IV FLUIDS.pptx dr syed obaid professor of surgery

 HOW MUCH IS WATER ON EARTH?

 HOW IS COMPOSITION OF FLUID IN
HUMAN BODY?

60% of the body is FLUID
40% of the body is SOLID

HOW IT VARIES WITH SEX AND AGE?

HOW THE FLUID IS DISTRIBUTED IN BODY?

 The body fluid is mainly having
 Intra cellular compartment (ICF)
 Extra cellular compartment (ECF)

Electrolytes(mEq/L) ECF ICF
Sodium 142 10
Potassium 4.3 150
Chloride 104 2
Biocarbonate 24 6
Calcium 5 0.01
Magnesium 3 40
Phosphate & Sulphate 8 150

 HOW THE BODY LOOSES WATER?
INSENSIBLE
AND
SENSIBLE
loss of water

 Oral or IV fluid intake and urine output are important
parameters of body fluid balance
 Normal daily insensible fluid loss:
Fluid loss – Fluid input = 1000-300 = 700 ml.
 Daily fluid requirement = urine output + insensible
loss
Insensible fluid input Insensible fluid loss
300 ml water due to oxidation 500 ml through skin
400ml through lung
100 ml through stool

URINE OUT PUT IS
=1.5ml/kg/hr
 For a person of 70kg
 Urine out put=70 x
1.5x24=2.5lit/day

 For a normal adult fluid requirement
is
 Urine out put +insensible loses
 2.5 lit + 0.7 lit= 3.2 lit/day

 THIS IS THE REQUIREMENT OF AN
INDIVIDUAL DAILY
 For an adult- 2ml/kg/hr
 Children - 4ml/kg/hr

 To maintain normal body fluid balance one must take
this much minimum water
 Whether a person is fasting or for surgery
 One must be given fluid to keep the fluid compartment
hydrated this is—
 Maintenance fluid therapy

 A VERY IMPORTANTASPECT
 ONE ML OF FLUID CONTAIN HOW MANY
DROPS?

 NORMAL IV SET 1ML= 15 drops
 PAEDIATRIC IV
SET
1ML= 60 drops

 Crystalloids:
hypotonic- 5% dextrose ,D5 1/2 NS OR 1/4NS
Isotonic- 0.9%Nacl, ringer lactate, ringer acetate
Hypertonic- 3%,5%, 7.5% Nacl.
 Colloids:
Hydroxyethyl
starches Gelatins
Dextran
Albumin.

Crystalloids are aqueous solutions of inorganic and
small organic molecules, the main solute being either
normal saline or glucose. Depending on the
concentration of the solute, crystalloid solutions are
isotonic, hypotonic, and hypertonic.
Colloids, in contrast, are homogeneous
noncrystalline substances containing large
molecules.
Colloids have much greater capacity to remain
within the intravascular space.

Distribution of
1,000 mL of fluid
given IV
Intracel
lular
Fluid
Interstit
ial Fluid
Intravas
cular
Fluid
5% Dextrose 666 249 83
Crystalloid 0 750 250
Colloid
Immedi
ate
0 0 1,000
After 4
hours
0 750 250
Blood 0 0 1,000

 Composition
 One liter contains 50 grams.
 Pharmacological Basis
 Corrects dehydration and
supplies energy.
 After consumption of glucose
remaining water is
distributed in all
compartments so it is best to
correct intracellular
dehydration.
 D5% provides 170 Kcal/L

 Composition
 One liter contains :
Glucose 50 gm, Chloride 154 mEq,
Sodium 154 mEq
 Each 100 ml contains 5 gm glucose
and 0.90 gm NaCl.

Potassium 4
 Composition
 One liter fluid supplies
Sodium 130 mEq,
mEq,
Calcium 3mEq, Bicarbonate
28mEq, Chloride 109mEq
 Each 100 ml contains Sodium Lactate
320 md, sodium chloride 600 mg,
Potassium chloride 40 mg, calcium
chloride 27 mg

nche
d
 Hydroxyethyl starches are
modified natural
polysaccharides similar to
glycogen.
 They are derived from
amylopectin, a highly bra
corn or potato starch.

 Produced by degradation of bovine collagen and
chemical modifications, gelatins are polydispersed
colloidal solutions.
 Three types
1. oxy-crosslinked,
2. urea-crosslinked,
3. and succinylated gelatins.
Molecular weight (average 30-35 kD),
concentrations (3.5%-5.5%) and volume-restoring
efficacy (volume effect 70%-100%).

 500ml, 3.5% solution
 100ml- 3.5 gms of
gelatin
 Stable for 3years
 Mw wt- 30000-350000
 Half life- 2-4 hours
a) Uses- a) hypovolemia
b) Pre loading
c)haemo dilution

 Dextrans are polydispersed colloids -synthesized
from sucrose by the bacterium Leuconostoc
mesenteroides.
 The formulations most frequently selected are
dextran 40 and dextran 70, with molecular weights of
40 and 70 kD, respectively.
 After intravenous administration, small dextran
molecules less than 50 kD are rapidly eliminated by
the kidneys (filtration). All other molecules are being
metabolized to carbon dioxide and water by cell-bound
enzymes in the kidneys, liver, and spleen.

 Albumin is purified from
human plasma and is
commercially available as a
1. 5% (iso-oncotic),
2. 20%, or 25% (hyperoncotic)
solution. Because albumin
is heated and sterilized by
ultrafiltration, the risk of
bacterial or viral disease
transmission should be
eliminated.
 Albumin is the most abundant
plasma protein.

• Crystalloids are
1. inexpensive
2. adverse effects are
rare or absent
3. There is no renal
impairment,
4. minimal interaction
with coagulation
5. no tissue
accumulation,
6. and no allergic
reactions
• Colloids are
1. better volume-
expanding
properties,
2. minor
edema
formation
3. improved
microcirculation.
4. Improve tissue
oxygenation.
5. expensive

Pre operative
Intra operative
Post operative

 Aims
 Correction of Hypovolemia
 Correction of Anemia
 Correction of Other Disorders.

 Hypovolemia jeopardizes O2 transport and increase the
risk of hypoxia & development of organ failure.
 Uncorrected hypovolemia is compensated by
increased vascular resistance and heart rate due to
normal baroreceptor reflex but these are lost during
induction of anesthesia.
 Causes : vomiting, nasogastric suction, blood loss,
third space loss, diuretic therapy etc

 Estimation severity of dehydration.
 Mild= 4% body weight fluid deficit.
 Moderate = 6-8 % body weight fluid deficit.
 Severe = 10 % body weight fluid deficit.
 Choice of fluid depends on nature of loss and
haemodynamic status,compositional abnormality.
 NS, RL , colloids & Whole blood are most widely used
fluids

 It is the space which normally dose not exist in
body
 It is created due to some complications like
Hydro Thorax,Acsities

 Rate of fluid administration varies depending on
severity of fluid disturbance, presence of continuing
losses and haemodynamic and cardiac status.
 In severe deficit FT may be started at 1000ml/hr
,gradually reducing the rate as the fluid status
improves.
 Elderly require slow and careful correction.

 Monitoring :Improvement in tachycardia and blood
pressure, absence of orthostatic hypotension and
achieving urine output of > 30-50 ml/hr (in absence
of diuretics) suggests correction of fluid deficit.

 Intraoperative volume can be calculated as-
1. MAINTANACE-Correction of fluid deficit due to
fasting
2. REPLACEMENT- Replace the lost components
3. SPECIFIC-Loss due to tissue dissection/
hemorrhage

 Volume to be replaced for starvation=
Duration of starvation(hrs) x2ml/kg body
weight
 1st hour = 50%
 2nd hour = 25%
 3rd hour = 25%
 Maintenance volume for intra-op:
2ml/kg/hours
 (fasting should never be more than 4-6 hrs, if so
we recommend to start iv fluids pre operatively)

 Fluid loss is
calcula
ted
as-
Type of surgery Fluid volume(ml/kg/hr)
Least trauma Nil
Minimal trauma 4
Moderate trauma 6
Severe trauma 8

 List trauma :

Minimum
 Moderate
 Severe
cataract, sebaceous cyst , surgery etc
: appendix, hernia, surgery etc
: laparotomy , hysterectomy etc
: THR, bowel resection, etc

 intra-op blood loss calculation
MABL= EBV x (sHct-tHct)/ sHct
 Methods of estimation-
 Weight the sponges before and after use.
The difference in gm = volume in ml of blood they have
absorbed
This has to be added to suction bottle blood.
Then increase the total by 50 %.
Result will give you the actual blood loss.
 If blood loss is more than 20% of blood
volume, give BT

 Total fluid would be
1st hr = 50 % of deficit+ maintenance + Fluid loss
according to surgery
2nd hr = 25 % of deficit+ maintenance + Fluid loss
3rd hr = 25 % of deficit+ maintenance + Fluid loss
4th hr onwards = Maintenance + Fluid loss according to
surgery.

 AIM
 BP > 100/70 mm of Hg or MAP >60 mm Hg
 HR < 120/min
 Urine output = 0.5 -1 ml/kg/hr along with normal
temperature , warm skin , normal respiration and
senses.
 How long to give fluids?--- it depends upon the
type and nature of surgery.

 If minor surgery - maintain fluid till NBM period
 Major surgery- fluids can be required till 24-48hrs.
 Fluid requirement = 2ml/kg/hr with isotonic
crystalloids
 Take into consideration Blood loss , urine output, blood
glucose levels, insensible fluid loss and titrate fluid
intake accordingly.
 Avoid glucose containing solutions in neurosurgical
patients, severely dehydrated patients & cautious use
in diabetic patients.

 WHAT HAPPENS IF FLUID IS EXCESS?

 So to avoid
complications
we have to monitor FLUID

 Hemodynamic
monitoring:
◦ Heart rate, Blood pressure
 Urine output monitoring
 Temperature & Sensorium
 Invasive monitoring
◦ CVP monitoring , Invasive BP,
PCWP
 Echo
 Serum Electolytes

 Fluid
overload
◦ Rise in BP, Tissue edema
◦ pulmonary edema
◦ poor wound healing
 hyperglycemia - Osmotic diuresis-
Dehydration
 Electrolyte imbalance
◦ Hypo/ Hypernatremia ,
◦ Hypo/ Hyperkalemia

 60% body weight is fluid
 40% is ICF,15% intertitial,5% intra vascular
 One requires 2ml/kg/hr water daily
 Intra operative 4ml,6ml,8ml /kg/hr as per
type of surgery
 Always consider total circulating volume
 1ml have 15 or 60 drops
 Never over infuse

I.V. Cannulation Technique
Identification & selection of a suitable
vein:
Patients medical history
Age, body size and general condition
Type of blood sample required for I.V. fluid/
medication to be infused
Expected duration of I.V. therapy
Your skill at venepuncture or cannulation

Technique cont.
For I.V therapy that is to continue
for several days, start with the
most distal location available
and move up as necessary.
For an obese patient the hand
veins may be the only
accessible site.
The cephalic vein can offer a
comfortable site in a thin
patient, if placed to avoid
interfering with flexion.

Technique cont.
Proficiency is achieved by:
Practicing on real patients and all types of arm
sites.
Observe the procedure several times, then try
yourself under supervision.
Ask for feedback
Do not be discouraged by failures, you may have a
few
CARDINAL RULE : Do not persist after two (2)
unsuccessful attempts on the same patient. Get
a more experienced member of staff to
help.

Technique cont.
Choosing the site: Adult patient
Veins in the hands may be a good first choice. Allows for
availability of more proximal sites. (Dorsal & Metacarpal
Veins)
Lower arm veins are good for shorter term I.V. therapy. Leaves
the patient’s hands free, larger arm veins do not become
phlebetic as quickly. (Cephalic & Basilic Veins)
The antecubital fossa provides good veins for blood sampling as
they are very prominent. They are not recommended for long
term I.V. therapy as placement interferes with flexion.
Upper arm veins should only be used as a third choice, when all
other sites have been used.

Technique cont.
Veins used as a last resort:
The inner aspect of the arm: painful site, prone to
bruising, phlebitis and infiltration.
Antecubital fossa: suitable for blood sampling and
short term infusion due to position.
Legs, feet and ankles: requires medical approval as
mobility is reduced and circulation can be
compromised.
The dorsum of the foot and the saphenous vein of
the ankle are the best sites to try if necessary.

I.V. sites
http://www//ebaying.com/05/i/000/b9/80/3259_1_501.JPG

Technique cont.
Sites to avoid:
Veins below previous I.V. infiltration or phlebetic
sites.
Sclerosed or thrombosed veins.
Areas of skin inflammation, bruising or
breakdown.
An arm affected lymphedema, node dissection after
mastectomy, thrombosis, cellulitis or infection.
Arm with an arteriovenous shunt or fistula.

Cannulation Devices
http://www.qub.ac.uk/cskills/iv_cannulation/different sizes.jpg

Vein Identification
Dorsal Metacarpal Veins – usually prominent and visible, lie
flat on the hand, easy to feel, easily accessible.
Hand provides a flat surface for stability.
Phlebitis and infiltration occur more easily due to small vein size
and hand movement.
Haematomas form rapidly.
May not be appropriate for elderly patient’s due to diminished
skin turgor and subcutaneous tissue.
Limited hand movement particularly for patients using crutches
and frames.
22gauge or smaller/1 inch or shorter.

Vein Identification cont.
Cephalic Veins begin in the dorsal venous network on the thumb side
of the hand and ascends along the lateral border of the forearm.
Excellent route for I.V. infusions.
Larger vein, providing haemodilution for hypertonic or irritating
solutions.
Arm bones act as a natural splint.
May be accessed from the wrist to the upper arm. Access in the wrist
can result in phlebitis and infiltration due to hand movement.
Vein tends to roll during insertion of cannula device.
Use the smallest and shortest cannula to accommodate therapy.
22-18 gauge

Basillic Vein begins in the dorsal venous network on the little
finger side of the hand and ascends along the medial side of
the forearm.
Straighter in the upper arm than the Cephalic vein, large and
prominent vein.
Inconspicous positioning on the medial side of the forearm,
results in this site often not being considered.
May be accessed anywhere along it’s course, vein tends to roll
and may be awkward to access due to it’s position.
Can accommodate a larger cannula.
22-18 gauge

Antecubital Veins located in the inner aspect of
the elbow and are comprised of the Median
Cubital, Accessory Cephalic and Basilic Veins
Often used for short term or emergency access,
generally blood sampling only.
Last resort site for I.V. therapy or PICC line or
midline catheter.
Painful site due to numerous nerve endings in this
area.
All gauge sizes are suitable.

Locating a suitable vein
Inspect and palpate
Vein should feel FIRM, ROUND, ELASTIC and
ENGORGED.
Do not use if vein feels KNOTTY, HARD or
SMALL.
AVOID ARTERIES – when cannulating in the
antecubital fossa, palpate for arterial pulsation.
Assess both arms before making final selection,
ask patient about past experiences.

Cannula Selection
Use the smallest cannula that will achieve the desired outcome
–
24 gauge can infuse 3 litres in 24hrs.
22 gauge can complete a 3 unit blood transfusion.
Cannula must be smaller than the vein to increase
haemodilution, thereby reduce irritation and prevent
mechanical phlebitis.
Solutions containing medications and Hypertonic solutions
requuire larger veins to be cannulated to dilute the fluid and
prevent mechanical phlebitis.

I.V. Therapy Equipment
Cannula & Needles:
Mostly made from teflon or
Polyurethane. Completely
retractable stylets to prevent
Needle stick injury, are recent
Advancements.
Recessed needles and cannula
will replace exposed needles
eventually.

I.V. Equipment cont.
I.V. administration sets
(giving set)
Moving to a needless system
where a blunt cannula can be
used in the Y port (Interlink ®).
Tubing is being developed
that will not absorb drugs or
‘leech’
plastic particles into the
solution.
Non PVC tubing will be less
toxic
when disposed of.

I.V. Equipment cont.
I.V. Drugs & Solutions
Many solutions and antibiotics
now come pre-mixed in “add-a-
Line’ giving bags.
Computerised delivery systems
will replace infusion pumps.
These systems will be multi-
channel and deliver drugs and
fluids according to I.V. protocols
That are preprogrammed.

Equipment required for Cannulation
Torniquet
Dressing pack
Absorbant pad “bluey”
Gloves
Selected I.V. cannula
Skin cleansing prep.
5 or 10ml syringes ( for saline flush and/or
blood sampling)
3 way tap or bung
I.V. fluids and primed giving set.
Occlusive dressing ‘Opsite” or ‘Tegaderm’.
Tape
Blood tubes if blood sampling performed.
Aseptic Handwash for 1 min. required
prior to donning gloves.

Preparation for the procedure
Gather equipment and prime I.V. tubing before approaching the
patient.
Explain the procedure, gain consent, reassure.
Position the patient to allow easy access to the desired site,
ensure patient and yourself are comfortable.
Position the arm below heart level to encourage capillary
filling.
Rub the arm (gently) to warm the skin and inspect the area of
intended insertion.
If necessary cover the arm with warm packs to promote
vasodilatation.
Be confident, but know your limitations.

1. Applying the torniquet
Apply 5-7cm below the antecubital
fossa, if cannulating the hand or
lower arm.
Tourniquet should be tight enough to
trap venous blood in the veins without
cutting off arterial flow.
Remove if veins are not filling up well.
Allow vessels to refill then reapply
the tourniquet. Veins may “rebound”
and fill better.
In elderly patients, lift the tourniquet
up, stretch the skin, and underlying
tissues away from the
venipuncture site. Gently lower the
tourniquet.
Ask the patient to clench their fist
several times to encourage the veins
to become turgid and more
rounded.

2. Pre-Cannulation
Identify desirable vein
Encourage vein to enlarge by
lightly flicking to stimulate
mechanical reflex dilation.
Palpate the vein, should feel
elastic and resilient.
Shave or clip hair if
necessary.
Cleanse site with skin prep. In a
circular motion from inside out.
Allow to dry. Much of the
solution’s germicidal action
takes place during the drying
period (+/- 1 min.)

3. Vein stabilisation
Immobilise vein: prevent rolling by
maintaining vein in a taut, distended,
stable position.
Hand vein:
-Grasp patient’s hand with your
non-dominant hand.
-Place your fingers under the palm
and fingers with your thumb on top of
the patient’s hand.
-Pull hand downward to flex wrist
and create an arch.
-Elbow remains supported on the
bed.
-Stretch skin down over the
knuckles with your thumb to stabilise
vein.
- Keep a firm grip during insertion.

Vein stabilisation cont.
Cephalic Vein:
Ask patient to clench their fist.
Pull fist down laterally.
Lower arm Vein:
Anchor vein below site of insertion with
thumb and pull skin taut.

4. Inserting the cannula
Venepuncture:
Hold the needle (with syringe) bevel side up over the vein.
Enter the vein – in a smooth deft motion – at a 25-30 degree angle.
Observe for blood in the coloured hub of the needle.
Holding the syringe steady, remove your anchor ‘hand’ and use it to
gently withdraw the syringe plunger until sufficient blood is obtained.
Collect cotton ball/gauze in your free hand, remove needle from the
vein in a quick motion, immediately place the cotton ball/gauze
over the puncture site and tape securely.
Maintain firm direct pressure over area for a few minutes (patient can
be asked to do this), to stop the bleeding.

Inserting the cannula
Cannulation:
Hold the flashback chamber of
the cannula, not the coloured
“hub”.
Hold the cannula over the vein,
bevel side up and pointing in
the direction of blood flow.
Use an approach angle of 15
degrees for superficial veins
and 25-30 degrees for deeper
veins.

5. Inserting the cannula
Insert the cannula through the
skin with a smooth assertive
motion.
Observe for “flask back” of
blood into the flash chamber.
This indicates that the vein has
been penetrated successfully.
Lower the cannula angle and
continue to advance the
cannula 2-3mm further into the
vein.

Inserting the cannula cont.
With one hand, hold the stylet in
place and use the other hand
to advance the catheter over
the stylet into the vein.
Release the tourniquet.
Remove the stylet whilst
holding the cannula hub,
minimise blood leakage by
applying pressure to vein
beyond cannula tip with finger.
NEVER reintroduce the stylet if
the cannula does not feed into
the chosen vein.The cannula
can shear off and enter the
patient’s circulation

Post-Cannulation
Flushing with 5ml of normal saline
checks patency of the vein.
Connect I.V. giving set, or tap to the
cannula.
Cover with sterile transparent
dressing, allows for observation of the
insertion site, allowing for early
detection of complications.
Label dressing with date and time of
insertion and cannula size.
Stabilise tubing independently of the
cannula, splint arm if necessary.
Commence I.V. infusion as required.
Reassure patient, dispose of
equipment correctly, wash hands,
document.

Troubleshooting
Back flow stops when stylet is removed:
Opposite wall of the vein may have been pierced.
Retract cannula slightly without removing
tourniquet, until “flash back” appears again. This
indicates the tip of cannula is back in the
lumen, quickly advance the cannula into the
vein.
Release tourniquet.
Stop procedure if haematoma develops or if there
is leakage from the insertion site. May occur in
elderly patient’s due to fragile veins.

Complications of IV
Therapy
 Classified according to their location


Local complication: at or near the insertions site
or as a result of mechanical failure
Systemic complications: occur within the vascular
system, remote from the IV site. Can be serious
and life threatening

Local complications




Occur as adverse reactions or trauma to the
surrounding venipuncture site
Assessing and monitoring are the key components to
early intervention
Good venipuncture technique is the main factor
related to the prevention of most local complications
associated with IV Therapy.
Local complications include: hematoma, thrombosis,
phlebitis, postinfusion phlebitis, thrombophlebitis,
infiltration, extravasation, local infection, and veno
spasm.

Hematoma

Hematoma and ecchymosis
demote formations resulting
from the infiltration of blood
into the tissues at the
venipuncture site



Related to venipuncture technique
Use of large bore cannula: Trauma to the vein
during insertion
Patients receiving anticoagulant therapy and long
term steroids

Hematoma



Subcutaneous hematoma is the most common
complication
Can be a starting point for other complications:
thrombophlebitis and infection
Related to:



Nicking the vein
Discontinuing the IV without apply adequate pressure
Applying the tourniquet to tightly above a priviously
attempted venipuncture site.

Hematoma
 Signs and symptoms:




Discoloration of the skin
Site swelling and discomfort
Inability to advance the cannula all the way into
the vein during insertion
Resistance to positive pressure during the lock
flushing procedure

Hematoma
Prevention





Use of an indirect method
Apply tourniquet just before venipuncture
Use a small need in the elderly and patients
on steriods, or patients with thin skin.
Use blood pressure cuff to apply pressure
Be gentle

Hematoma
Treatment



Apply direct, light pressure
for 2-3 minutes after needle
removed
Have patient
elevate extremity
Apply Ice
 Document

Thrombosis




Catheter-related
obsturctions can be
mechanical or non-
thrombotic
Trauma to the endothelial
cells of the venous wall
causes red blood cells to
adhere to the vein wall, forms
a clot or Thrombosis

Thrombosis
Types of Thrombus or occlusion






Persistent withdrawal occlusion
Partial occlusion
Complete occlusion
Fibrin tail
Fibrin sheath
Mural thrombosis

“In Need of tPA Occlusions”
“Reopen the Pipeline”, Hadaway C,
Nursing.
2005, 35(8)
Fibrin
Flap
Intaluminal
thrombus
“Reopen the Pipeline”, Hadaway C, Nursing.2005, 35(8)
Total Occlusion
Probable cause: Intraluminal thrombus Symptom:
Unable to infuseor aspirate
Partial Occlusion
Probable cause: Fibrin flap
Symptom: Unable to aspirate

Thrombosis
Types of Thrombus or occlusion
 Thrombosis related to:





Hypertensive pt; blood backing up
Low flow rate
Location of the IV cannula
Compression of the IV line for an extended
period of time
Trauma to the wall of the vein

Thrombosis
 Signs and Symptoms



Fever and Malaise
Slowed or stopped infusion rate
Inability to flush
 Prevention





Use pumps and controllers to manage flow rate
Microdrip tubing for rate below50mL/hr
Avoid areas of flexion
Use filters
Avoid lower extremeties

Thrombosis
 Treatment



Never flush a cannula to remove an
occlusion Discontunue the cannula
Notify the physician and assess the
site for circulatory impairment
 Document

Phlebitis
 Inflammation of the vein in which the
endothelial cells of the venous wall become
irritated and cells roughen, allowing platelets
to adhere and predispose the vein to
inflamation-induced phlebitis
 Tender to touch and can be very painful

Phlebitis
 Mechanical:


To large a catheter for the size of the vein
Manipulation of the catheter: improper stabilization
 Chemical: vein becomes inflamed by irritating or
vessicant solutions or medication




Irritation medication or solution
Improperly mixed or diluted
Too-rapid infusion
Presence of particulate matter

Phlebitis
 Chemical (cont):




The more acidic the IV solution the
greater the risk
Additiv
es:
Potassi
um
Type of
materia
l
Length
 30% by day 2, 39-40% by day 3 (Macki and Ringer)
 The slower the rate of infusion the less irritation

Chemical Phlebitis - Nafcillin

Phlebitis
Bacterial



Also called Septic phlebitis: least common
Inflammation of the intima of the vein
Contributing factors







Poor aseptic technique
Failure to detect breaks in the integrity of the equipment
Poor insertion technique
Inadequate stabilization
Failure to perform site assessment
Aseptic preparation of solutions
Hand washing and preparing the skin

Phlebitis
Postinfusion


Inflamation of the vein 48-96 hr after discontinued
Factors that contribute:







Insertion technique
Condition of the vein used
Type, compatibility, pH of solution used
Gauge, size, length, and material
Dwell time
Infrequent dressing change
Host factors: age, gender, age and
presence of disease

Phlebitis




Immune system causes leukocytes to gather at
the inflamed site
Pyrogens stimulate the hypothalamus to raise
body temperature
Pyrogens stimulate bone marrow to release
more leukocytes
Redness and tenderness increase

Phlebitis






Redness at the site
Site warm to
touch Local
swelling
Palpable cord along the vein
Sluggish infusion rate
Increase in basal
temperature of 1degree C or
more
 Prevention


Use larger veins for hypertonic solutions
Central lines for Infusions lasting longer than 5 days

Phlebitis Scale





0 – No clinical symptoms
1 Erythema at access site with or without pain
2 Pain at access site, with erythema and / or edema
3Pain at access site with erythema and / or edema,
streak formation, and palpable venous cord
4Pain at access site with erythema and / or edema,
streak formation, palpable venous cord > 1 inch,
purulent drainage

Thrombophlebitis


Thrombophlebitis denotes a twofold injury:
thrombosis and inflammation
Related to:



Use of veins in the lower extremity
Use of hypertonic or highly acidic infusion
solutions
Causes similar to those leading to phlebitis

Thrombophlebitis







Sluggish flow rate
Edema in the limbs
Tender and cord like vein
Site warm to the touch
Visible red line above venipuncture site
Diminished arterial pulses
Mottling and cyanosis of the
extremities

Thrombophlebitis
 Prevention







Use veins in the forearm rather than the hands
Do not use veins in a joint
Assess site q 4 hr in adults, q 2 hr in children
Catheter securment
Infuse at rate prescribed
Use the smallest size catheter to do the job
Proper dilution

Thrombophlebitis
 Septic thrombophlebits can be prevented:



Appropriate skin preparation
Aseptic technique in the maintance of infusion
Proper hand hygiene



60% from patients skin
35% from the line
itself 5% from hands

Infiltration



The inadvertent administration of a
non- vesicant solution into surrounding
tissue
Dislodgment of the catheter from the
vein
Second to phlebitis as a cuase of IV therapy
morbidity

Infiltration
 Related to:






Puncture of the distal vein wall during access
Puncture of the vein wall by mechanical friction
Dislodgement of the catheter from the intima of
the vien
Poor securment
High delivery rate
Overmanipulation

Infiltration






Coolness of the skin around site
Taut skin
Dependent edema
Absence of blood return
“Pinkish” blood return
Infusion rate slows

Infiltration
 Complications fall into 3 catagories



Ulceration and possible tissue necrosis
Compartment syndrome Reflex
sympathetic dystrophy syndrome

Infiltration – What else is wrong with this picture?

Extravasation
 Inadvertent administration of a vesicant
solution into surrounding tissue


Vesicant is a fluid or medication that causes the
formation of blisters, with subsequent sloughing
of tissues occurring from the tissue necrosis
Extravasations related to:



Puncture of the distal wall
Mechanical friction
Dislodgement of the catheter

Examples of Vesicants









Phenergan pH is 4 to 5.5
Dilantin pH is 12 (Drano has a pH of 14)
High concentration KCL pH is 5 to 7.8
Calcium gluconate pH is 6.2
Amphotericin B pH is 5.7 to 8
Dopamine pH is 2.5 to 5
Nipride pH is 3.5 to 6
10%, 20% or 50% dextrose pH is 3.5 to 6.5
Sodium bicarbonate pH is 7 to 8.5

Extravasations







Complaints of pain or burning
Swelling proximal to or distal to the IV site
Puffiness of the dependent part of the limb
Skin tightness at the veinpuncture site
Blanching and coolness of the skin
Slow or stopped infusion
Damp or wet dressing

Extravasations
 Prevention:




Use of skilled practitioners
Knowledge of vesicants
Condition of the patients veins
Drug administration
technique





If continuous give in CVAD
Only with brisk blood return of 3-5 cc
Use of a free flow IV
Do not use a pump on vesicants given peripherally
Assess for blood return frequently

Extravasations (cont)
 Prevention (cont)


Site of venous access
Condition of the patient



Vomiting, coughing, retchin
Sedated
Unable to communicate
 Treatment

Other
Complications
 Local infection:


Microbial contamination of the cannula or the
infusate
Thrombus becomes infected
 Venous Spasm: a sudden involuntary
contraction of a vein or an artery resulting in
temporary cessation of blood flow through
a vessel

Systemic Complications
 We will cover when we talk about Central
Venous Access Devices

SAVE WATER ,
SAVE EARTH ,
GIVE WATER,
G
IVE LIFE

 In 2013 NICE(National Institute for health and care excellence)
reported that:
Majority of I/V fluid prescriber(Surgeon/Assisstant surgeon/Trainee) –
1. know neither the fluid and electrolyte needs for the
patients
2. nor the specific composition of the fluid

1. Inadequate I/V fluid
2. Excess I/V Fluid
Effect/Outcome of lack of knowledge:
1. Increase morbidity and mortality
2. Prolong hospital stay
3. Increase cost
4. Ultimately death…………..

1. Emergency Department
2. Acute admission Unit
3. General Ward
Place of Good I/V fluid Practice
4. Operation Theatre
5. Intensive care unit(ICU)
6. High dependency unit(HDU)
7. Dialysis Unit

To prescribe, following are recommendated :
 Knowledge of Physiology or principle of body fluid
balance
 Knowledge of Electrolyte physiology
 Knowledge of Type of I/V fluid and its composition
 Knowledge of Selection of I/V fluid for the patient
 Knowlede of Monitoring
 Knowledge of I/V fluid related events

The average 70-kg male can be considered to
consist:
 fat(13 kg) and
fat-free mass (or lean body mass: 57 kg)
composed primarily of –
1. protein(12 kg),
2. Water (42 kg) and
3. minerals (3 kg)

Infant 90% of body weight
Children 70-80% of body weight
Male(Ault) 60% of body weight
Female(Adult) 55% of Body wight

◦ Transport nutrients to the cells and carries waste products
away from the cells
◦ Maintains blood volume
◦ Regulates body temperature
◦ Serves as aqueous medium for cellular metabolism
◦ Assists in digestion of food through hydrolysis
◦ Acts as solvents in which solutes are available for cell
function
◦ Serves as medium for the excretion of waste
products

A. Intracellular fluid(ICF) – 28 litres
B. Extracellular Fluid(ECF) – 14 litres
Distribution of extracellular fluid(ECF)
 Interstitial fluid(fluid between cells in tissues) – 11 litres
 Plasma – 3litre
 Transcellular fluid – 1 litre
N.B Transcellular fluid Examples
1. cerebrospinal fluid,
2. ocular fluid and
3. joint fluid

 Plasma > ISF > ICF
 Plasma and ISF seperated by capillary membrane
 ISF and ICF separated by cell membrane
 2 pressure COP(Colloidal osmotic pressure) and Hydrostatic
pressure(HP) also play a part in fluid movement
 COP tendency to keep/ draw fluid inside the vessels but HP
tends to push fluid out

Between Plasma and ISF:
 H2O and electrolyte freely mobile
 Protein cant move
Between ISF and ICF
 H2O freely mobile
 Electrolyte restrictly permeable(Move in fluid imbalance)

Intake Volume(ML) Output Volume(ml)
Drink 1500 Urine 1500
Water from food 700 Insensible loss 1000
Metabolic 359 Faeces 100
Total 2600 Total 2600

Adult 30-40 ml/kg/day or
 1st 10 kg 100 ml/kg/day
 2nd 10 kg 50 ml/kg/day
 After each/1 kg 20 ml/kg/day
Example 60 kg male would
require 10 x 100 = 1000 ml
10 x 50 = 500 ml




40 x 20 =
Total =
800 ml
2300 ml/day

 1st 10 kg =
 2nd 10 kg =
4 ml/kg/ hour
2 ml/kg/ hour
= 1 ml/kg/hour
 After 20 kg
Example 60 kg male would require
10 x 4 =
10 x 2 =


 40 x 1 =
Total 100 ml/hour
40 ml
20 ml
40 ml
(2400 ml/day)

Daily requirements of major electrolytes:
 Sodium 1 mmol / k g / day
 Potassium 1 mmol/kg/ day
 Chloride 1 mmol/kg/ day
 Calcium 2 g / day
 Magnesium 20 mEq / day
 Glucose 100gm/day
Example of a 60 kg woman - 60 mmol needed for
Na, K, Cl

A. Crystalloid
B. Colloid
C. Blood products
On the basis of tonicity
1. Isotonic
2. Hypertonic
3. Hypotonic

1. Isotonic(tonicity similar to plasma) solution
 5% DA
 0.9% NaCl(Normal Saline)
 Hartman solution
 Ringers Lactate solution
NB. Normal plasma osmolality 280-295 mOsm

Hypotonic Solution(plasma osmolality is more
than that of solution)
 0.45% NaCl,
 0.33% sodium chloride,
 0.2% sodium chloride, and
 2.5% dextrose in water

2. Hypertonic solution(plasma osmolality is
less than that of solution)
 5% DNS
 3% NaCl

Solutions containing high-molecular weight substances
such as proteins or large glucose polymers.
Types of Colloids
 Blood derived Human albumin.
 Synthetic
* Hydroxyethyl Starches(Hespan)
* Gelatins(Haemaccel)
* Dextrans.
 Function: Plasma expanders by increasing plasma
oncotic pressure moving fluids from IS to IV spaces i. e.
Abnormal protein loss. e.g peritonitis & Severe burns.

Differences between colloids and crystalloids
 Colloids stay more in IV space (3-6 h.) but Crystalloids (20-
30 m.)
 Colloids 3 times potent than crystalloids.
 Severe IV fluid deficits can be more rapidly corrected using
colloids.
 Colloid resuscitation more expensive.
 Rapid administration of large amounts of crystalloids (>4-5L)
is more frequently associated with significant tissue edema.

 1. In practical terms, operative blood loss up to 500 ml can
be replaced with saline(Colloid or crystalloid)
 Only if > 1 L of blood has been lost in a healthy adult should
you consider giving blood.

 For the majority of patients undergoing elective or
emergency surgery a transfusion trigger of 8 g dl"1 is
appropriate.
 A pt undergoing operation with a normal Hb of
approximately 14 g dl"1 can afford to lose 1.5 litres of
blood before red cell transfusion becomes necessary.
 Recent RCT showed A trigger haemoglobin of 7-8 g dl-
1 is therefore appropriate even in the critically ill.
 critical level of of Hb is 4-5 g dl"1. because at this level,
oxygen consumption begins to be limited .

Pre-Operative:
1. Pt is symptomatically anemic
2. Hb< 6gm/dl
3. HCT < 21%
4. Bone marrow failure resulting from drug or RT or CT
Per operative/post operative:
 Blood loss> 1-1.5 litre
N.B:
 One unit of red cells raises the haemoglobin by 1 g
dH.
 Transfusion may correct a severely low haemoglobin
but
not correct iron deficiency
 So Oral iron replacement therapy is required for 4-6
months.
 Alternatively, give a total dose infusion of iron.

 Requirement 15ml/kg/day
 One unit contain 150ml
FFP
 Frozen at -30°C. stored upto 12 months.
 Once thawed it should be used within 2 h because
degradation of the clotting factors at room temperature.
 FFP contains coagulation factors, including the labile
factors V and VIII and the vitamin K-dependent factors
II, VII, IX and X.
 Indication:
 To correct abnormal coagulation in patients with liver disease.
 To reverse oral anticoagulation as from, for example, over
warfarinization.
 DIC
 Massive BT

1. Normal Saline
2. 5% DA
3. 5% DNS
4. Hartman solution
5. Rigers Lactate

 Contaion : Na+ 154 mmol/L,
Cl+ 154
mmol/L Isotonic(308
mOsm/L)
Indication:
1. Correction of volume in shocked pt due to Hge,
burn, dehydration
2. Peritoneal wash(lavage), stomach Wash,
3. Syringe wash, injured area, wound burn, ulcer
4. Dressing purpose
5. Dilution of drug
6. Preservative

 Contaion – 50 gm Glucose(dextrose)/L
Isotonic(280 mOsm/L)
Indication:
1. Posotoperative Patient(When kept NPO)
2. Post head injury Pt
3. Channel maintainence for emergency
medication

Cl+ 154
mmol/L
50 gm Glucose(dextrose)/L
Hypertonic(320mOsm/L)
Indication:
 Intraoperative fluid
 Post operative fluid
 Resuscitation

Cl-
130 mmol/L
K+ 5 mmol/L
Lactate
29 mmol/L
Isotonic(280 mOsm/L)
Indication:
 Correction of volume in shocked pt due to Hge,
burn, dehydration
 Intraoperative fluid
 Post operative fluid

Cl- 111
mmol/L
K+ 5
mmol/L
Ca+ 2
mmol/L
HCO3 29
mmol/L Isotonic(280
mOsm/L)
Indication:
 Correction of volume in shocked pt due to
Hge, burn,

Problem:
1. Lack of evidence of study
2. Problem with salt and water overload:




Renin anigiotensin, aldosterone, ADH system
Provision of high inappropriate I/V fluid
Misinterpretation of postop dilutional
hyponataremia Misconception of body potassium
 Malnutrition
3. Problem in making accurate assessment of
abnormal fluid and electrolyte loss
4. Problem from internal fluid redistribution.
5. Problem of organ dysfunction.
6. Problem of poor record keeping.

 NICE designated 4 R for prescribing fluid along with 5t h
R for reassessment :
1. Resuscitation
2. Routine maintainence
3. Replacement
4. Redistribution
All are depend on :
 History
 General Examination
 CVP
 Electrolyte measurement
 Urine output
 External loss
 Weight chart

Who need?
 Acute multi system trauma
 Acute post operative haemorrhage
 Sepsis
Why need?
To restore intravascular fluid
What type of fluid?
Normal Saline, Hartman,
Ringers lactate, Albumin,
Haemaccel
How ?
Initial – 500ml bolus over <
15 min then reassess,
if still need resuscitation then give another 250 ml
bolus no response >2000ml over 2 hour already given but no
response-> seek expert help

It provide daily physiological fluid
and electrolyte requirements
How much Normal
Requirements:
 Fluid 30-40 ml kg/kg/day
 Na+ and K+, 1 mmol/kg/day
 Glucose 100gm/day
What type of fluid?
 5% DA
 Normal Saline
 Hartman

 This fluid prescribing is wrong.
If the Pt Wt is 60 kg then he
need
2400ml fluid
So ,
 5% glucose 2000ml
 0.9% saline 500ml
Is appropriate for Postop
order

Provision of fluid for
 ongoing fluid and elctrolyte loss ,
 previous deficit with daily maintenance fluid
 When to give:
Fistula(ECF),
Ileostomy,
NG aspiration or drainge,
vomiting, diarrhoea,
 Electrolyte imbalance(detected by daily electrolyte measurement)




 abdominal drain tube collection.
What type of fluid?
 Normal Saline with added potassium
 Riger’s Lactate
 Hartman

A 60 kg Pt with abdominal surgery on 1st post
operative day, with NG collection 300 ml and
drain tube collection 200 ml, prescribe his
fluid regime:
His daily requirement is 2400ml
Today Ongoing loss is 500 ml(Total 2900ml)
So fluid therapy should be
 5% glucose 1400ml
 5% DNS 500ml
 Rigers lactate 1000ml

calculate the deficit: Formula
For Na deficit = (Normal Na level- Measured
plasma level of Na)X Wt in KgX0.6
For K deficit = (Normal K level- Measured
plasma level of K)X Wt in KgX0.2

Na K Cl HCO3
Saliva 10 25 10 30
Stomach 50 15 110
Duodenum 140 5 100
Ileum 140 5 100 30
Pancrease 140 5 75 1115
Bile 140 5 100 35

 Despite fluid therapy they are not remain in the circulation
and not participate in normal exchange mechanism(third
space fluid loss)
Check for edema, ascities, renal failure, liver failure, post
operative fluid retention
Best fluid therpay is difficult, too little- to hypovolumia - too
more , fluid overload
So it is best to reduce overall fluid and
electrolyte provision to permit a negative
sodium and water balance to aid edema
resolution.

 Why? To altered or stop the fluid therapy
 How:
1. Daily reassessment of clinical fluid status
2. Daily Fluid balance chart(Input/Output)
3. Measurement of CVP, PAWP
4. Wt measurement twice weekly
Laboratory:
5. Daily measurement of Urea, creatinine, electrolyte, Hb%,
Albumin
6. Urinary Na+, K+, Albumin

Fluid requirement Increased in:
 Fever(if 101 add 7% extra
fluid)
 Hyperthyroidism
 Hyperventilation
 Abnormal fluid loss, etc
Fluid requirement decreased in:
 Hypothermia
 Raised humidity
 Hypothyroidism
 Immobilise pt
 Uncoscious Pt
 Cerebral edema:
Meningitis, stroke
 Fluid retention
 Oliguria
 CCF, etc

 Cause:
 Excess infusion of 5%
DA/Hypotonic saline
 Misinterpretation of fluid regime in
Pt with CRF, Head injury Pt,
cerebral infection Pt
 Excess irrigation during
prostatectomy.
C/F:
A. Peripheral edema(if
>2L):
Puffy face, ankle edema, ascities,
pleural effusion
B. Raised JVP
, BP may raised
C. Urine out put> 2ml/kg/hour
D. Cerebral edema, confusion,
convulsion , coma
Investigation:
S. Na+, Hb%, PCV, Albumin(all
are decreased)
Treatment:
Its an emergency
1. Stop all fluid therapy
2. Mannitol diuretis(not by
frusemide because which
causes both water and
Na+ loss)
3. Monitoring the Patient.

The patient is starved for 6-12 h, there may
be blood loss, plasma loss, ECF loss and
evaporation of water from exposed bowel - >
As part of the stress response to surgery
the patient retains water and sodium.
 What Fluid to give ?
Hartmann's solution 5 ml/kg/h.

 5 %
DA
= 1600 ml
 0.9% NaCl = 500 ml
 Ringer lactate = 500 ml
 Monitoring:
patients thirst, puffiness of face, CVP, peripheral perfusions,
leg
edema, chest, urine output
Daily: elctrolytes, CBC

 5 % DA
 5% DNS
 Ringer lactate
=
=
=
1600 ml
500
ml
1000 ml
Monitoring:
 patients thirst, CVP, peripheral perfusions, leg edema, chest, urine
output
 Daily: elctrolytes, CBC

 5 % DA = 1600 ml
 5% DNS = 500 ml
 Ringer lactate = 500 ml
Monitoring:
output

=
=
=
1100 ml
1000 ml
500
ml
 5 % DA
 5% DNS
 Ringer lactate
 60 mmol KT/day
Monitoring:
output

If Patient is NPO more than 5
Consider
Days.

 Principle: intensive monitoring and aggressive management
of perioperative Hemodynamics in high risk patients to
optimize oxygen delivery or manipulate a patient’s physiology
to achieve targets that are associated with an improved
outcome
Aim: The right fluid, for the right patient, at the right time
What Goal we can target:
1.Stroke volume
2.Oxygen Delivery or consumption
How to achieve:
 By measurements of cardiac
output (CO) which direct the use of
I/V
fluid and ionotrpes.
What operations? Which patients?
 expected blood loss >500 mL( major abdominal general surgical,
orthopedics, urological, gynae)
 Trauma, pt with sepsis, burn

IV FLUIDS.pptx dr syed obaid professor of surgery

IV FLUIDS.pptx dr syed obaid professor of surgery

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