Intravenous Fluid Therapy

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Intravenous Fluid Therapy
Paramedic Class
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5 Purposes

• Provide maintenance requirements for FE
• Replace previous losses
• Replace concurrent losses
• Provide a mechanism for administration of
  medications/blood products
• Provide nutrition

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Intravenous Solutions

• Colloids
• Crystalloids
• Blood products

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Colloids

• Large protein molecules
• Cant cross capillary membrane
• Draw fluid from interstitial and intracellular
  compartments into vascular compartment.
• Work well in reducing edema while expanding
  vascular compartment

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Colloids

• Too costly
• Difficult to store
• Never used as first solution
• Albumin, steroids

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Crystalloids

• Contain electrolytes
• Move across capillary membranes

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Crystalloids

• Need 2-3 times the volume lost

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Tonicity

• A solutions salt balance compared to plasma
• Around 300 mOsm/L

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Isotonic

• Nearly the same as serum
• NS 0.9 Sodium Chloride
• LR
• Generally, initial fluid replacement should not
  exceed three liters before blood is infused

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Isotonic

• Balanced salt solutions
• Isotonic crystalloids
• Remember! 3 ml of isotonic crystalloid are needed
  to replace 1 ml of blood

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Hypertonic

• Higher osmolarity
• Pulls FE from intracellular and interstitial
  compartments into intravascular compartment.

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Hypertonic, cont.

• Can help stabilize BP, increase urine output,
  reduce edema
• Rarely used in prehospital setting.
• Dangerous if cell dehydration exists
• D-5-W in Lactated Ringers, 10 NS
• Example Albumin

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Hypotonic

• Less osmolarity than serum
• Dilutes serum
• 0.45 NaCl
• D5NS.45 (5 Dextrose in ½ normal saline)

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Hypotonic, cont.

• Water is pulled from vascular compartment into
  interstitial fluid compartment, then into
  adjacent cells
• Helpful when cells are dehydrated
• Dialysis pt on diuretics
• Hyperglycemia - DKA
• Can be dangerous sudden fluid shift can cause
  cardiovascular collapse and ICP

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REMEMBER - WATER GOES WHERE THE SALT IS

• Isotonic no movement initially
• Hypertonic attracts water
• Hypotonic gives up water

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Isotonic crystalloid

• EMTs first choice
• Normal Saline 0.9
• Lactated Ringers, Plasmalyte-A, Normosol-R

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Hypertonic Solution

• Higher concentration of ions
• 1.8 NaCl, D5W/LR

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Hypertonic Solution

• Usually no prehospital application
• Crenation

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Hypotonic Solution

• Lower concentration
• 0.45 NaCl, 0.25 NaCl

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Hypotonic Solution

• No prehospital application
• Lysis

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Administration Sets

• Microdrip (60 drops per ml)
• Macrodrip (1015 drops per ml)

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Administration Sets

• Others (12, 20 drops/ml, adjustable)
• Soluset (pediatric set)

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Microdrip

• Usually for secondary IV or limited fluid
  administration
• Used for IV mixed medications

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Microdrip

• Lidocaine, Bretylium
• Dopamine,
• Epinephrine

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Macrodrip or regular set

• For initial or primary IV
• Runs fluid faster

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Cannulas

• Hollow needles (butterfly)
• Angiocath (catheter over the needle)
• Intracath (needle over the catheter)

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Angiocath

• Usual prehospital device
• Smaller number is larger size
• 14, 16, 18, 20, 22 gauge

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Peripheral

• You can see it or touch it
• Brachial, cephalic, saphenous

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Peripheral

• Dorsal plexus, antecubital fossa
• External jugular

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Central

• Femoral is allowed in Oregon

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Central

• Internal jugular (physician only)
• Subclavian (physician only)

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Butterfly / Scalp vein

• Scalp veins in infants
• Draw blood
• Small gauge (23 gauge)

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Complications of IV Therapy

• Pain
• Extravasation
• Hematoma

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Complications of IV Therapy

• Infiltration
• Local infection
• Pyrogenic reaction

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Complications of IV Therapy

• Catheter shear
• Arterial puncture
• Circulatory overload

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Complications of IV Therapy

• Thrombophlebitis
• Air embolism
• Sepsis

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Flow rates

• TKO (to keep open)
• KVO ( keep vein open)
• WFO (wide full open)

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Flow rates

• Drops per minute
• Volume in mls x drops/ml of the set

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Flow rates

• Divided by the time in minutes

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120 ml/hour using a 10 drop set

• 120 x 10
• Divided by 60 min.
• 20 drops per minute

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Subcutaneous catheters

• Portacatheter
• Most common
• Hickman catheter
• PICC line

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IV Pumps

• Allows primary line, secondary line and piggyback
  line
• 1 999 ml/hr
• KVO 1 ml/hr
• Battery operation 8 hrs at 125 ml/hr or 1000 ml
  total

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Procedure demonstrated
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IV starts Improve your odds!

• A calm start
• Confidence
• Gravity and position
• Three-point landing
• Universal precautions

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IV starts, cont.

• Failed?
• Shaving?
• Removing tape
• Removing the cannula
• The best tourniquet
• Clean well
• NTG venodilation

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IV starts, cont.

• Cant see? Trust your fingers
• Hard veins
• Ask the patient
• Float it in
• Less often used veins
• Right or Left?
• The Stroke Side?

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• Moving with the target
• Drip or Lock?
• What size cannula?
• Loose skin?
• Tape well
• Use a light?
• Its NOT about your ego!