IV THERAPY AN OVERVIEW
Anatomy , Physiology
& Basic Concepts of IV Fluids
Dr.Ravindar Bethi, MD
Specialist , Anesthesia & ICU,
Al Rass General Hospital, KSA.
IV THERAPY AN OVERVIEW
Intravenous therapy or IV therapy is
the giving of liquid substances
directly into a vein.
IV THERAPY AN OVERVIEW
Compared with other routes of
administration, the intravenous route is
the fastest way to deliver fluids and
medications throughout the body.
Before we get started…
Safe work aids project…
• http://www.friendtofriend.org/drugs/vein-care.html
• Harm reduction (or less commonly known as harm minimisation)
refers to a range of public health policies designed to reduce the
harmful consequences associated with recreational drug use and
other high risk activities. Harm reduction is put forward as a useful
perspective alongside the more conventional approaches of
demand and supply reduction.[1]
• Many advocates argue that prohibitionist laws criminalize people
for suffering from a disease and cause harm, for example by
obliging drug addicts to obtain drugs of unknown purity from
unreliable criminal sources at high prices, increasing the risk of
overdose and death.[2] Its critics are concerned that tolerating risky
or illegal behaviour sends a message to the community that these
behaviours are acceptable
Types of IV Needles
 Steel needles: Butterfly catheters, named for the plastic
tabs that look like wings. Used for small quantities of
medicine, infants, and to draw blood although the small
size of the catheter can damage blood cells. Usually
small gauge needles.
 Over-the-needle catheters: Peripheral-IV catheters are
usually made of various types of Teflon or silicone
materials which determines how long the catheter can
remain in your vein. These typically need to be
replaced about every 1 to 3 days.
 Inside-the-needle catheters: Larger than Over-theneedle catheters, typically used for central lines.
Gauges
• Needles & Catheters are sized by diameters
which are called gauges.
• Smaller diameter = larger gauge
• IE: 22-gauge catheter is smaller than a 14gauge
• Larger diameter = more fluid able to be
delivered
• If you need to deliver a large amount of fluid,
typically 14- or 16-gauge catheters are used.
Intravenous Catheter Complications
• About 25 million Americans have intravenous
catheters placed each year. Intravenous
catheters (or IVs) are a very important part of
medical treatment for acute illnesses, cancer,
surgery, anesthesia, and trauma, allowing
medications to reach as quickly and effectively
as possible, via the bloodstream, the parts of
the body where they work.
Intravenous Catheter Complications
• IV catheters can be placed in a hand, arm or
leg. These are known as "peripheral" IVs. IVs
placed in the central circulation, like the
internal jugular vein (neck) or subclavian vein
(just beneath the collar bone), are known as
"central lines". The rest of this article will deal
with peripheral IVs, the most common type of
IV.
Intravenous Catheter Complications
• During the placement of an IV, a needle is inserted
through the skin and into an accessible blood vessel. A
Teflon (plastic) cannula is then slid over the needle,
which is withdrawn. No needle remains in your body.
(So-called "butterfly" needles are an exception to this).
Some healthcare providers use a little bit of local
anesthetic beforehand, with a very tiny needle, to
numb the area of skin where the IV is inserted. Local
anesthetic cream is sometimes applied 45-60 minutes
beforehand to achieve the same effect. This is
particularly helpful in the care of children.
Complications
• Local Infection
• In any case where there is an open wound on the body,
disrupting the protective lining of skin, an infection can
occur. A microscopic organism may use the tiny hole in
the skin created by the IV catheter to find its way into
the body, and cause an infection. Common signs of
local infection ("abscess") include a large lump that is
painful and hot to touch.
• Treatment - If you suspect an infection, see your
healthcare provider immediately. Antibiotics may be
used to control the bacterial infection.
Complications
• Infiltration
• This occurs when the catheter unintentionally enters the tissue
surrounding the blood vessel. In this case the IV fluid and
associated medications will go into the tissues and there will be a
lump where the IV has been inserted. It would be cool to touch (this
differentiates it from inflammation due to infection, which is warm
to the touch).
• Treatment - If you notice this inform your healthcare professional
and they will administer appropriate care immediately. Infiltrated
IVs are not a big problem usually unless the medication being
administered is very irritant, such as certain chemotherapy and
circulatory medicines. The intravenous infusion must be stopped,
obviously, to avoid putting any more fluid or medication into the
tissues. Another IV may need to be started elsewhere.
Complications
• Hematoma
• A hematoma is a collection of blood caused by internal
bleeding. This happens when the catheter punctures
through the vein and causes a hematoma. Hematomas
generally occur with unsuccessful IV insertion but can
also happen when an IV is taken out. This is why
pressure must be applied to the insertion site, to try to
make the hematoma as small as possible.
• A hematoma may appear as a visible bruise or a lump.
• Treatment - A hematoma normally recovers over time
(a few hours or days) without treatment.
Complications
• Nerve Damage
• It is also possible for the IV needle to penetrate and injure a nerve, and for
bruising and bleeding to irritate a nerve. Nerves are invisible from the skin
surface so it?s easy to understand how this could happen. If you feel a
sudden sharp pain radiating along your arm as the IV is inserted, let your
healthcare provider know immediately as this may be a sign that the
needle has come into contact with a nerve.
• A 1996 study of 419,000 blood donations showed that 1 in every 6300
donors had a nerve injury. Fortunately, most got better within a month.
The symptoms included excessive or radiating pain, and loss of arm or
hand strength. Fifty-two of 56 donors achieved a full recovery, and 4 other
donors had only a mild, localized, residual numbness.
• Treatment - Nerve damage tends to repair itself in a few weeks to a few
months. If you suspect a nerve injury contact your doctor. In rare instances
(such as persistent weakness) specific treatment, even surgery, may
become necessary.
In classical terms, thrombosis is caused by abnormalities in one
or more of the following (Virchow's triad):
• The composition of the blood (hypercoagulability)
• Quality of the vessel wall (endothelial cell injury)
• Nature of the blood flow
The formation of a thrombus is usually caused by Virchow's
triad. To elaborate, the pathogenesis includes: an injury to the
vessel's wall (such as by trauma, infection, or turbulent flow at
bifurcations); by the slowing or stagnation of blood flow past
the point of injury (which may occur after long periods of
sedentary behavior—for example, sitting on a long airplane
flight); by a blood state of hypercoagulability (caused for
example, by genetic deficiencies or autoimmune disorders).
IV THERAPY AN OVERVIEW
It is commonly referred to as a
drip because it employs a
drip chamber,
which prevents
air entering the blood stream
(air embolism)
and allows an estimate of
flow rate.
IV THERAPY AN OVERVIEW
ANATOMY AND PHYSIOLOGY
FLUIDS AND
ELECTROLYTES
Dorsal
venous arch
ANATOMY AND PHYSIOLOGY
Basilic vein
ANATOMY AND PHYSIOLOGY
Cephalic vein
ANATOMY AND PHYSIOLOGY
dorsal veins
of forearm
ANATOMY AND PHYSIOLOGY
ANATOMY AND PHYSIOLOGY
Medial
cubital vein
ANATOMY AND PHYSIOLOGY
Brachial
artery
Medial
cubital vein
ANATOMY AND PHYSIOLOGY
Brachial
artery
Medial
cubital vein
Median
Nerve
ANATOMY AND PHYSIOLOGY
Dorsal
venous arch
Femoral Vein
Great Saphenous
Vein
ANATOMY AND PHYSIOLOGY
Scalp Veins
ANATOMY AND PHYSIOLOGY
…the new access site has to be
proximal to the "blown" area to
prevent extravasation of
medications through the damaged
vein…
…for this reason it is advisable to
site the first cannula at the most
distal site on the vein.
Interosseous Route
The only alternative
in emergency
that is equally reliable
ANATOMY AND PHYSIOLOGY
Central Venous Lines
Central Lines flow through a catheter with its
tip within a large vein, usually the
superior vena cava or inferior vena cava, or
within the right atrium of the heart.
Central Venous Lines
Central Lines flow through a catheter with its
tip within a large vein, usually the
superior vena cava or inferior vena cava, or
within the right atrium of the heart.
Central Venous Lines
Central Lines flow through a catheter with its
ADVANTAGES
tip within
a large vein, usually the
• Fluidsvena
irritating
veinscava,
can or
superior
cavato
orperipheral
inferior vena
be given
within
the right atrium of the heart.
• Chemotherapy
• Total parenteral nutrition
• Medications reach the heart
immediately, and are quickly
distributed to the rest of the body.
• Central venous pressure can be
measured
Central Venous Lines
Central Lines flow
through a catheter with its
DISADVANTAGES
tip within a large vein, usually the
• Risksvena
of bleeding,
air cava, or
superior
cava orinfection,
inferior vena
embolism.
within
the right atrium of the heart.
• Technically difficult–
• needs experienced clinician
knowing the appropriate
landmarks and/or
• using an ultrasound probe to
safely locate and enter the vein.
• Pleura and carotid artery are at risk of
damage with the potential for
pneumothorax or puncture/
cannulation of the artery.
Central Venous Lines
Central Lines flow through a catheter with its
INTERNAL
tip within
a largeJUGULAR
vein, usually the
• Nursing
care
superior
vena cava
or inferior vena cava, or
within
right atrium
the heart.
• Bethe
cautious
with of
potassium
Central Venous Lines
Central Lines flow through a catheter with its
tip within a large vein, usually the
SUBCLAVIAN
superior vena cava or inferior vena cava, or
• Nursing
care
is easier
within
the right
atrium
of the heart.
• Open even in shock
• Incompressible
Central Venous Lines
Central Lines flow through a catheter with its
tip within aFEMORAL
large vein, usually the
superior vena cava or inferior vena cava, or
• Emergency
situations
within
the right atrium
of thewhere
heart.
it is difficult to cannulate
Internal jugular vein or
Subclavian vein
• High risk of infection
• Preferred for potassium
infusions
Central Venous Lines
Central Lines flow through a catheter with its
tip within a large vein, usually the
superior vena cava or inferior vena cava, or
within the right atrium of the heart.
Central Venous Line Vs Pulmonary Artery Catheter
Some special types of
Central Venous Lines
CentralPeripherally
Lines flowinserted
through
a catheter
central
catheter with its
tip within a large vein, usually the
superior vena cava or inferior vena cava, or
within the right atrium of the heart.
•
•
ADVANTAGES
Safer to insert with a
relatively low risk of
uncontrollable bleeding
no risks of damage to the
lungs or major blood
vessels.
With proper hygiene, care,
can be left in place for
several weeks for patients
who require extended
treatment.
Some special types of
Central Venous Lines
CentralPeripherally
Lines flowinserted
through
a catheter
central
catheter with its
tip within a large vein, usually the
DISADVANTAGES
superior vena cava or inferior vena cava, or
within the right atrium of the heart.
• Must travel through a
relatively small peripheral
vein which can take a less
predictable course on the
way to the superior vena
cava . Hence, more
technically difficult to place
in some patients.
• Travels through the axilla.
Hence, can become kinked
causing poor function.
Some special types of
Central Venous Lines
Central Lines flow through a catheter with its
Tunneled
Lines
tip within
a large vein,
usually the
superior
vena
or inferior
vena cava, or
Hickman
linecava
or Broviac
catheter
within the right atrium of the heart.
• “Tunneled" under the skin to emerge
a short distance away. from the
central vein
• Reduced risk of infection, since
bacteria from the skin surface are not
able to travel directly into the vein;
• Catheters are also made of materials
that resist infection and clotting.
A Hickman line in a
leukemia patient.
It is tunneled under the
skin to the jugular vein
Some special types of
Central Venous Lines
Central Lines flow through a catheter with its
Implantable
ports
tip within
a large vein,
usually the
vena
cava or
inferior vena
cava, or
•superior
Silicone
rubber
reservoir,
implanted
withinthe
theskin.
right atrium of the heart.
under
• Medication is injected via its silicone
cover, into the reservoir.
• The cover can accept several
hundreds of needle sticks during its
lifetime. It is possible to leave the
ports in the patient's body for years.
Some special types of
Central Venous Lines
Central Lines flow through a catheter with its
Implantable
ports
tip within
a large vein,
usually the
superior vena cava or inferior vena cava, or
within the
rightmaintenance.
atrium of the heart.
• Needs
regular
If it is
plugged a thrombus can form with
the accompanying risk of
embolisation
• Commonly used for patients on longterm intermittent treatment.
IV Fluids
• Crystalloids
• Colloids
IV Fluids
• Colloids
IV Fluids
• Crystalloids
IV Fluids
• Colloids
• Contain larger insoluble
molecules, such as
albumen.
• Preserve a high colloid
osmotic pressure in the
blood
• Blood itself is a colloid.
IV Fluids
• Colloids
IV Fluids
• Crystalloids
• Aqueous solutions of watersoluble molecules.
• The most commonly used
crystalloid fluid is normal
saline=, a solution of sodium
chloride at 0.9% concentration,
•
What
is
which is close to the
concentration in the blood
(isotonic).
• What is
isotonic?
Iso-osmolar ?
IV Fluids
• Crystalloids
IV Fluids
• Crystalloids
IV Fluids
• Crystalloids
•
•
isotonic
Fluid of choice in multiple
situations
• Trauma
• Metabolic alkalosis
Not to be given in
hyperchloremic acidosis
IV Fluids
• Crystalloids
hypotonic
IV Fluids
• Crystalloids
? Isotonic/ Hypotonic
Isotonic in vitro
• Hypotonic in vivo
•
• Iso-osmolar , compared
to Normal Saline
• Hypotonic to
the human cells
due to Insulin
• Hypertonic in insulin
deficiency
IV Fluids
• Crystalloids
? Isotonic/ Hypertonic ?
IV Fluids
• Crystalloids
Nearly Isotonic
Contains calcium, potassium and
Lactate
• Don’t give in alkalosis
• Don’t give in hyperkalemia
• Don’t give with Blood
• Mind its Calcium content, when
giving with Mg therapy
IV Fluids
• Crystalloids
• When giving KCl in
the treatment of
hypokalemia, don’t
add it to solutions
containing Dextrose.
• Don’t give
potassium
• When giving
therapy with
Dextrose containing
Dextrose
solutions, add KCl to
containing
prevent hypokalemia
solutions
Crystalloids
move up to
here
Colloids
stay
here
Distribution of fluid
in human body
Risks and complications of
IV THERAPY
1.
2.
3.
4.
5.
6.
Infection
Phlebitis
Infiltration and extravasation
Embolism
Fluid overload
Electrolyte Imbalance
Electrolytes
• Sodium
• Potassium
135 – 145 mmol/L
3.5 – 5.0 mmol/L
• Calcium
2.12 – 2.75 mmol/L
( Ionised calcium 1.0-1.3 mmol/L)
• Magnesium 1.5 – 2.2 m Eq/L
• Phosphorous 0.81 – 1.20 mmol/L
Electrolytes
• Sodium
135 – 145 mmol/L
• Potassium
Low
sodium
3.5 – 5.0
mmol/L– lower
osmolality
• Calcium
2.12 – 2.75 mmol/L
• Magnesium High
1.5 –sodium
2.2 m Eq/L–
osmolality
higher
• Phosphorous 0.81 – 1.20 mmol/L
Electrolytes
• Sodium
• Potassium
135 – 145 mmol/L
3.5 – 5.0 mmol/L
Hypokalemia
• Calcium
2.12 – 2.75 mmol/L
( Ionised calciumHyperkalemia
1.0-1.3 mmol/L)
• Magnesium 1.5 – 2.2 m Eq/L
• Phosphorous 0.81 – 1.20 mmol/L
Hyperkalemia
• Sodium
• Potassium
• Calcium
BE – 145 mmol/L •
135
GOOD
•
3.5 – 5.0 mmol/L
IN
•
CLINICAL
•
2.12 – 2.75 mmol/L
SKILLS
•
Bicarbonate
Glucose +
Insulin
Calcium
Sorbitol
( Ionised calcium 1.0-1.3 mmol/L)
• Magnesium 1.5 – 2.2 m Eq/L
•
KEEP
• Keyexalate
PhosphorousDRUGS
0.81 – 1.20 mmol/L
• Dialysis
AWAY
• Albuterol
ACLS - 2006
Electrolytes
• Sodium
• Potassium
135 – 145 mmol/L
3.5 – 5.0 mmol/L
• Calcium
2.12 – 2.75 mmol/L
( Ionised calcium 1.0-1.3 mmol/L)
• Magnesium 1.5 – 2.2 m Eq/L
• Phosphorous 0.81 – 1.20 mmol/L