How Not to Blow a Vein.....

As an IV therapy nurse, no matter how “pro” you consider yourself to be, there are still times when you encounter problems when it comes to IV insertion, such as very fragile veins.
Here are some tips to avoid blowing veins in IV insertion.
Assess. Feel the veins.
Don’t just look at a vein, instead, try palpating the area to search for a vein. It is important to palpate using your index and third finger pad to evaluate the vein’s resilience, patency, valves, and size. Check if the vein is straight, soft and bouncy, and large enough to accommodate the catheter needed for the IV therapy. Go for the straightest vein. For geriatric patients, a deeper vein may be less prone to blowing since they are more stabilized and less movable.
Choose the right size.
This is with regards to the IV cannula to be used. If possible and if not contraindicated, try using smaller sizes. For adults, G-22 is commonly used while for pediatric patients, G-22-26 are used.
Check tourniquet application
A too tight or too loose tourniquet can cause veins not to distend and may result to you cutting off their arterial circulation. A BP cuff may be used as a tourniquet when dealing with very fragile veins of elderly and chemo patients.
Check the bevel. Make sure that it is facing upwards
This technique is done to make sure you don’t blow a vein when advancing forward. Also, you can control the angle of insertion more when the bevel is facing upward as you have easier glided point of entry as the sharp end-tip of the needle enters the skin.
Use warm/hot packs of the arm is cold
This is to dilate the blood vessels and them pop out quickly. Warm washcloths or blanket may be used if hot packs are not available.
Anchor the vein
This is to keep an unstable vein from moving sideways as you puncture it. This can be done by holding the skin and veins taut with your non-dominant hand.
Angle well and insert the catheter directly on top of the vein
Adjust your angle of approach accordingly if your target vein is too shallow or too deep. Usually, you may do it in a 15 to 30 degree angle. Then, insert the vein catheter on top of the vein to reduce the chances of going through the two vein walls. Do it slowly but steadily.
Upon hitting a vein and seeing backflow, stop advancing the catheter and drop the angle approach.
This is to avoid puncturing the vein wall again. Release the tourniquet first. Drop your angle of approach as you advance the catheter a little bit more. Then pull back the needle a little bit before advancing the whole catheter. When you have successfully inserted the catheter, pull back the needle quickly to attach the IV fluid set and start the IV infusion with the first few drops running very slowly.
Use available visualization devices
This may include transilluminator lights and pocket ultrasound machines. These devices will illuminate vein pathways so you can track the direction of where you should insert your IV catheter.
Sources:
http://www.nursebuff.com/2014/10/tips-for-nurses-on-how-to-prevent-blown-veins/
http://piccresource.com/piccnurseblog/how-to-start-ivs-8-tips-to-improve-your-iv-success/

Central Line Dressing Change Demonstration

PCA Manage Part 2

PCA Setup Part 1

PCA Machines part one Intro...

Catheter-Related Infections: Bundle Up for Prevention.....

• CLABSI, which is associated with the use of CVCs, is a type of catheter-related bloodstream infection defined as the presence of bacteremia originating from an IV catheter. CLABSI -- the most common cause of nosocomial bacteremia -- is frequent, lethal, and costly. Although the use of CVCs is increasing, there is evidence that the incidence and rate of CLABSIs can be reduced. Central lines are required for adequate volume replacement in patients who are severely dehydrated or intravascularly volume depleted for any reason. Although necessary in such situations, use of central lines puts patients at risk for a number of complications, including CLABSIs.
  

  Defining CLABSI

  A CLABSI is defined by the US Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance System (NNIS) and the National Healthcare Safety Network (NHSN) as a primary bloodstream infection in a patient who had a central line within the 48-hour period before the development of the bloodstream infection.^[1,2] According to the NNIS, diagnosis of CLABSI requires that at least 1 of the criteria in the box below be met.
  

  Criterion 1: Patient has a recognized pathogen cultured from 1 or more blood cultures, and the organism cultured from the blood is not related to infection at another site. Criterion 2: Patient has at least 1 of the following signs or symptoms: Fever (temperature, > 38°C) Chills Hypotension and signs and symptoms and positive blood culture results are not related to infection at another site and common skin contaminant (eg, diphtheroids, Bacillus species, Propionibacterium species, coagulase-negative staphylococci, or micrococci) cultured from 2 or more blood samples drawn on separate occasions (Figure 1). Criterion 3: Patient < 1 year of age has at least 1 of the following signs or symptoms: fever (> 38°C core), hypothermia (< 36°C core), apnea, or bradycardia and signs and symptoms and positive laboratory results are not related to an infection at another site and common skin contaminant (ie, diphtheroids [Corynebacterium species], Bacillus [not Bacillus anthracis] species, Propionibacterium species, coagulase-negative staphylococci [including Staphylococcus epidermidis], viridans group streptococci, Aerococcus species, Micrococcus species) is cultured from 2 or more blood cultures drawn on separate occasions.

  
  Figure 1. Normal flora colonies from skin.
  
  
   
• Central lines are intravascular infusion devices that terminate at or close to the heart or in 1 of the great vessels. Pacemaker wires are not considered central lines because they are not used to infuse or withdraw fluids.

Several types of intravascular devices are commonly used (Table 1). A central line is an intravascular device that terminates close to the heart or near a great vessel that is used for infusion, withdrawal of blood, or hemodynamic monitoring. The aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, and common femoral veins are considered great vessels. Pacemaker wires are not considered central lines because they are not used to infuse or withdraw fluids.



Table 1. Types of Intravenous Devices Used for Infusion of Fluids and/or Hemodynamic Monitoring

Type of Catheter	Length	Description
Peripheral
Peripheral venous catheter	< 7.6 cm	Usually inserted into a forearm or hand vein; most commonly used short-term intravascular device; rarely associated with bloodstream infection
Midline catheter	7.6-20.3 cm	Peripheral catheter is inserted via the antecubital fossa into the proximal basilic or cephalic veins; does not enter central veins; associated with lower rates of phlebitis and infection than CVCs
Central
Nontunneled CVC	≥ 8 cm	Inserted percutaneously into central veins (subclavian, jugular, femoral); most commonly used CVC; accounts for about 90% of all catheter-related bloodstream infections
Percutaneously inserted central catheter (PICC)	≥ 20 cm	Inserted via basilic, cephalic, or brachial veins into the superior vena cava; easier to maintain and associated with fewer mechanical complications (eg, hemothorax) than nontunneled CVCs
Tunneled CVC	≥ 8 cm	Surgically implanted into subclavian, internal jugular, or femoral veins; the tunneled portion exits the skin; a Dacron cuff just inside the exit site inhibits migration of organisms into the catheter tract by stimulating growth of surrounding tissue, thus sealing the catheter tract
Totally implantable device	≥ 8 cm	Subcutaneous port or reservoir with self-sealing septum that is tunneled beneath the skin; implanted in subclavian or internal jugular vein; accessed by a needle through intact skin; low rates of infection

CVCs = central venous catheters
Data from Mermel LA, et al. Clin Infect Dis. 2001;32:1249-1272.

Pathogenesis of CLABSI

CVCs become colonized with microbes from the skin surrounding the insertion site or from the catheter hub.^[3] The pathogenesis of a CLABSI depends on the type of catheter. A CLABSI related to a catheter of short-term use is usually secondary to extraluminal colonization. Long-term use of tunneled catheters usually causes infection via intraluminal colonization, most commonly from contamination of the catheter hub.
Certain catheter materials are thrombogenic, which may also predispose to catheter colonization and CLABSI.^[4] Other factors that may contribute to microbial colonization are depicted in Figure 2.^[3] The adherence properties of a microorganism may also play a role in the pathogenesis of a CLABSI. For example, Candida species may produce adherence factors in the presence of glucose-containing IV fluids, which may explain why patients receiving parenteral nutrition have an increased incidence of fungal bloodstream infections. Therefore, prevention strategies should target ways to minimize colonization of the catheter.

Figure 2. Pathogenesis of vascular access-related infections. Potential sources of infection include the contiguous skin flora, contaminated catheter hub and lumen, contaminated infusate, and hematogenous colonization of the device from distant, unrelated sites of infection.
HCW = healthcare worker
From Crnich CJ, et al. Clin Infect Dis. 2002;34:1232-1242.

Epidemiology

Bloodstream infections are a common nosocomial infection and are responsible for 30%-40% of all nosocomial infections in the ICU.^[5] A national surveillance study reported the incidence of nosocomial bloodstream infection as 60 cases/10,000 hospital admissions; approximately 50% of the cases occurred in the ICU.^[1] Central lines are the most frequent cause of catheter-related infections.^[4]
 
It is important to note that the CLABSI rate (not incidence) is calculated by dividing the number of CLABSIs by the number of central line-days and multiplying the result by 1000. For example, if an ICU had 5 central line infections and 100 central line-days, the CLABSI rate would be calculated as follows: 5/100 x 1000 = 50 central line infections/1000 central line-days. In the United States, the CLABSI rate is 80,000 central line-days per year.^[6,7]

 
CLABSIs are associated with significant morbidity and mortality, and excessive hospital costs. The associated mortality rate and excess hospital length of stay are 0%-15% and 9-12 days, respectively.^[5,8] Until recently, the association between CLABSI and mortality in critically ill patients was unclear, but a meta-analysis by Siempos and colleagues that evaluated the mortality of ICU patients with and without catheter-related bloodstream infections found that catheter-related bloodstream infection was associated with higher all-cause mortality (odds ratio, 1.81).^[9]
 

Microbiology

The pathogens most commonly associated with nosocomial bloodstream infections are listed in Table 2.^[10] Since the 1980s, gram-positive organisms have been the predominant organisms associated with nosocomial bloodstream infections, but gram-negative and Candida species are also problematic. Yeasts colonizing the endolumen of a CVC are shown in Figure 3.


Table 2. Pathogens Associated With Nosocomial Intravascular Catheter-Related Bloodstream Infections

Class of Pathogen	Specific Pathogens
Gram-positive organisms	Coagulase-negative staphylococci Staphylococcus aureus Enterococci
Gram-negative organisms	Pseudomonas species Enterobacter species Serratia species Klebsiella species Escherichia coli Acinetobacter baumannii
Fungal organisms	Candida species C albicans, C glabrata

Figure 3. Electron micrograph of yeasts colonizing the endolumen of a central venous catheter.
Image courtesy of Dr. P. Kite, Department of Medical Microbiology, Leeds Teaching Hospitals).
Using surveillance data from the CDC, Burton and colleagues examined trends in the rate of methicillin-resistant Staphylococcus aureus (MRSA)-related CLABSIs in ICUs in the United States from 1997 to 2007. They found that the overall incidence of MRSA-related and methicillin-sensitive S aureus-related CLABSIs decreased during this period in adult ICUs.^[11] Specifically, a 50% decline in MRSA-related CLABSIs since 2001 was observed among the ICUs that reported data to the CDC, suggesting that efforts at prevention are succeeding.
Additional host factors that increase susceptibility include age, comorbid conditions, severity of underlying illness, loss of skin integrity, and immune deficiency states. Of note, female sex is associated with a reduced risk for CLABSI.

Patient Profile, Continued

Upon transfer to the ICU, MW was resuscitated with IV fluids and vasopressors, and she was started on empirical antibiotic therapy. While performing an initial assessment, MW's nurse notices that the femoral CVC dressing is loose and there is erythema around the insertion site. CLABSI is the suspected source of sepsis. The femoral CVC is removed, and a new CVC is inserted into her right subclavian vein for hemodynamic monitoring and administration of IV fluids, vasopressors, and antibiotics. A transparent dressing is applied.

Prevention of CLABSI

The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) jointly published a guideline, Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals, which highlights practical recommendations for implementing and prioritizing CLABSI prevention efforts before, during, and after central line insertion in acute care hospitals.^[6] Although the compendium is an evidence-based guideline, the evidence base for many interventions comes from nonrandomized clinical trials, case-control studies, and expert opinion, and the quality of evidence varies.

CVC Insertion: Before, During, and After

Prevention of CLABSI is a multidisciplinary approach that begins with education of clinicians involved in insertion, care, and maintenance of vascular catheters. Education should include the standard of care (clinical practice guidelines), including infection prevention and control measures, selection of the type of catheter and insertion site, use of ultrasound guidance for catheter insertion,^[12] tools to facilitate the standard of care, and the potential consequences of breaching the standard of care. Zingg and colleagues conducted a prospective interventional cohort study of clinicians working in medical and surgical ICUs.^[13] The intervention was an educational program on hand hygiene, standards of catheter care, and preparation of IV drugs. The study showed that a multimodal educational program focused on evidence-based catheter care techniques can effectively reduce the rate of CLABSIs.
The standard of care for CVC insertion and maintenance can be summarized as follows:

• Explanation of procedure to patient and informed consent;
• Selection of insertion site;
• Selection of catheter type;
• Central line catheter cart;
• Hand hygiene;
• Barrier precautions;
• Skin antisepsis;
• Sterile dressing application;
• Care of administrations system; and
• Catheter removal.

The reader is also referred to a Video in Clinical Medicine in The New England Journal of Medicine illustrating placement of a central venous line.^[12]
Potential sources of infection during and after catheter insertion include the contiguous skin flora, contaminated catheter hub and lumen, contaminated stopcocks, contaminated infusate, and hematogenous colonization of the device from distant, unrelated sites of infection (Figure 2). Catheter hub manipulation increases the likelihood of catheter contamination and as a result increases the risk for CLABSI.^[14] Frequent access allows contamination via the skin or the skin flora of clinicians.

Figure 2. Pathogenesis of vascular access-related infections. Potential sources of infection include the contiguous skin flora, contaminated catheter hub and lumen, contaminated infusate, and hematogenous colonization of the device from distant, unrelated sites of infection.


HCW = healthcare worker
From Crnich CJ, et al. Clin Infect Dis. 2002;34:1232-1242.
Catheter hubs, needleless connectors, and injection ports of stopcocks should be disinfected with an alcoholic chlorhexidine preparation or 70% alcohol before accessing the catheter or tubing.^[6] Antimicrobial catheter lock solutions may also help decrease CLABSI.^[15] The lumen of a catheter hub is filled with an antimicrobial solution that is left in place until the catheter is reaccessed. There is concern about the emergence of resistance in exposed organisms; therefore, these locks should only be used for prophylaxis in patients with limited venous access and a history of CLABSI, or patients who are at high risk for severe complications from a CLABSI (ie, patients with recently implanted intravascular devices).^[6] Administration sets that are not used for infusing blood, blood products, or lipids should be changed at more frequent intervals (eg, every 96 hours). Administration sets that are used for infusing blood, blood products, or lipids should be changed at regular intervals (eg, every 24 hours).

Catheters coated with chlorhexidine/silver sulfadiazine have been shown to reduce the risk for CLABSI compared with noncoated catheters,^[4] and are recommended if it is anticipated that the catheter will remain in place more than 5 days.^[16] Minocycline/rifampin-coated catheters have been shown to reduce the risk for CLABSI,^[15,17] and have been shown to be superior to first-generation chlorhexidine/silver sulfadiazine-impregnated catheters for preventing CLABSI after 6 days of use.^[18]


The safety of changing semitransparent dressings every 7 days vs the standard practice of every 3 days was recently reaffirmed in a multicenter, randomized controlled trial comparing the application of a chlorhexidine gluconate-impregnated sponge with standard dressings at the catheter-skin insertion site of patients with central lines or arterial catheters.^[20] This study also compared a strategy of changing unsoiled adherent dressings every 7 days vs the standard practice of every 3 days. The safety of changing dressings every 7 days was demonstrated in both the control and intervention (chlorhexidine gluconate-impregnated sponge) groups. However, the use of chlorhexidine gluconate-impregnated sponges is more expensive.^[15] The SHEA/IDSA guidelines recommended considering sponge dressings for CVCs in units with high CLABSI rates and in certain high-risk patients.^[6]


There is no evidence that the following reduce the CLABSI rate:

• Routine, scheduled replacement of CVCs;
• Routine, scheduled guidewire replacement^[21-23];
• Culturing of CVC catheter tip; and
• Application of antibiotic ointment to the catheter insertion site.
•  

In fact, scheduled routine exchanges of catheters over a guidewire are associated with a trend toward an increasing rate of catheter-related infections,^[21] and the application of antibiotic ointment to catheter insertion sites increases the rate of catheter colonization by fungi and promotes the emergence of antibiotic-resistant bacteria.

Documentation and Surveillance

Recording the details of the CVC insertion in a standardized way is important for documenting and monitoring adherence to the standard of care. Information that should be routinely documented in the medical record includes:

• Informed consent;
• Indication for CVC;
• Name of person who inserted the CVC;
• Insertion site;
• Date and time of insertion;
• Insertion technique (ie, sterile skin preparation, use of local anesthetic);
• Amount and character of fluid withdrawn during insertion;
• Estimated blood loss;
• Complications;
• Laboratory and other diagnostic tests ordered; and
• Type of dressing applied over catheter insertion site.

Bringing It All Together: The Central Line Bundle

 

A strategy for reducing the risk for CLABSI is the use of predetermined bundles of interventions that focus on a few specific, high-yield measures to simplify and focus measures for prevention of infection. The central line bundle consists of a group of evidence-based interventions for patients with central lines that, when implemented together, have been shown to result in better outcomes than when implemented individually.^[24] The bundle includes measures that prevent extraluminal and intraluminal contamination, migration, adhesion, and colonization. The 5 components of the central line bundle are described in Table 4.
Table 4. Implementing the Central Line Bundle

Components of Bundle	Rationale
Hand hygiene	Proper hand hygiene reduces the likelihood of central line infections. Washing hands or using an alcohol-based waterless hand cleaner can help to prevent contamination of central line sites and bloodstream infections.[4] Clinicians who insert or manipulate vascular catheters should perform hand hygiene with an alcohol-based hand rub or antiseptic soap and water, regardless of whether examination or surgical gloves are worn.
Maximal barrier precautions	Maximal barrier precautions clearly reduce the odds of developing catheter-related bloodstream infections.[25,26] This approach has been shown not only to decrease the rate of CLABSIs,[25] but also to reduce cost.[26] For the operator placing the central line and for those assisting in the procedure, maximal barrier precautions mean strict compliance with handwashing and wearing a cap, mask, sterile gown, and gloves. The cap should cover all hair and the mask should cover the nose and mouth tightly. These precautions are the same as for any other surgical procedure that carries a risk for infection. For the patient, maximal barrier precautions means covering the patient from head to toe with a sterile drape with a small opening for the site of insertion.
Chlorhexidine skin antisepsis	Chlorhexidine skin antisepsis has been proven to provide better skin antisepsis than other antiseptic agents, such as povidone-iodine solutions.[24] Chlorhexidine-based antiseptic skin preparation should be used for patients older than 2 months of age, and should be allowed to air-dry for approximately 2 minutes before beginning insertion of the catheter.[24]
Optimal catheter insertion site selection, with avoidance of the femoral vein for central venous access in adults	The catheter insertion site influences the risk for an infectious complication, partly due to the risk for phlebitis and the density of local skin flora. Lower-extremity insertion sites are associated with a higher risk for infection. A higher risk for infection is associated with internal jugular vs subclavian catheter insertion.[27-29] Whenever possible, the femoral site should be avoided and the subclavian site should be preferred over the jugular and femoral sites for nontunneled catheters in adult patients. This recommendation is based solely on the likelihood of reducing infectious complications.[24] Subclavian placement may have other associated risks. The Central Line Bundle requirement for optimal site selection suggests that other factors (eg, the potential for mechanical complications, the risk for subclavian vein stenosis, and catheter-operator skill) should be considered when deciding where to place the catheter. In these instances, teams are considered compliant with the bundle element as long as they use a rationale construct to choose the site. The core aspect of site selection is the risk-benefit analysis by a physician as to whether the subclavian vein is most appropriate for the patient. There will be occasions when the physician determines that the risks of using the subclavian vein outweigh the benefits, and a different vessel is selected. For the purposes of bundle compliance, if there is dialogue between the clinical team members as to the selection site and rationale, and there is documentation as to the reasons for selecting a specific different vessel, this aspect of the bundle should be considered as in compliance.[24]
Daily review of the necessity for all central lines and prompt removal of unnecessary lines	Daily review of the necessity of central lines will prevent unnecessary delays in removing lines that are no longer clearly necessary in the care of the patient. Many times, central lines remain in place simply because of their reliable access and because personnel have not considered removing them. The risk for infection increases over time as the line remains in place, and that risk is decreased if the line is removed.

 

 
The use of a central line bundle was tested in a large statewide collaborative initiative.^[2] The Michigan "Keystone Project" assessed a CLABSI prevention bundle similar to the one described above. To this bundle, the Keystone project team added a catheter insertion checklist to ensure that healthcare workers were observing the essential prevention measures and a catheter insertion cart to ensure that necessary supplies were always available for each insertion.^[2] The Keystone project also empowered ICU nurses to halt insertion efforts when the checklist was not fully implemented or when asepsis was violated. The use of this checklist and nurse-overseen prevention bundle was implemented in 108 ICUs in Michigan. The results were dramatic. CLABSI rates were reduced by up to 66% and sustained over the 18-month study period. The proven success of the central line bundle, such as the one used in the Keystone project, demonstrates that focusing on a few high-yield prevention measures can markedly reduce CLABSI rates. Whether similar results can be achieved with the use of bundles with fewer components (ie, simply daily cleansing of ICU patients with chlorhexidine) remains to be tested.

Best Practice

Routine surveillance should be done to monitor for CLABSIs. CLABSI rates should be measured at baseline and monitored over time to evaluate unit-specific performance improvement efforts and to benchmark against national CLABSI rates (Figure 4).

Figure 4. Catheter-related bloodstream infection rates in a surgical ICU compared with National Nosocomial Infections Surveillance System rates.
From Earsing KA, et al. Nurs Manage. 2005;36:18-24.

Patient Profile, Continued

MW was weaned off of vasopressor support within 24 hours. Blood cultures grew MRSA and IV vancomycin was initiated. A transesophageal echocardiogram ruled out endocarditis. Once she was hemodynamically stable and clinically improved, a peripheral IV catheter was inserted and the CVC was removed.

Summary

CLABSIs are associated with the use of CVCs, and are defined as the presence of bacteremia originating from an IV catheter in a patient who had a central line within the 48-hour period before the development of the bloodstream infection. Worldwide, CLABSIs are the most common cause of nosocomial bacteremia and are frequent, lethal, and costly. CLABSIs are common in all hospital settings, but CLABSI rates are higher in non-ICU settings, such as hematology/oncology wards, bone marrow and solid organ transplant units, inpatient dialysis units, and long-term acute care areas.
Risk factors for CLABSIs include emergent CVC insertion, repeated CVC access, the site of CVC insertion, prolonged use of CVCs, and the physical properties of the CVC as well as host factors, such as age, sex, comorbidities, severity of illness, loss of skin integrity, and immune deficiency.
CLABSIs are a largely preventable complication of medical care. Prevention of CLABSI requires a multidisciplinary approach, including education of clinicians on the consequences of CLABSIs, and clinical practice guideline recommendations and best practices, such as the central line bundle for prevention. Continuous quality monitoring is critical to reducing variance in standards of care and improving outcomes.

References

Additional Reading found at-http://en.wikipedia.org/wiki/Nosocomial_infection

http://emedicine.medscape.com/article/967022-overview

Source -Borrowed from  MedScape-http://www.medscape.org/viewarticle/708524

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IV therapy links, and Tips......

Peripheral Venous Access Devices:

• Video: Becton-Dickinson Saf-T-Intima IV Catheter Insertion (click on the image to start the download) http://media.medsch.wisc.edu/photography/video/01.html
• Video: Insertion of Peripheral IV http://mediasite.cidde.pitt.edu/mediasite/Catalog/Front.aspx?cid=173b9208-1b55-4581-b337-c0ba47c1933f
• Video: Insertion of Peripheral IV http://currency.medicine.dal.ca/videos/video1.htm
• Video: IV Access http://meds.queensu.ca/~pmsp/iv/IVrun2.htm
• PowerPoint: http://www.templejc.edu/dept/ems/documents/Presentations/1stSemesterParamedic/IvMedAdmin/IVTher apy.ppt - IV Therapy for emergencies
• Video: Phlebotomy (blood drawing) http://currency.medicine.dal.ca/videos/video3.htm
• https://nursing.advanceweb.com/Common/CE/Course.aspx?CourseID=562&CreditID=1 - Venous Access Devices. Click the link to read the article. There are two pages to the article. (link is good until November of 2008)
• http://www.guideline.gov/summary/summary.aspx?doc_id=8338&nbr=004666&string=central +AND+venous+AND+access+AND+devices - Access device guidelines: recommendations for nursing practice and education. Everything you wanted to know about the insertion, maintenance, complications, removal and more of peripheral and subcutaneous catheters, Midline catheters, PICCs, non-tunneled and tunneled central vascular lines, implanted ports, Apheresis/Hemodialysis Catheters, Arterial Access Devices, Intraventricular Access Devices, Epidural and Intrathecal Access Devices, Intraperitoneal Catheters, and Implanted Pumps
• http://www.childbirths.com/cypress/ivtherapy.htm - IV Therapy - discusses IV devices, IV fluid, vein selection, insertion technique, and solving IV flow rate calculations. Includes drawings/pictures.
• http://www.muw.edu/nursing/IV.htm
• http://www.mrprotocols.com/sset/iv.html - nice pictures of starting an IV!
• http://www.medtrng.com/blackboard/initiate_iv.htm - initiating and managing complications of an IV
• http://www.answers.com/topic/intravenous-therapy?cat=health - Intravenous Drip
• http://employees.csbsju.edu/mbyrne/IVSite/abc_of_ivmain.htm - The ABC's of IV's. Click on links at left side of page to access information.
• http://en.wikipedia.org/wiki/Intravenous_therapy
• http://www.adhb.govt.nz/newborn/Guidelines/VascularCatheters/IVCannulationPreparation.htm - pediatric IVs; diagrams of veins in arms, hands, legs and feet
• http://www.adhb.govt.nz/newborn/Guidelines/VascularCatheters/IVInfiltrationInjuries.htm - Infiltration; clysis in pediatric patients
• http://www.lhsc.on.ca/critcare/icu/procedures/bldwdrw.html - procedure for drawing blood from an IV line. Includes labeled photos
• http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=12209 - article on phlebitis and infiltration of peripheral IVs
• http://www.netwellness.org/healthtopics/anesthesiology/ivcomplications.cfm - complications of peripheral IV therapy
• http://www.infusionpartners.com/cc/q303.pdf - Preventing IV Therapy Complications, Part 2:
  Mechanical and Bacterial Phlebitis
• http://medi-smart.com/pitfalls.htm - Pitfalls of IV Therapy
• http://www.mccfl.edu/pages/2463.asp - Procedure: Initiating Intravenous Fluids into an Existing IV Site
  
• http://www.mccfl.edu/pages/2478.asp - Procedure: Administering IVP (IV push) medication into an Existing IV Line
  
• http://www.mccfl.edu/pages/2479.asp - Procedure: Administering IVP (IV push) medication via INT (intermittent infusion device)/prn adapter/Lock device
  
• http://www.mccfl.edu/pages/2483.asp - Procedure: Administering IVPB (IV piggyback) Medication via INT (intermittent infusion device)/prn adapter/Lock device
  
• http://www.mccfl.edu/pages/2482.asp - Procedure: Administering IVPB (IV piggyback) Medications into Primary IV Lines
  

Central Venous Access Devices (CVADs):

• http://ht.edwards.com/resourcegallery/products/swanganz/pdfs/cvcquickguide.pdf - QUICK GUIDE TO Central Venous Access; 153 page manual with extensive information
• http://www.nlm.nih.gov/medlineplus/ency/imagepages/19861.htm - illustration of anatomical placement of a central venous catheter
• http://www.nlm.nih.gov/medlineplus/ency/imagepages/19868.htm - illustration of IV and central line sites used in babies
• http://www.gene.com/gene/products/education/vascular/cvads.html - an brief overview of the types of CVADs and the classifications of occlusions of central lines
• http://www.cancerhelp.org.uk/netscape/help/default_printer_friend.asp?page=302 - Chemotherapy given by intravenous injection. Has drawings illustrating a peripheral IV, a Hickman line, an implanted port and how it is accessed, and a PICC line
• http://www.mccfl.edu/pages/2653.asp - Procedure: Central Line Dressing Change
• http://www.sjhlex.org/documents/Nursing/implanted_ports_mini_082607.pdf - Tips on Accessing, Assessing and Maintaining Implanted Ports with Non-Coring Huber needles
• http://doctors.shorehealth.org/nursing/iv/CV-ACCES-REMOV.pdf - Central Venous Access Removal Procedure
• http://www.uams.edu/nursingmanual/Procedures/procedure116.htm - PROCEDURE FOR REMOVAL OF NON-TUNNELED CENTRAL VENOUS CATHETERS, AND ARTERIAL LINES, EXCLUDING PERIPHERALLY INSERTED CENTRAL CATHETERS
• http://www.smh.com/sections/services-procedures/medlib/nursing/Procedures/Central_Lines/cen04_Removal_091907.pdf - Nursing Procedure: REMOVAL OF VENOUS CENTRAL LINE CATHETER

PICC lines:

• http://picclinenursing.com/picc_lines.html - PICC Line Nursing website
• http://www.rnceus.com/course_frame.asp?exam_id=17&directory=picc - PICC Line Care and Maintenance: An Introduction
• http://www.bardaccess.com/nurse-grosh-picc.php - image of a Bard groshong P.I.C.C.
• PICC Line Instruction Sheet.doc - example of a Grosong PICC line care instruction sheet

TPN (Total Parenteral Nutrition):

• http://healthlinks.washington.edu/nutrition/index.html#table - Resource Book for Delivering Enteral and Parenteral Nutrition for Adults
• http://www.merck.com/mmpe/sec01/ch003/ch003c.html - TPN: indications, nutritional content, solutions, monitoring and complications – includes a table of the Basic Adult Daily Requirements for Total Parenteral Nutrition
• http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/Nursing/P-35.pdf - one hospital's nursing TPN policy.
• http://www.lhsc.on.ca/critcare/icu/protocols/tpn.pdf - sample pre-printed TPN order form. Note the nursing orders at the left side of the order page.
• http://www.guideline.gov/summary/summary.aspx?doc_id=8739&nbr=004851&string=Total+A ND+Parenteral+AND+Nutrition - Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition.

IV Flow Rate and Calculation Problems:

• http://www.m2hnursing.com/MedCal/index.php - Module 3 has IV flow rate tutorials and problems - you do not have to login to access the tutorial
• http://www.testandcalc.com/quiz/testiv.htm -- practice IV flow rate quiz and answers
• http://www.geocities.com/Heartland/Valley/3049/iv/clcltns.html
• http://classes.kumc.edu/general/IVPump/IVSimulation.html -- a cool interactive IV pump simulator!

Blood Transfusion:

• http://classes.kumc.edu/son/nurs420/unit8/blood_transfusion_guide.htm - Blood Transfusion Guide
• Chart of Commonly Transfused Blood Products.doc - Chart of Commonly Transfused Blood Products, what they consist of, why they are used, how they are administered and nursing considerations
• http://www.guideline.gov/summary/summary.aspx?doc_id=9850&nbr=005274&string=blood+A ND+transfusion - Blood Transfusion: Indications and Administration
• http://campbellteaching.co.uk/lesson%20notes/nursing/BLOOD%20TRANSFUSIONS.htm
• http://library.med.utah.edu/WebPath/TUTORIAL/BLDBANK/BLDBANK.html - tutorial on blood banking and blood transfusion. Includes discussion on compatibility, cross matching and transfusion reactions
• http://www.muw.edu/nursing/IV.htm - the last half of this document has information about the procedure of blood transfusion and transfusion reactions
• http://www.nhlbi.nih.gov/health/prof/blood/transfusion/transfin.htm - indications for the use of Red Blood Cells, Platelets and Fresh Frozen Plasma from the National Heart Lung and Blood Institute.
• http://rnweb.com/rnweb/article/articleDetail.jsp?id=310561 - Your guide to safe transfusions. From RNWeb. Includes a blood compatibility chart at the very bottom of the page.
• http://www.redcross.org/services/biomed/profess/pgbtscreen.pdf - Practice Guidelines for Blood Transfusion
• http://labtestsonline.org/lab/bloodbank.html - blood banking-scroll through the series of pages that explains what this is

IV Infusion Devices/Pumps

• http://www.rnweb.com/rnweb/article/articleDetail.jsp?id=254828 - " Technology today: Smart IV pumps". Includes photos of some of these pumps.

Table of Commonly Used IV Solutions

• Table of Commonly Used IV Solutions.doc - most commonly used IV solutions; includes tonicity, pH, the ingredients of the solutions, its uses and complications

IV Tips & Tricks:

• http://allnurses.com/forums/f18/iv-tips-tricks-3793.html - this thread over on the Emergency Nursing Forum has an immense amount of good information from experienced nurses on starting IV's

Table of Commonly Used IV Solutions[1]

Management of Hypernatremia...

The ED management of hypernatremia revolves around 2 tasks: restoration of normal serum tonicity, and diagnosis and treatment of the underlying etiology. When possible, providing free water to a patient orally is preferred.
Hypernatremia should not be corrected at a rate greater than 1 mEq/L per hour.
Carefully monitor all patients' inputs and outputs during treatment.
Consider CNS imaging to exclude a central cause or to identify CNS bleeding from stretching of veins.
Using isotonic sodium chloride solution, stabilize hypovolemic patients who have unstable vital signs before correcting free water deficits because hypotonic fluids quickly leave the intravascular space and do not help to correct hemodynamics. Once stabilization has occurred, free water deficits can be replaced either orally or intravenously.
Euvolemic patients can be treated with hypotonic fluids, either orally or intravenously (ie, dextrose 5% in water solution [D5W], quarter or half isotonic sodium chloride solution), to correct free fluid deficits.
Hypervolemic patients require removal of excess sodium, which can be accomplished by a combination of diuretics and D5W infusion. Patients with acute renal failure may require dialysis.
Traditionally, correction of hypernatremia begins with a calculation of the fluid deficit as shown below. Predicted insensible and other ongoing losses are added to this number and the total is administered over 48 hours. Recheck serum electrolyte levels frequently during therapy. To avoid cerebral edema and associated complications, the serum sodium level should be raised by no more than 1 mEq/L every hour. In patients with chronic hypernatremia, an even more gradual rate is preferred.
An alternative method to plan the correction of sodium imbalances has been proposed by Adrogue and Madias. They have devised a formula that can be used to calculate the change in serum sodium level after the administration of 1 L of a given infusate. This formula has the advantages of taking into consideration the tonicity of the infusate and encouraging reassessment of the treatment plan with each liter of solution or new set of electrolytes.
Free Water Deficit = Body Weight (kg) X Percentage of Total Body Water (TBW) X ([Serum Na / 140] - 1)
The percentage of TBW should be as follows:

• Young men - 0.6%
• Young women and elderly men - 0.5%
• Elderly women - 0.4%

An example is as follows: A serum sodium level of 155 in a 60-kg young man represents a fluid deficit of 60 X 0.6 X ([155 / 140] - 1) or 3.9 L. With another 900 mL of insensible losses, the patient requires 4.8 L of fluid in the next 48 hours, resulting in an infusion rate of 100 mL/h.
The Adrogue and Madias formula is as follows: Change in Serum Sodium = ([Na] Infused - [Na] serum) / (TBW + 1)
The "1" in the denominator represents the extra liter of infusate added to TBW. When TBW is calculated as above, TBW = Body Weight (kg) X Percent Water
An example is as follows: For the patient above, the expected change can be calculated with D5W or D5 half isotonic sodium chloride solution.
For D5W, Change = (0 - 155) / ([60 X 0.6] + 1) = -4.18 mEq/L
For half isotonic sodium chloride solution, Change = (77 - 155) / ([60 X 0.6] + 1) = -2.1 mEq/L
If D5W is chosen to avoid fluid overload, an infusion rate of 250 mL/h results in a correction just over 1 mEq/h. (Note: This assumes the patient has no other losses during this time. Intrinsic losses make the correction slower [more conservative] than calculated.)

The right plasma volume expander....

Daniel O'Neill, BSc, RN, is a staff nurse, A&E, John Radcliffe Hospital, Oxford
Plasma volume expanders are used for the treatment of circulatory shock. They restore vascular volume, stabilising circulatory haemodynamics and maintaining tissue perfusion. Two general categories of expander are used: crystalloids or colloids, or a mixture of both (Baskett, 1994; Astiz and Rackow, 1999).

Plasma volume expanders are used for the treatment of circulatory shock. They restore vascular volume, stabilising circulatory haemodynamics and maintaining tissue perfusion. Two general categories of expander are used: crystalloids or colloids, or a mixture of both (Baskett, 1994; Astiz and Rackow, 1999).

The crystalloids most commonly used are normal saline (0.9% NaCl) or lactated Ringer's solution. Colloids include Haemaccel, Gelofusin and the naturally occurring plasma substances (albumin, plasma protein fraction). Debate on the preferred type of volume expander is ongoing (Holt and Dolan, 2000).

Albumin is normally present in the blood and constitutes 50-60% of the plasma proteins and 80-85% of the oncotic pressure. Plasma protein fraction consists of 88% albumin and 12% globulins. Plasma protein fraction is effective in maintaining blood volume but does not increase oncotic pressure.

How do plasma volume expanders work?
Plasma volume expanders increase the oncotic pressure in the intravascular space. Water moves from the interstitial spaces into the intravascular space, increasing the circulating blood volume. This increased volume leads to an increase in central venous pressure, cardiac output, stroke volume, blood pressure, urinary output and capillary perfusion, and a decrease in heart rate, peripheral resistance and blood viscosity.

Key functions
The administration of a volume of 25% albumin solution causes three-and-a-half times the administered volume to be drawn into the circulation within 15 minutes. A single infusion of dextran 40 increases the circulating blood volume to a maximum within a few minutes but the effect tails off as it breaks down more rapidly than dextran 70 or 75, which reaches maximum volume within an hour but maintains this for longer. Hetastarch (etherified starch) produces a volume expansion that is slightly greater than the amount administered, with maximum expansion occurring within minutes. With all these products, volume expansion lasts about 24 hours.

Dextran 40, unlike the higher molecular weight dextran products, also improves microcirculation independently of its volume-expanding effects. The exact mechanism of this activity is unknown, but it is believed to occur by minimising erythrocyte aggregation and/or decreasing blood viscosity.

Dextran is used clinically in the prophylaxis of venous thrombosis and pulmonary embolism in patients undergoing surgery that carries a high risk of thromboembolic complications.

The main features of crystalloids are that they have an intravascular half-life of between 30 and 60 minutes and must be given in amounts equal to three times the volume lost. Colloids such as Haemaccel last several hours and replace the volume of blood lost in a ratio of one to one.

Which plasma volume expander is best?
Some clinicians have strong opinions on the pros and cons of using a crystalloid versus a colloid plasma expander. A study of 26 A&E patients with hypovolaemia and septic shock compared the haemodynamic and respiratory effects of normal saline (NS), albumin and hetastarch (Rackow et al, 1983). Patients were given enough plasma expander to reach a target central venous pressure.

About two to four times greater fluid volume was needed when using NS compared with albumin and hetastarch. The only haemodynamic differences included a greater increase in cardiac output in the albumin and hetastarch groups compared with the NS group.

Colloid osmotic pressure decreased below baseline in the NS group, which is interesting as it could cause serious problems, especially if either function is impaired, resulting in a higher incidence of pulmonary oedema in the NS group compared with the other groups.

Both albumin and hetastarch groups maintained or increased the colloid osmotic pressure compared with the baseline. In general there were no significant differences between the albumin and hetastarch groups.

Potential complications
Nurses overseeing an infusion of plasma expanders must be aware of the possible complications. Anaphylaxis reactions can occur with hetastarch, albumin or any of the dextran preparations. Dextran is produced by a bacterium, Leuconostoc mesenteroides, which contributes to its antigenicity. However, improved preparation methods have resulted in the incidence of hypersensitivity reactions falling. Of the dextran products, dextran 40 has less potential to cause an adverse reaction. The risk of antigenicity is lower with hetastarch than with dextran. With albumin, anaphylactic reactions are more likely to occur with high doses or repeat administration than with low doses.

With any product, the patient should be closely observed during the first few minutes of administration. Allergic reactions include urticaria, nasal congestion, wheezing, tightness of the chest, nausea and vomiting, periorbital oedema and hypotension, which can be mild or severe. Volume expander therapy should be stopped at the first sign of an allergic reaction.

Substances with a molecular weight of 50,000 daltons or less can be filtered by the glomerulus, so dextran 40 could cause renal injury if tubular flow is decreased. Dextran 40 undergoes rapid urinary excretion, increasing the viscosity and specific gravity of urine. Patients with a reduced flow of urine are particularly susceptible to tubular stasis and blocking, so it is essential to maintain hydration. Renal failure does not occur with dextran 70 or 75, but input and output must be monitored as volume overload may lead to cardiovascular effects, as can fluid overload with a crystalloid.

Excessive administration of albumin, dextran or hetastarch can precipitate cardiac failure, pulmonary oedema and peripheral oedema of the lower extremities, hypertension or tachycardia. Concentrations in plasma protein fraction may cause a higher incidence of hypotension. Nurses need to monitor patients' haemodynamic state.

In acutely ill patients measurements other than central venous pressure, such as cardiac output studies, may need to be carried out. Fluid balance may need to be sustained in conjunction with inotropic/cardiosupportive drug therapy.

Bleeding is a serious concern with hetastarch therapy. Hetastarch appears to affect total platelet count and haemodilution can exacerbate this. A prolonged bleeding time, partial thromboplastin time and prothrombin time can result as a temporary adverse effect. However, at volumes less than 1,500ml, effects on coagulation are minor.

Conclusion
To be able to administer intravenous therapies, the nurse must have a thorough knowledge of the principles and their applications. Intravenous medications should never be given without full knowledge of immediate and late effects, toxicity and nursing implications (UKCC, 1992). Only by continually updating and reviewing practice can the nurse develop as a safe practitioner.

Choosing the right fluid to counter hypovolemic shock........

A PATIENT THREATENED by hypovolemic shock needs immediate intravenous (I.V.) fluid resuscitation to survive. Do you know which fluids are appropriate-and which to avoid? In this article, we'll examine the fluids used for resuscitation and discuss which one is right for your patient, depending on his condition. Let's start by looking at how fluid loss or shifts within the body lead to hypovolemia.

What causes hypovolemia?

The body has two main fluid compartments: Fluid in the cells is called intracellular fluid; fluid in plasma (intravascular) and interstitial space is called extracellular fluid.


In a healthy person, the amount of fluid in intracellular and extracellular spaces is relatively constant, but water and solutes, such as electrolytes, move among the compartments to maintain homeostasis. Fluid intake and output provide a rough measure of homeostasis: They must be approximately equal to maintain balance. Illness or injury upsets the balance, requiring your intervention.

Hypovolemia results from internal fluid shifts or external fluid losses:

* Internal fluid shifts leading to hypovolemia occur as fluid moves out of the intravascular compartment into another area of the body, such as the interstitial space; for example, during internal hemorrhage associated with a hemothorax, long-bone fracture, or ruptured spleen. Third-spacing occurs when fluid accumulates in the extracellular and intracellular spaces and in a third body space (such as the intestinal lumen) that doesn't support circulation.

* External fluid loss can result from bleeding, vomiting, diarrhea, nasogastric suction, diuretic therapy, diabetes insipidus, hyperglycemic osmotic diuresis, severe burns, trauma, and surgery.

The goal of fluid resuscitation is to maintain perfusion to the patient's vital organs, especially the brain and heart, by restoring circulating volume.

Warning signs of shock

Untreated hypovolemia can quickly evolve into hypovolemic shock, which produces characteristic signs and symptoms depending on severity:

* mild hypovolemic shock-diaphoresis, anxiety, increased capillary refill time, and cool extremities

* moderate hypovolemic shock-the same as for mild shock, plus increased heart and respiratory rates and decreased urine output

* severe hypovolemic shock-the same as for moderate shock, plus hemodynamic instability, hypotension, and altered mental status, including coma.

Regular assessments can help you identify and treat hypovolemia at an early stage, before the patient's condition deteriorates. Remember that very young and elderly patients are especially vulnerable to fluid imbalances.

Choosing the right fluid

Parenteral fluids can be classified in several ways; for example, crystalloid or colloid, blood and blood products, and pharmaceutical plasma expanders. Two main factors affect the choice of fluid for your patient: how the volume loss occurred and which solutes need to be replaced.

First, address the underlying problem; for example, stop the bleeding or treat the vomiting or diarrhea. Next, provide I.V. fluids to restore circulating blood volume. Let's look at how I.V. fluids are categorized and when each type is indicated.

Crystalloids

Crystalloid solutions closely mimic the body's extracellular fluid. Common examples are 0.9% sodium chloride solution and Ringer's solution. Given I.V., crystalloid solutions diffuse through the capillary walls that separate plasma from interstitial fluid. They can be used to expand both intravascular and extravascular fluid volume.

Crystalloids are further classified by tonicity, or the number of particles (or solutes) in the solution. A fluid's tonicity controls fluid movement between fluid compartments. To maintain homeostasis, fluids move from areas of lower solute concentration to areas of higher solute concentration, a process called osmosis.

Isotonic fluids have the same tonicity as plasma. They're useful in raising intravascular volume without altering fluid shifts in or out of cells or changing plasma electrolyte concentration. Common isotonic fluids include 0.9% sodium chloride solution, D^sub 5^W, Ringer's solution, and lactated Ringer's solution.

Use isotonic fluids for patients whose fluid losses stem from vomiting and diarrhea, those awaiting an infusion of blood and blood products, and patients who lost fluid during surgery. Because isotonic fluids expand circulating volume, monitor for fluid excess or overload.

Hypotonic fluids, such as 0.45% sodium chloride solution, help the body restore homeostasis by moving fluid into the intracellular compartment. Because hypotonic fluids have a lower concentration of particles than plasma, they exert less osmotic pressure than the fluid in the extracellular compartment. Hypotonic fluids often are given to patients whose sodium intake must be restricted, such as those with hypernatremia.

Monitor the patient closely; too much of a hypotonic fluid can cause intravascular fluid depletion, hypotension, and cellular edema and tissue damage.

Hypertonic fluids have a greater tonicity than fluid in the extracellular compartment, so they exert more osmotic pressure. These solutions draw fluid from the intracellular to the extracellular compartment, causing cells to shrink and relieving cellular edema. But hypertonic solutions (such as 3% or 5% sodium chloride solution) raise the risk of volume overload, especially in a patient with heart failure, so assess his response to treatment frequently.

Another hypertonic solution, concentrated dextrose in water (20%, 40%, 50%, 60%, or 70%) is often added to amino acid solutions administered via central vascular access devices to correct hypoglycemia and provide calories. Monitor the patient's blood glucose levels for hyperglycemia and urine output and urine specific gravity for osmotic diuresis. Also monitor the patient's serum electrolytes.

Colloids

Colloids contain undissolved particles, such as protein, sugar, and starch molecules, which are too big to pass through capillary walls. A colloid solution draws fluid from the interstitial and intracellular spaces, increasing intravascular volume. The degree of osmotic pull that a colloid exerts depends on its particle concentration.

Colloid solutions have the same effect as hypertonic solutions and are given in smaller volumes. They also have a longer duration of action because the larger molecules stay in the intravascular compartment longer.

Albumin is the most frequently used colloid solution. A commercially prepared solution, albumin is extracted from human plasma and heated to kill pathogens. It's available in 5% or 25% concentrations (the 5% solution is isotonic) and contains no clotting components. Use albumin for volume expansion when crystalloid solutions are inadequate, as a plasma substitute when treating patients with hypovolemic shock and massive hemorrhage, and to treat patients exhibiting third-spacing of fluid into the interstitial spaces.

A patient who's lost fluid during thoracic surgery would benefit from albumin used as the primary fluid in resuscitation because it enhances blood volume, improves hemodynamics, and reduces the need for blood transfusions.

Blood and blood products

Whole blood contains red blood cells (RBCs), white blood cells, platelets, and plasma. Because storage degrades blood quality fairly quickly, units of whole blood are typically broken down into separate units of RBCs, platelets, and fresh frozen plasma. White blood cells may be removed from the plasma during processing of the blood product. Blood loss can often be managed with blood components and crystalloid and colloid solutions. Whole blood is rarely used unless it's less than 24 hours old and the patient is exsanguinating.

Packed RBCs have the same cell mass as whole blood, making them a good choice for patients who need increased RBC mass and oxygen-carrying capacity without volume overload or for patients with symptomatic anemia, hypovolemic shock, or symptomatic acute or chronic blood loss. Each unit of packed RBCs is typically infused over 1 to 2 hours, but always within 4 hours. Monitor a patient with a poor ejection fraction or a history of heart failure closely. He may require infusions of packed RBCs (smaller-volume infusions than whole blood), perhaps alternating with doses of a diuretic.

Fresh frozen plasma contains albumin, globulins, antibodies, and all other plasma proteins and clotting factors. Although it shouldn't be used for volume expansion, it's useful when clotting factors are required; for example, to counteract the effects of warfarin therapy.

Pharmaceutical plasma expanders

These colloid fluids include hetastarch (Hespan), a synthetic polymer with volume-expanding traits similar to 5% albumin, but with longer-lasting effects. Hetastarch is useful for patients with intravascular volume loss related to trauma, burns, hemorrhage, or surgery.


Dextran is available in low molecular weight (dextran 10%) or high molecular weight (dextran 6%). Composed of large glucose polymers that draw water into the intravascular space, dextran exerts its maximum effect about 1 hour after administration; however, effects may last 24 hours.

Mannitol is a sugar alcohol substance dissolved in 0.9% sodium chloride solution. Available in concentrations from 5% to 25%, mannitol contains an inactive sugar that remains in the vascular space to pull water from the interstitial and intracellular spaces, increasing plasma volume and producing an osmotic diuresis. Mannitol's primary uses are to decrease intracranial pressure from cerebral edema, reverse cerebrospinal fluid buildup, and lower intraocular pressure. Mannitol is sometimes also used for patients in hypoperfused states; for example, a postoperative patient who's had renal artery clamping during abdominal aortic aneurysm repair. During this procedure, perfusion to the kidneys is poor or absent for 15 to 20 minutes. When the clamp is released, mannitol is given to increase intravascular volume and produce osmotic diuresis, improving glomerular filtration and increasing urine flow.

Monitoring for complications

Consider any patient needing fluid resuscitation to be hemodynamically unstable and monitor him closely for complications. Besides keeping meticulous intake and output measurements, record daily weights, lab values, base deficit, serum lactate levels, and vital signs trends. Keep an eye on your patient's skin integrity, as fluid loss or displacement puts him at risk for skin breakdown.

Even a successful fluid resuscitation carries certain risks. For example, aggressive administration of crystalloid solutions can lead to volume overload, electrolyte disturbances, coagulopathy heart failure, pulmonary edema, interstitial edema, and acute respiratory distress syndrome. Colloids and blood products can trigger allergic reactions, including anaphylactic shock. During any fluid resuscitation involving blood components, implement safety measures to assess for and prevent transfusion reactions; be ready to intervene quickly if a reaction occurs.

Massive infusions of cool or room temperature solutions can cause hypothermia. Warm resuscitation fluids according to the manufacturer's guidelines and your facility's policies and procedures to prevent hypothermia.

Diving in

By watching for signs of hypovolemic shock, identifying the source of your patient's fluid loss, and choosing the right replacement, you can correct your patient's fluid imbalance and restore homeostasis.

SELECTED REFERENCES

Corrigan, A., ed: Core Curriculum for Intravenous Nursing, 2nd edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2000.

Gahart, B., and Nazareno, A.: Intravenous Medications 2003, 20th edition. St. Louis, Mo., Mosby, Inc., 2003.

Kruse, J., et al., eds: Saunders Manual of Critical Care, 1st edition. Philadelphia, Pa., W.B. Saunders Co., 2002.

McKenry, L., et al.: Mosby's Pharmacology in Nursing, 21st edition. St. Louis, Mo., Mosby, Inc., 2001.

BY LOUISE DIEHL-OPLINGER, RN, APRN,BC, CCRN, MSN, AND MARY FRAN KAMINSKI, RN, CCRN

Louise Diehl-Oplinger is an advanced practice nurse at Popkave-Mascarenhas Cardiology in Phillipsburg, N.J. Mary Fran Kaminski is clinical educator in the critical care division at Sacred Heart Hospital in Allentown, Pa.

Types of IV Access........

extravasation see above for complication in the Image

Types of IV access
The Hickman catheter is softer than a simple triple-lumen catheter, and is usually inserted in an operating room. The actual access to the subclavian vein is still by puncture under the clavicle, but the distal end of the catheter is pulled under the skin for 2-4 inches and comes out of the chest close to the nipple. This creates a "tunnel" which decreases the risk of infection. The Hickman catheter, which is made of silastic (a silicone elastomere), comes in double-lumen and triple-lumen varieties. These catheters can stay in place for weeks to months; some patients have had the same Hickman catheter for years!
 
The Groshong catheter is very similar to the Hickman catheter, but has a valve at the tip of the catheter which makes it unnecessary to leave a high concentration of heparin in the catheter (see below). The Broviac catheter is also similar to the Hickman catheter, but is of smaller size. This catheter is mostly used for pediatric patients.
 
Pheresis catheters are larger and sturdier than Hickman catheters. Pheresis catheters can also be used for hemodialysis, and are often called "dialysis catheters". The Hickman catheters are not designed to handle high-flow blood withdrawals; they are so soft that the walls of the catheter collapse (pull vacuum) when the dialysis, or pheresis, machine attempts to pull blood into the machine (see also Apheresis). These dialysis/pheresis catheters can either be inserted without a tunnel (e.g., Arrow Catheter?/i>) at the bedside, or with a tunnel (e.g., PermCath?/i>) in the operating room. Such tunneled pheresis catheters can serve both for the collection of stem cells and for support of the patient during the transplant episode.
 
Implantable Ports are catheters which are inserted completely under the skin. The distal end of the catheter is formed by a small metal "drum" or reservoir, which has on one side a membrane for needle access. This drum is surgically placed under the skin, just below the clavicle, with the membrane immediately below the skin. The catheter runs from the drum into the subclavian vein. Access is always with a special needle that is pushed through the skin and the membrane into the reservoir inside the drum. Such ports come in different sizes, and can have either one or two lumens. Since the entire catheter is under the skin, the risk of infection is smaller than with external catheter

Pictures of IV Access Devices

Peripheral IV (INT, HL, Angiocath, etc)
Multi-Lumen Central Catheter *Above: Triple-lumen Central Catheter   Below: Quad-lumen Central Catheter
Implantable Vascular Access Devices (Port-A-Cath; PAS Port) Implantable Ports are catheters which are inserted completely under the skin. The distal end of the catheter is formed by a small metal "drum" or reservoir, which has on one side a membrane for needle access. This drum is surgically placed under the skin, just below the clavicle, with the membrane immediately below the skin. The catheter runs from the drum into the subclavian vein. Access is always with a special needle that is pushed through the skin and the membrane into the reservoir inside the drum. Such ports come in different sizes, and can have either one or two lumens. Since the entire catheter is under the skin, the risk of infection is smaller than with external catheter *From left to right: Single Lumen Port; PAS Port; Duel Lumen Port; Quarter; Duel Lumen Port
VasCath Pheresis catheters are larger and sturdier than Hickman catheters. Pheresis catheters can also be used for hemodialysis, and are often called "dialysis catheters". The Hickman catheters are not designed to handle high-flow blood withdrawals; they are so soft that the walls of the catheter collapse (pull vacuum) when the dialysis, or pheresis, machine attempts to pull blood into the machine (see also Apheresis). These dialysis/pheresis catheters can either be inserted without a tunnel (e.g., Arrow Catheter?/i>) at the bedside, or with a tunnel (e.g., PermCath?/i>) in the operating room. Such tunneled pheresis catheters can serve both for the collection of stem cells and for support of the patient during the transplant episode. *Above: VasCath   Below: Tip of VasCath
Percutaneous Intravenous Catheter
Hickman Catheter The Hickman catheter is softer than a simple triple-lumen catheter, and is usually inserted in an operating room. The actual access to the subclavian vein is still by puncture under the clavicle, but the distal end of the catheter is pulled under the skin for 2-4 inches and comes out of the chest close to the nipple. This creates a "tunnel" which decreases the risk of infection. The Hickman catheter, which is made of silastic (a silicone elastomere), comes in double-lumen and triple-lumen varieties. These catheters can stay in place for weeks to months; some patients have had the same Hickman catheter for years!
Groshong Catheter The Groshong catheter is very similar to the Hickman catheter, but has a valve at the tip of the catheter which makes it unnecessary to leave a high concentration of heparin in the catheter (see below). The Broviac catheter is also similar to the Hickman catheter, but is of smaller size. This catheter is mostly used for pediatric patients.
Huber Needles

Problems With IV Therapy
Infusion Phlebitis - inflammation of the vein associated with infusion phlebitis is seen in this photograph. Careful/regular monitoring of intravenous access sites is recommended.

Infection - adhering to aseptic technique is vital in the prevention of intravenous related infections. Asepsis should be maintained at insertion, during clinical use and at removal of the device.

Bruising - may occur at any time during an episode of intravenous therapy.

Extravasation - the inadvertent administration of a vesicant substance into the tissues can have disastrous outcome.

Infiltration- regular monitoring of infusion sites, choice of correct access device/intravenous dressing and the use in-line pressure monitors may help to reduce the extent to which infiltration occurs.