IV FLUIDS AND VASCULAR ACCESS DEVICES

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IV FLUIDS AND VASCULAR ACCESS DEVICES

• Rick Slaven
• NREMT-P Critical Care
• Claiborne County EMS

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Reasons for IV Infusion

• Life sustaining fluids
• Electrolytes
• Route for medication administration
• Immediate results
• Predictable therapeutic effects
• There are more than 200 types of commercially
  prepared IV fluids

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Types of Solutions

• CRYSTALLOIDS
• Isotonic
• Hypotonic
• Hypertonic

• COLLOIDS
• Always hypertonic

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Crystalloids

• Solutions with small molecules that flow easily
  from the bloodstream into cells and tissues.

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Crystalloid Solutions

• Isotonic solutions have a concentration of
  dissolved particles equal to that of
  intracellular fluid.
• Hypertonic solutions have a greater concentration
  of dissolved particles than does intracellular
  fluid.Fluid is pulled from cells
• Hypotonic solutions have less particles than does
  intracellular fluid.Fluid flows into cells

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SO WHAT!!!!

• The wrong fluid for the wrong patient can make a
  critical difference in their outcome. Dont
  depend on the physician. KNOW YOUR FLIUDS

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OSMOSIS and DIFFUSION

• In Osmosis, fluid moves passively from areas with
  more fluid to areas with less fluid
• FLUID MOVES

• In Diffusion, solutes(particles) move from an
  area of high concentration to an area of lesser
  concentration.
• PARTICLES MOVE

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ISOTONIC FLUIDS

• Osmotic pressure is the same both inside and
  outside the cell.
• Cells neither shrink nor swell with fluid
  movement.
• Same tonicity as plasma

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Hypotonic Solutions

• Osmotic pressure is less than intracellular fluid
• Water is drawn into the cells from the
  extracellular fluid causing them to swell
• Inappropriate use can result in increased ICP and
  cardiovascular collapse from volume depletion.
• May cause blood cells to burst
• Volume Depletion?

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Hypertonic Solutions

• Osmotic pressure is greater than that of
  intracellular fluid. Hypertonic solutions have a
  large concentration of solutes(particles).
• Water is drawn from the cells to equalize the
  concentration, which causes the cells to shrink.
• Inappropriate use can cause fluid overload and
  pulmonary edema

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Isotonic Fluids

• 0.9 Sodium Chloride ( Normal Saline )
• Lactated Ringers
• Dextrose 5 in Water (D5W)

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Normal Saline

• Uses
• Shock
• Resuscitation
• Fluid challenges
• Blood transfusions
• Metabolic alkalosis
• Hyponatremia
• DKA

• Special considerations
• Use with caution in patients with heart failure,
  edema, or hypernatremia
• Can lead to overload

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Lactated Ringers

• Uses
• Dehydration
• Burns
• GI tract fluid loss
• Acute blood loss
• Hypovolemia

• Special Considerations
• Contains Potassium, can cause hyperkalemia in
  renal patients
• Patients with liver disease cannot metabolize
  lactate
• Lactate is converted into bicarb by liver

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D 5 W

• Uses
• Fluid loss and dehydration
• Hypernatremia

• Special Considerations
• Solution becomes Hypotonic when dextrose is
  metabolized
• Do not use for resuscitation
• Use cautiously in renal and cardiac patients

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Hypotonic Solutions

• 0.45 Sodium Chloride (1/2 normal saline)

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0.45 Sodium Chloride

• Uses
• Gastric fluid loss
• Cellular dehydration from excessive diuresis
• Hypertonic dehydration
• Slow rehydration

• Special Considerations
• Do not give to patients at risk for ICP
• Not for rapid rehydration
• Electrolyte disturbances can occur

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Hypertonic Solutions

• 5 Dextrose in 0.9 Sodium Chloride(D5NS)
• 5 Dextrose in Lactated Ringers (D5LR)
• 5 Dextrose in 0.45 Sodium Chloride (D51/2NS)

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D5NS

• Uses
• Heat related disorders
• Fresh water drowning
• Peritonitis

• Special Considerations
• Should not be given to patients with impaired
  cardiac or renal function
• Draw blood before administering to diabetics

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D5LR

• Uses
• Hypovolemic Shock
• Hemorrhagic Shock
• Certain cases of acidosis

• Special Considerations
• Do not administer in patients with cardiac or
  renal dysfunction
• Monitor for circulatory overload

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D5 1/2NS

• Uses
• Heat exhaustion
• Diabetic disorders
• TKO solution in patients with renal or cardiac
  dysfunction

• Special Considerations
• Not for rapid fluid replacement

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Colloids

• Albumin
• Plasma Protein fraction
• Dextran
• Hetastarch
• Colloids are made up of much larger solutes than
  are crystalloids

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Colloids

• Plasma Expander
• Used if crystalloids do not improve blood volume
• Colloids pull fluid into the bloodstream,
  remember they are always Hypertonic
• Watch for increased BP, Dyspnea, and bounding
  pulse

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VASCULAR ACCESS DEVICES

• Short-Term
• Mid-Term
• Long-Term
• Tunneled or Non-Tunneled

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Tunneled Vs Nontunneled

• Groshong, Broviac, and Hickman
• Single or multi lumen
• Tunneled through tissue for several inches to the
  cannulated vein
• Used for intermittent or continued therapy

• Single or multi lumen
• Inserted peripherally(PICC) or centrally(central
  line)directly into vasculature
• Short term therapy(analgesics,TPN,fluids,meds)CVP
  monitoring through distal port

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Short Term Devices

• Standard IV access
• Heplock or saline lock
• Short term central catheters(i.e. triple lumen,
  Swan-Ganz)
• Quinton catheter

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Swan-Ganz Catheter

• The Swan - Ganz is a long plastic tube with
  several openings.Its purpose is to measure the
  pressures in the heart and vessels going to the
  lungs.After placement, a monitor is attached that
  displays numbers and wave forms that help to
  assess heart and lung function.

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• Proximal Port (Blue) - Monitors RA pressure. Port
  for blood samples. Meds and fluids.
• Distal Port (Yellow) - Monitors PA pressure.
  Monitors PCWP.
• Thermistor Port (Square White Box) - Cardiac
  output port.
• Inflation Port (Balloon Port)

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Multi Lumen Devices

• Central catheters
• Enter in subclavian and are advanced into right
  atrium
• Used for medication administration, blood draws,
  CVP monitoring, fluid administration,cardiac
  pacing

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Quinton Catheter

• Temporary hemodialysis access
• 2 lumens, one for intake and one for venous
  return
• Infection risk is high.

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Mid-Term Devices

• Peripherally Inserted Central Catheter
• Mid Line Catheter

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PICC

• Can be single or multi lumen.
• Used for extended home TPN
• Home health care use
• Administration of meds and fluids
• Used when repeated IV sticks would be necessary

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Midline Catheter

• Similar to a PICC but not a true central line
• Catheter is advanced only into the upper arm
• Not used when caustic agents such as chemo will
  be needed

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Long Term Devices

• Hickman-Broviac Catheter
• Groshong Catheter
• Implantable Venous Access Devices(Port-a-cath)
• Hohn Catheter
• Long term catheters are almost always tunneled
  and the scar tissue serves to anchor the catheter

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Hickman-Broviac

• Tunneled from chest wall to subclavian vein and
  continues to superior vena cava
• Good as long as line is patented and not
  infected(months-years)
• Commonly used for oncology
• Broviac is smaller and generally used in peds

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Groshong

• Similar to Hickman however catheter is closed
  when not in use
• Requires only a saline flush weekly
• Used in patients where heparin is undesirable due
  to low platlet count
• Good for long periods

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Groshong
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IVADs

• Portacath-Inserted in the chest below the
  clavicle.Access is gained by puncturing the skin
  then the synthetic port
• Permacath-Lasts longer.Up to a year
• Passport-Placed in the arm instead of
  chest.Cheapest

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Hohn Catheter

• Similar to Hickman but it lies just under the
  insertion point rather than up the subcutaneous
  portion of the catheter body

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REMEMBER

• Many of these vascular access devices are sealed
  with a heparin solution. Some contain as much as
  5000U - 7500U. You can significantly
  anticoagulate your patient if this heparin is not
  drawn off before administering fluids or
  medications

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QUESTIONS