IntravenousTherapy：静脉注射疗法课件

1、Intravenous Therapy74第1页，共45页。Thirty years agoRampart, Squad 51.We have a 20 year old male motorcycle rider involved in a motor vehicle collision complaining of neck, back and leg pain.He presents with compound fractures to both femurs and has significant blood loss.We are requesting an order for tw

2、o large bore IVs and Ringers Lactate.第2页，共45页。ObjectivesIdentify the reasons IV therapy is performed in the prehospital settingIdentify the fluids commonly administeredState the basis of fluid and electrolyte balanceIdentify factors affecting water lossExplain the recommended uses of IV solutionsIde

3、ntify common complications and reactionsCalculate a flow rateDemonstrate proper skin cleansing and aseptic venipuncture techniqueDemonstrate proper IV cannulation technique第3页，共45页。Why do we cannulate?Fluid administrationMedication administrationTo maintain life (electrolytes, blood)Do we do them to

4、 be EHSNS protocol compliant?第4页，共45页。IV fluidsNormal saline (0.9% NS)Lactated Ringers (LR)Also known as Hartmans solution or RLD5W NSD5 NSD5RL (D5LR)第5页，共45页。Isotonic SolutionsCharacteristicsSame tonicity as plasmaOsmotic pressure is the same as the inside of the cellFluid never leaves or enters th

5、e cellApproximate osmolarity is 240 340 mOsm/LWill increase circulating volume, which may lead to fluid volume excess or overload.Solutions2.5% dextrose/0.45% NaCl0.9% NaClLactated Ringers2.5% dextrose in lactated ringers6% dextan and 0.9% NaCl10% dextran and 0.9% NaCl第6页，共45页。Normal SalineMost comm

6、only administered IV fluid prehospitallyIV fluid of choice for EHSNS protocolsWhy?第7页，共45页。Lactated RingersComposed of multiple electrolytes in salineHas fallen out of favor as one of main IV fluids for treatment of traumatic hypovolemia in past decadeWhy?第8页，共45页。Hypotonic SolutionsCharacteristicsM

7、ay cause blood cells to swell and burstMay cause changes or damage endothelial cellsExert less osmotic pressure than the fluid in the extracellular compartmentFluid is drawn into the cellsApproximate osmolarity 340 mOsm/lSolutions5% dextrose/0.2% NaCl5% dextrose/0.9% NaClD5WD10WD50W5% NaHCO310%, 15%

8、 and 20% Mannitol6% dextran and 0.9% NaCl第10页，共45页。Administration SetsThe calibration of the administration set must be known in order to calculate the flow of the IV fluids correctly. Macrodrip sets10, 15 or 20 gtts/mlMicrodrip (minidrip)60 gtts/ml第11页，共45页。Where do we cannulate?HandForearmNeckFoot

9、第12页，共45页。Equipment RequiredSolutionAdministration setIV cannulaTourniquetAlcohol swabGlovesSharps binOp site and gauzeTape If performing a LockLock, syringe and saline第13页，共45页。Catheter specificsColorSizeInt Dia/LengthMax FlowGrey16 G1.4 mm/45 mm180 mls/minGreen18 G1.0 mm/45 mm80 mls/minPink20 G0.8

10、 mm/32 mm54 mls/minBlue22 G0.6 mm/25 mm31 mls/minThe length and diameter will affect the amount of fluid able to be infused through the catheterLarger diameter and shorter length gives more fluidSmall diameter and long length gives less fluid第14页，共45页。Types of cathetersJelcoCathelonInsyte第15页，共45页。T

11、ypes of cathetersProtectiveProtective Plus第16页，共45页。Administration Sets10 gtts/ml15 gtts/ml60 gtts/mlBlood sets第17页，共45页。Vein SelectionBased on:ConditionPalpate to confirm type of vesselShould be soft and spongyStraight with no turns or bumpsLocationIs the pt right or left handedIs the extremity inj

12、uredAvoid joints (stabilization)Does the pt have a shunt (fistula)PurposeFluid replacement, Medication route, Safety line (lock)Dictates flow rate and type of fluid to be infusedTry to use large veins for large quantities of fluidDurationWhat type of patient (trauma, cardiac or outpatient)Patient co

13、mfort over long period of timeProlonged therapy may require multiple puncturesFor long durations use distal veins first第18页，共45页。Fluid ReplacementBloodReplaced at a ratio of 3:1 of IV fluid to blood being replacedMinimum daily requirements1st 10 kg100 ml/hr2nd 10 kg50 ml/hr3rd 10 kg20 ml/hr4th 10 kg

14、10 ml/hr5th 10 kg10 ml/hrExample50 kg patient100 ml/hr + 50 ml/hr + 20 ml/hr + 10 ml/hr + 10 ml/hr = 190 ml/hr第19页，共45页。ContraindicationsDistal to a fracture site in a limbThrough damaged or abraded skinBurns may be an exception if there is no other accessible siteIn an arm affected by a radical mas

15、tectomy, edema, blood clot or infectionIn an arm with a fistula for dialysis or a peripherally inserted control catheter (PICC Line)第20页，共45页。ProcedureObtain consent and explain rationale for IV therapyAssess that the pt meets the criteria for the procedureEnsure that there are no contraindications

16、for the procedureObserve universal precautions for body substance exposuresPrepare all necessary equipmentPosition the patientApply a tourniquet 3 5 inches above the selected sitePatient may make a fist to assist in engorging the veinSelect the most appropriate venipuncture siteConditionLocationPurp

17、oseDurationPrepare the pts arm using alcohol swab第21页，共45页。ProcedureInsert needle through skinShould be at an 30 angle Lower angle (15)and enter veinObserve flashbackEnter vein a little bit moreEnter catheter into veinRelease tourniquetWithdraw needle and discard in sharps container, tamponade the v

18、ein to avoid blood spillAttach iv tubing and open flow valve observing for infiltrationCover with Op site or other sterile dressing, tape in place第22页，共45页。IV Access 第23页，共45页。Complications Local complicationsHematomasInfiltrationNecrosisThrombophlebitisSystemic complicationsPulmonary edemaSpeed sho

19、ckPyrogenic reactionPulmonary embolismbloodAirCatheter shear第24页，共45页。Local - Hematomas Causes:Symptoms:Preventative actions:Punctured veinBruisingTendernessSwellingProper techniques第25页，共45页。Local - Infiltration Causes:Symptoms:Preventative actions:Poor insertion techniquesImproper tapingOver activ

20、e patientIV slows or stopsSwelling or hardnessFeeling of coldnessLeaking at the siteArmboards, proper tapingRoutine checks of IV flow and site第26页，共45页。Local - NecrosisCauses:Symptoms:Preventative actions:Irritation of tissues from infiltrated drug or fluidSwelling, tendernessInflammation or bruisin

21、gRoutine checksReport any changes第27页，共45页。Local - ThrombophlebitisCauses:Symptoms:Preventative actions:Trauma to endothelium from chemical meansPain, redness, swelling along infected veinGeneralized symptoms such as fever, malaise, rapid pulseAvoid insertion over jointSelect veins with adequate blo

22、od flow for infusions of hypertonic solutions第28页，共45页。Systemic Pulmonary EdemaCauses:Symptoms:Preventative actions:Circulatory overload from too rapid infusion when patient has impaired renal or cardiac functionJVD, BP, Resps, dyspnea, agitationWatch rateOxygen, sit pt uprightSlow IV and contact OL

23、MC第29页，共45页。Systemic Speed ShockCauses:Symptoms:Preventative actions:IV running to rapidlyRapid injection of a drugBP, rapid pulseLabored resps, cyanosisFaint, LOCUse controlled volume infusion setUpon initiation, ensure free flowing prior to rate adjustment第30页，共45页。Systemic Pyrogenic ReactionCause

24、s:Symptoms:Preventative actions:Contaminated IV solutionsSymptoms generally occur after IV beguntemp, chills, headache, N/V, circulatory collapseCheck IV fluids for cloudiness and particlesUse fresh open IVs第31页，共45页。Systemic PE (Blood/Embolus)Causes:Symptoms:Preventative actions:Unfiltered bloodPar

25、tially dissolved drugParticulate matter in IV solutionDyspnea, cyanosis, pain, anxiety, tachycardia, tachypneaInfuse blood through filterDissolve drugs completelyUse good judgment when syringing IVs第32页，共45页。Systemic PE (Air)Causes:Symptoms:Preventative actions:Failure to clear tubing of airAllowing

26、 air to enter the systemCyanosis, BP, weak, tachycardia, LOC, non-specific chest or ABD painDont let IV run dryClear tubing properlyCheck syringe prior to injectingIf occurs place pt on left side and contact OLMC第33页，共45页。TroubleshootingIf blood begins to flow back in the IV tubingCheck location of

27、the bag to insure it is in a gravity flow locationInsure all valves are openIf continues, reassess site and assure arterial cannulation has not occurredIf your IV does not runStart at the top, work your way back to the patientIs the bag empty?Check the IV set clamps to insure they are openCheck tubi

28、ng for kinksCheck site for any problemsBlood backing upInfiltrationDo you need to flush the siteIs your tourniquet still one!第34页，共45页。External Jugular (EJ) cannulation第35页，共45页。EJsOften used in severe cases of shock, unresponsiveness and cardiac arrest since they are HUGE and relatively easy to can

29、nulate.Why are they not commonly used in those who are conscious ?Why are they not a good choice for patients of multi system trauma ?第36页，共45页。EJ cannulation procedurePlace patient supine / slight reverse TrendelenburgWhy ?Turn patients head slightly to opposite sideCleanse with antiseptic using un

30、iversal precautionsCreate tourniquet effect with fingers by applying light pressure to the inferior aspects of the EJ being cannulated.第37页，共45页。ProcedureAim needle towards ipsilateral nippleInsert needle and enter veinObserve flashbackWithdraw needle and attach IV tuningCover site with sterile dres

31、sing第38页，共45页。EJ cannulation第39页，共45页。Calculating flow ratesDrip setsFactor10 gtt/ml (macro)10 drops = 1 ml615 gtt/ml15 drops = 1 ml420 gtt/ml20 drops = 1 ml360 gtt/ml (micro)60 drops = 1 ml1Volume to be administered (ml)Time to be infused (min)XDrip set (gtts/ml)=Drops/min (gtts/min)第40页，共45页。Calculation