IntravenousTherapy：静脉注射疗法.ppt

IntravenousTherapy 7 4 Thirtyyearsago Rampart Squad51 Wehavea20yearoldmalemotorcycleriderinvolvedinamotorvehiclecollisioncomplainingofneck backandlegpain Hepresentswithcompoundfracturestobothfemursandhassignificantbloodloss WearerequestinganorderfortwolargeboreIV sandRinger sLactate Objectives IdentifythereasonsIVtherapyisperformedintheprehospitalsettingIdentifythefluidscommonlyadministeredStatethebasisoffluidandelectrolytebalanceIdentifyfactorsaffectingwaterlossExplaintherecommendedusesofIVsolutionsIdentifycommoncomplicationsandreactionsCalculateaflowrateDemonstrateproperskincleansingandasepticvenipuncturetechniqueDemonstrateproperIVcannulationtechnique Whydowecannulate FluidadministrationMedicationadministrationTomaintainlife electrolytes blood DowedothemtobeEHSNSprotocolcompliant IVfluids Normalsaline 0 9 NS LactatedRinger s LR AlsoknownasHartman ssolutionorRLD5W NSD5 NSD5RL D5LR IsotonicSolutions CharacteristicsSametonicityasplasmaOsmoticpressureisthesameastheinsideofthecellFluidneverleavesorentersthecellApproximateosmolarityis240 340mOsm LWillincreasecirculatingvolume whichmayleadtofluidvolumeexcessoroverload Solutions2 5 dextrose 0 45 NaCl0 9 NaClLactatedRingers2 5 dextrosein lactatedringers6 dextanand0 9 NaCl10 dextranand0 9 NaCl NormalSaline MostcommonlyadministeredIVfluidprehospitallyIVfluidofchoiceforEHSNSprotocolsWhy LactatedRingers ComposedofmultipleelectrolytesinsalineHasfallenoutoffavorasoneofmainIVfluidsfortreatmentoftraumatichypovolemiainpastdecadeWhy HypotonicSolutions CharacteristicsMaycausebloodcellstoswellandburstMaycausechangesordamageendothelialcellsExertlessosmoticpressurethanthefluidintheextracellularcompartmentFluidisdrawnintothecellsApproximateosmolarity 240mOsm l Solutions0 45 NaCl10 dextranand5 dextrose slightlyhypotonic HypertonicSolutions CharacteristicsMaycausebloodcellstoshrinkMaycausedame changestoendothelialcellsExertmoreosmoticpressurethentheextracellularfluidFluidisdrawnfromthecellintothevascularspaceApproximateosmolarity 340mOsm l Solutions5 dextrose 0 2 NaCl5 dextrose 0 9 NaClD5WD10WD50W5 NaHCO310 15 and20 Mannitol6 dextranand0 9 NaCl AdministrationSets ThecalibrationoftheadministrationsetmustbeknowninordertocalculatetheflowoftheIVfluidscorrectly Macrodripsets10 15or20gtts mlMicrodrip minidrip 60gtts ml Wheredowecannulate HandForearmNeckFoot EquipmentRequired SolutionAdministrationsetIVcannulaTourniquetAlcoholswabGlovesSharpsbinOpsiteandgauzeTapeIfperformingaLockLock syringeandsaline Catheterspecifics ColorSizeIntDia LengthMaxFlowGrey16G1 4mm 45mm180mls minGreen18G1 0mm 45mm80mls minPink20G0 8mm 32mm54mls minBlue22G0 6mm 25mm31mls minThelengthanddiameterwillaffecttheamountoffluidabletobeinfusedthroughthecatheterLargerdiameterandshorterlengthgivesmorefluidSmalldiameterandlonglengthgiveslessfluid Typesofcatheters JelcoCathelonInsyte Typesofcatheters ProtectiveProtectivePlus AdministrationSets 10gtts ml15gtts ml60gtts mlBloodsets VeinSelection Basedon ConditionPalpatetoconfirmtypeofvesselShouldbesoftandspongyStraightwithnoturnsorbumpsLocationIstheptrightorlefthandedIstheextremityinjuredAvoidjoints stabilization Doesthepthaveashunt fistula PurposeFluidreplacement Medicationroute Safetyline lock DictatesflowrateandtypeoffluidtobeinfusedTrytouselargeveinsforlargequantitiesoffluidDurationWhattypeofpatient trauma cardiacoroutpatient PatientcomfortoverlongperiodoftimeProlongedtherapymayrequiremultiplepuncturesForlongdurationsusedistalveinsfirst FluidReplacement BloodReplacedataratioof3 1ofIVfluidtobloodbeingreplacedMinimumdailyrequirements1st10kg100ml hr2nd10kg50ml hr3rd10kg20ml hr4th10kg10ml hr5th10kg10ml hrExample50kgpatient100ml hr 50ml hr 20ml hr 10ml hr 10ml hr 190ml hr Contraindications DistaltoafracturesiteinalimbThroughdamagedorabradedskinBurnsmaybeanexceptionifthereisnootheraccessiblesiteInanarmaffectedbyaradicalmastectomy edema bloodclotorinfectionInanarmwithafistulafordialysisoraperipherallyinsertedcontrolcatheter PICCLine Procedure ObtainconsentandexplainrationaleforIVtherapyAssessthattheptmeetsthecriteriafortheprocedureEnsurethattherearenocontraindicationsfortheprocedureObserveuniversalprecautionsforbodysubstanceexposuresPrepareallnecessaryequipmentPositionthepatientApplyatourniquet3 5inchesabovetheselectedsitePatientmaymakeafisttoassistinengorgingtheveinSelectthemostappropriatevenipuncturesiteConditionLocationPurposeDurationPreparethept sarmusingalcoholswab Procedure InsertneedlethroughskinShouldbeatan30 angleLowerangle 15 andenterveinObserveflashbackEnterveina littlebitmore EntercatheterintoveinReleasetourniquetWithdrawneedleanddiscardinsharpscontainer tamponadetheveintoavoidbloodspillAttachivtubingandopenflowvalveobservingforinfiltrationCoverwithOpsiteorothersteriledressing tapeinplace IVAccess Complications LocalcomplicationsHematomasInfiltrationNecrosisThrombophlebitisSystemiccomplicationsPulmonaryedemaSpeedshockPyrogenicreactionPulmonaryembolismbloodAirCathetershear Local Hematomas Causes Symptoms Preventativeactions PuncturedveinBruisingTendernessSwellingPropertechniques Local Infiltration Causes Symptoms Preventativeactions PoorinsertiontechniquesImpropertapingOveractivepatientIVslowsorstopsSwellingorhardnessFeelingofcoldnessLeakingatthesiteArmboards propertapingRoutinechecksofIVflowandsite Local Necrosis Causes Symptoms Preventativeactions IrritationoftissuesfrominfiltrateddrugorfluidSwelling tendernessInflammationorbruisingRoutinechecksReportanychanges Local Thrombophlebitis Causes Symptoms Preventativeactions TraumatoendotheliumfromchemicalmeansPain redness swellingalonginfectedveinGeneralizedsymptomssuchasfever malaise rapidpulseAvoidinsertionoverjointSelectveinswithadequatebloodflowforinfusionsofhypertonicsolutions Systemic PulmonaryEdema Causes Symptoms Preventativeactions CirculatoryoverloadfromtoorapidinfusionwhenpatienthasimpairedrenalorcardiacfunctionJVD BP Resps dyspnea agitationWatchrateOxygen sitptuprightSlowIVandcontactOLMC Systemic SpeedShock Causes Symptoms Preventativeactions IVrunningtorapidlyRapidinjectionofadrug BP rapidpulseLaboredresps cyanosisFaint LOCUsecontrolledvolumeinfusionsetUponinitiation ensurefreeflowingpriortorateadjustment Systemic PyrogenicReaction Causes Symptoms Preventativeactions ContaminatedIVsolutionsSymptomsgenerallyoccurafterIVbegun temp chills headache N V circulatorycollapseCheckIVfluidsforcloudinessandparticlesUsefreshopenIV s Systemic PE Blood Embolus Causes Symptoms Preventativeactions UnfilteredbloodPartiallydissolveddrugParticulatematterinIVsolutionDyspnea cyanosis pain anxiety tachycardia tachypneaInfusebloodthroughfilterDissolvedrugscompletelyUsegoodjudgmentwhensyringingIV s Systemic PE Air Causes Symptoms Preventativeactions FailuretocleartubingofairAllowingairtoenterthesystemCyanosis BP weak tachycardia LOC non specificchestorABDpainDon tletIVrundryCleartubingproperlyChecksyringepriortoinjectingIfoccursplaceptonleftsideandcontactOLMC Troubleshooting IfbloodbeginstoflowbackintheIVtubingChecklocationofthebagtoinsureitisinagravityflowlocationInsureallvalvesareopenIfcontinues reassesssiteandassurearterialcannulationhasnotoccurredIfyourIVdoesnotrun Startatthetop workyourwaybacktothepatientIsthebagempty ChecktheIVsetclampstoinsuretheyareopenChecktubingforkinksChecksiteforanyproblemsBloodbackingupInfiltrationDoyouneedtoflushthesiteIsyourtourniquetstillone ExternalJugular EJ cannulation EJ s Oftenusedinseverecasesofshock unresponsivenessandcardiacarrestsincetheyareHUGEandrelativelyeasytocannulate Whyaretheynotcommonlyusedinthosewhoareconscious Whyaretheynotagoodchoiceforpatientsofmultisystemtrauma EJcannulationprocedure Placepatientsupine slightreverseTrendelenburgWhy TurnpatientsheadslightlytooppositesideCleansewithantisepticusinguniversalprecautionsCreatetourniqueteffectwithfingersbyapplyinglightpressuretotheinferioraspectsoftheEJbeingcannulated Procedure AimneedletowardsipsilateralnippleInsertneedleandenterveinObserveflashbackWithdrawneedleandattachIVtuningCoversitewithsteriledressing EJcannulation Calculatingflowrates DripsetsFactor10gtt ml macro 10drops 1ml615gtt ml15drops 1ml420gtt ml20drops 1ml360gtt ml micro 60drops 1ml1 Volumetobeadministered ml Timetobeinfused min X Dripset gtts ml Drops