

Slide 59

JSOMTC, SWMG(A)

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

Slide 60

JSOMTC, SWMG(A)

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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Slide 61

JSOMTC, SWMG(A)

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

Slide 62

JSOMTC, SWMG(A)

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

Slide 63

JSOMTC, SWMG(A)

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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Slide 64

JSOMTC, SWMG(A)

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”

• ver first gauze

 Secure gauze with

tape or Coban

 Document procedure

Slide 65 JSOMTC, SWMG(A)

Identify the Complications of IV Fluid Therapy

Slide 66

JSOMTC, SWMG(A)

Complications of IV Fluid Therapy

 Divided into two categories  Local

• Hematoma
• Infiltration
• Infection
• Phlebitis and

thrombophlebitis

• Extravasation
• Arterial cannulation

 Systemic

• Circulatory (fluid)
• verload
• Catheter related sepsis
• Pyrogenic reaction
• Catheter embolism
• Air embolism

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Slide 67

JSOMTC, SWMG(A)

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

Slide 68

JSOMTC, SWMG(A)

Hematoma

 Treatment

• Remove catheter
• Apply direct pressure to

site

• Reattempt at another site

 Prevention

• Utilize proper technique

when initiating or discontinuing IV

Sub-Optimal

Slide 69

JSOMTC, SWMG(A)

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

24

Slide 70

JSOMTC, SWMG(A)

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 

Slide 71

JSOMTC, SWMG(A)

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

Slide 72

JSOMTC, SWMG(A)

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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Slide 73

JSOMTC, SWMG(A)

Phlebitis and Thrombophlebitis

 Both can result from poor insertion technique, use

• f solution or drug with inappropriate pH or
• smolality, or IV catheter remaining in place too

long

 Phlebitis

• Inflammation of vein
• Mechanical, chemical, or bacterial

 Thrombophlebitis

• Irritation of vein with clot formation

Heavy sigh…

Slide 74

JSOMTC, SWMG(A)

Phlebitis and Thrombophlebitis

 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!

Slide 75

JSOMTC, SWMG(A)

Phlebitis and Thrombophlebitis

 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!

26

Slide 76

JSOMTC, SWMG(A)

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/amputation

REALLY!!!

Slide 77

JSOMTC, SWMG(A)

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

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JSOMTC, SWMG(A)

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

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JSOMTC, SWMG(A)

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

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JSOMTC, SWMG(A)

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

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Slide 82

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Catheter Related Sepsis

 Improper technique in catheter insertion, infusion

• f contaminated solution, multiple line violation

and manipulation, or skin colonization adjacent to catheter site

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JSOMTC, SWMG(A)

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

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JSOMTC, SWMG(A)

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

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JSOMTC, SWMG(A)

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

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JSOMTC, SWMG(A)

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

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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

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JSOMTC, SWMG(A)

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

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JSOMTC, SWMG(A)

Demonstrate Initiating and discontinuing a peripheral IV

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Slide 91

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Questions?

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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

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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

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Reason

 Hemorrhagic shock is a

leading cause of death

• n the battlefield

 Infusion of intravenous

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

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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

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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

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Slide 97 JSOMTC, SWMG(A)

IV Fluid Therapy Lecture and Demo PFN: SOMPSD03

Hours: 2.0 Instructor: