IV Fluid Therapy Lecture and Demo PFN: SOMPSD03 Hours: 2.0 Instructor: JSOMTC, SWMG(A) Slide 1 Terminal Learning Objective Action: Communicate knowledge of IV fluid therapy Condition: Given a lecture and demonstration in a classroom environment Standard: Received a minimum score of 75% on the written exam IAW course standards JSOMTC, SWMG(A) Slide 2 References Fluids and Electrolytes Made Incredibly Easy, 5 th edition, 2011 The ICU Book, 3 rd edition, 2007 AACN Essentials of Critical Care Nursing, 2006 Infusion Nursing an Evidence Based Approach, 3 rd edition, 2010 PHTLS Manual, Military 7 th edition, 2011 JSOMTC, SWMG(A) Slide 3 1
Reason Hemorrhagic shock is a leading cause of death on the battlefield Infusion of intravenous fluids and blood products will help sustain the casualty until surgical intervention occurs IV cannulation enables providers to administer a variety of life saving drugs for both clinical and trauma scenarios JSOMTC, SWMG(A) Slide 4 Agenda Identify the physiology, indications, and contraindications of IV fluids Identify the indications and considerations for a peripheral IV Identify the peripheral IV sites Identify the characteristics of common IV equipment JSOMTC, SWMG(A) Slide 5 Agenda Identify the steps for initiating and discontinuing a peripheral IV Identify the complications of IV fluid therapy Demonstrate initiating and discontinuing a Peripheral IV JSOMTC, SWMG(A) Slide 6 2
Identify the physiology, indications, and contraindications of IV fluids JSOMTC, SWMG(A) Slide 7 IV Fluids IV fluid bags are good for 24 hours after being spiked, IV sites/lines are good for 72 hours Crystalloids Inexpensive, common, non‐infectious Lack O2 carrying/coagulation capability, and have short IV half‐life Colloids Greater osmotic pull Potential reactions and storage issues JSOMTC, SWMG(A) Slide 8 Crystalloids Solutes capable of crystallization are easily mixed and dissolved in a solution May be electrolytes or non‐electrolytes, such as dextrose Contain small molecules that flow easily across semi‐permeable membranes, allowing for transfer from bloodstream into cells and body tissues May increase fluid volume in both interstitial and intravascular spaces Useful in replenishment or dilution in the treatment of fluid and electrolyte disturbances JSOMTC, SWMG(A) Slide 9 3
Crystalloids Distinguished by their relative tonicity (before infusion) in relation to plasma Tonicity refers to concentration of dissolved molecules held within solution Isotonic, Hypotonic, and Hypertonic JSOMTC, SWMG(A) Slide 10 Isotonic Crystalloids Dissolved particles concentration similar to plasma Osmotic pressure constant both inside and outside cells Fluid shift does not occur. Cells neither shrink nor swell Distributed between intravascular and interstitial spaces, thus increasing intravascular volume 0.9% sodium chloride, lactated Ringer's, Plasmalyte, D 5 W JSOMTC, SWMG(A) Slide 11 0.9% Sodium Chloride Contains only water, sodium (154 mEq/L), and chloride (154 mEq/L) Often called "normal saline (NS)" because percentage of NS dissolved in solution is similar to concentrations of sodium and chloride in intravascular space Because water goes where sodium goes, 0.9% sodium chloride increases fluid volume in extracellular spaces JSOMTC, SWMG(A) Slide 12 4
0.9% Sodium Chloride Indications Hyponatremia and hypercalcemia Rhabdomyolysis Medication and blood administration Used as a vehicle for many parenteral drugs to replenish electrolytes for maintenance of deficits of extracellular fluid Contraindications Shock • Large volumes of normal saline leads to hyperchloremic acidosis Cardiac or renal disease JSOMTC, SWMG(A) Slide 13 Lactated Ringer's Electrolyte content is most closely related to body's blood serum and plasma 130 mEq/L Sodium 109 mEq/L Chloride 4 mEq/L Potassium ‐ 3 mEq/L Calcium 28 mEq/L Lactate Indications Shock/Burns ‐ Alkalization helps attenuates metabolic acidosis Dehydration JSOMTC, SWMG(A) Slide 14 Lactated Ringer's Contraindications Rhabdomyolysis • Due to K+ content of solution Conditions decreasing lactate metabolism and excretion • Liver failure prevents lactate conversion into bicarbonate • Kidney failure: Hyperkalemia risk • PH >7.5 due to alkalinization Not given w/blood products • C++ can increase hypercoagulable state which results in emboli JSOMTC, SWMG(A) Slide 15 5
Plasmalyte‐148 Electrolyte content is similar to LR, with many of the same indications 140 mEq/L Sodium 98 mEq/L Chloride 27 mEq/L Acetate 23 mEq/L Gluconate 5 mEq/L Potassium 1.5 mEq/L Magnesium Indications Same as LR plus…… JSOMTC, SWMG(A) Slide 16 Plasmalyte‐148 Uses acetate and gluconate as buffers. May be used in liver failure pts w/caution Approved for use in use with blood product transfusion No calcium/citrate interaction Contraindications Rhabdomyolysis/ PH >7.5 Kidney failure: Hyperkalemia and Hypermagnesemia risk JSOMTC, SWMG(A) Slide 17 D 5 W (Dextrose in Water) D5W's initial tonicity comparable to intravascular fluid (isotonic). Dextrose is metabolized leaving no osmotically active particles (hypotonic) Indications: Moderate nutrition Hypernatremia/Isotonic dehydration Dilute concentrated drugs for IV infusion Contraindications: Shock, TBI, stroke, hyperglycemia, transfusions, corn allergy, renal failure JSOMTC, SWMG(A) Slide 18 6
Hypotonic Crystalloids Compared with intracellular fluid, hypotonic solutions have lower concentration, or tonicity, of solutes (electrolytes) Lowers serum osmolality within vascular space, causing fluid to shift from intravascular space to both intracellular and interstitial spaces Solutions will hydrate cells, although their use may deplete fluid within circulatory system 0.45% NaCl, 0.33% NaCl, 0.2% NaCl, 2.5% dextrose in water JSOMTC, SWMG(A) Slide 19 Hypotonic Crystalloids Indications Intracellular dehydration conditions • Only after the initial resuscitation of DKA is complete A SOCM will not initially use a hypotonic solution for resuscitation Contraindications Trauma ‐ Shock, burns Hypotension Increased ICP JSOMTC, SWMG(A) Slide 20 Hypertonic Crystalloids Hypertonic solutions have higher sodium and chloride concentrations Solute concentration > ICS. Water drawn out of ICS, temporarily increasing fluid volume in the IVS 3% NaCl, 5% NaCl Vasoregulatory, immunologic, and neurochemical effects can attenuate post injury complications JSOMTC, SWMG(A) Slide 21 7
Hypertonic Crystalloids Indications Increased ICP/Cerebral edema • Osmolarity almost identical to Mannitol w/o risks of diuresis, and subsequent hypovolemia • Less chance of rebound in ICP Hyponatremia Contraindications: Pulmonary edema Hypertension JSOMTC, SWMG(A) Slide 22 Hypertonic Crystalloids Complications Central Pontine Myelinolysis • Rapid transition from hyponatremia to hypernatremia • Manifested clinically as lethargy and quadriplegia/paresis Hypernatremia Hypervolemia Pulmonary edema JSOMTC, SWMG(A) Slide 23 Colloids Unlike crystalloids, colloids contain molecules too large to pass through semipermeable membranes, such as capillary walls Remain in intravascular compartment Expand intravascular volume by drawing fluid from interstitial spaces into intravascular compartment • Known as volume expanders or plasma expanders Same effect as hypertonic crystalloids of increasing intravascular volume, but have longer duration of action and require administration of less total volume JSOMTC, SWMG(A) Slide 24 8
Colloids Blood products (SOCM fluid of choice for hemorrhagic shock) Packed RBCs (PRBC) • Store at 33‐43 degrees F • 2 units given w/FFP at a 1:1 ratio Plasma (FFP) • Shelf life once thawed: 3 days at 33‐43 degrees F, 30 min room temperature • Supplied as AB or A, RH factor is not a concern Platelets (PLTS) Whole blood (WB) • Equivalent of FFP, PBRC and PLTS in a 1:1:1 ratio • 24 hours shelf life or refrigerated for 21‐42 days JSOMTC, SWMG(A) Slide 25 Colloids Albumin 5% solution ‐ 25% solution One of the most commonly utilized colloid solutions Used to maintain a normotensive state, or even a hypervolemic state in neuro trauma (Triple H therapy) Dextrans ‐ LMWD (Dextran 40) and HMWD (Dextran 70) Reduces erythrocyte aggregation, Factor VIII‐Ag (Von Willebrand), platelet adhesiveness, and can inhibit a‐2 anti‐plasimin Interferes with blood cross matching/labs. Anaphylactoid risks Hydroxyethylstarches ‐ Hespan and Hextend JSOMTC, SWMG(A) Slide 26 Hydroxyethylstarches Hypertonic synthetic colloids used for volume expansion Hespan • 6% hetastarch in normal saline Hextend • 6% hetastarch in Lactated Ringer’s Effects can last 24 hours JSOMTC, SWMG(A) Slide 27 9
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