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

IV Fluid Therapy Lecture and Demo PFN: SOMPSD03 Hours: 2.0 Instructor: JSOMTC, SWMG(A) Slide 1 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 JSOMTC, SWMG(A) Slide 2 References  Fluids and Electrolytes Made Incredibly Easy, 5 th edition, 2011  The ICU Book, 3 rd edition, 2007  AACN Essentials of Critical Care Nursing, 2006  Infusion Nursing an Evidence Based Approach, 3 rd edition, 2010  PHTLS Manual, Military 7 th edition, 2011 JSOMTC, SWMG(A) Slide 3 1

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 JSOMTC, SWMG(A) Slide 4 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 JSOMTC, SWMG(A) Slide 5 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 JSOMTC, SWMG(A) Slide 6 2

Identify the physiology, indications, and contraindications of IV fluids JSOMTC, SWMG(A) Slide 7 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 JSOMTC, SWMG(A) Slide 8 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 JSOMTC, SWMG(A) Slide 9 3

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 JSOMTC, SWMG(A) Slide 10 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, D 5 W JSOMTC, SWMG(A) Slide 11 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 JSOMTC, SWMG(A) Slide 12 4

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 JSOMTC, SWMG(A) Slide 13 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 JSOMTC, SWMG(A) Slide 14 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 JSOMTC, SWMG(A) Slide 15 5

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…… JSOMTC, SWMG(A) Slide 16 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 JSOMTC, SWMG(A) Slide 17 D 5 W (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 JSOMTC, SWMG(A) Slide 18 6

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 JSOMTC, SWMG(A) Slide 19 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 JSOMTC, SWMG(A) Slide 20 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 JSOMTC, SWMG(A) Slide 21 7

Hypertonic Crystalloids  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 JSOMTC, SWMG(A) Slide 22 Hypertonic Crystalloids  Complications  Central Pontine Myelinolysis • Rapid transition from hyponatremia to hypernatremia • Manifested clinically as lethargy and quadriplegia/paresis  Hypernatremia  Hypervolemia  Pulmonary edema JSOMTC, SWMG(A) Slide 23 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 JSOMTC, SWMG(A) Slide 24 8

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 JSOMTC, SWMG(A) Slide 25 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 JSOMTC, SWMG(A) Slide 26 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 JSOMTC, SWMG(A) Slide 27 9