Reference Section

Intravenous Therapy
a report by

Steve Martin
Assistant Professor, Physician Assistant Program, College of Allied Health and Nursing, Nova Southeastern University

Steve Martin is the Assistant Professor of the Physician Assistant Program in the College of Allied Health and Nursing at Nova Southeastern University. He is also the Associate Program Director of the Master of Medical Science Program and the Director of the Physician Assistant Postgraduate Program in Family Medicine at Nova Southeastern University, where he also lectures on the clinical procedure of intravenous (IV) therapy. Mr Martin is a fellow and member of the American Academy of Physician Assistants and a member of American Academy of Physician Assistants. He has been a physician assistant since 1996 and has had clinical experience at Plains Medical Center, Colorado, and Aiken Regional Medical Center, South Carolina. He is currently studying for a PhD in International Health at Touro University International College of Health Sciences, and completed his Masters Degree in Physician Assistant Studies at the University of Nebraska Medical Center in 1999.

Intravenous Devices

There are many types of intravenous (IV) needles and catheters:

Steel Needles

An example of a steel needle is the butterfly catheter (see Figure 1), named after the wing-like plastic tabs at the base of the needle. They are used to deliver small quantities of medicines, to deliver fluids via the scalp veins in infants and, sometimes, to draw blood samples (although not routinely, since the small diameter may damage blood cells). These are smallgauge needles (i.e. 23-gauge).
Over-the-needle Catheters

An example of this is a patient who comes into an accident and emergency department with gastroenteritis and is dehydrated from vomiting and diarrhoea. Acutely, the patient receives a fluid bolus to expand his/her intravascular volume. The patients blood chemistry shows that his/her electrolytes are outside of the normal parameters, so the IV fluid is adjusted to bring them within normal parameters. The patient is also given medication for nausea via his/her IV and will remain on maintenance IV fluids until he/she is able to drink adequate amounts of fluids. There are three main types of fluids: isotonic fluids; hypotonic fluids; and hypertonic fluids.
Isotonic Fluids

An example of an over-the-needle catheter is the peripheral-IV catheter (see Figure 2). A close-up view of the catheter/needle tip is provided in Figure 3.
Inside-the-needle Catheters

Figure 3 depicts an inside-the-needle catheter arrangement.

Gauges

Isotonic fluids are close to the same osmolarity as serum. They remain inside the intravascular compartment, thus expanding it. They can be helpful in hypotensive or hypovolemic patients, however, they can also be harmful. There is a risk of fluid overloading, especially in patients with congestive heart failure and hypertension. An example is provided in Figure 5.
Hypotonic Fluids

Catheters (and needles) are sized by their diameter, which is called the gauge. The smaller the diameter, the larger the gauge. Therefore, a 22-gauge catheter is smaller than a 14-gauge catheter. Obviously, the greater the diameter, the more fluid can be delivered. To deliver large amounts of fluid, a large vein should be selected and a 14- or 16-gauge catheter used. To administer medications, an 18- or 20-gauge catheter in a smaller vein will suffice (see Figure 4).
IV Fluids

Hypotonic fluids have less osmolarity than serum (i.e. less sodium ion concentration than serum). It dilutes the serum, which decreases serum osmolarity. Water is then pulled from the vascular compartment into the interstitial fluid compart-ment. As the interstitial fluid is diluted, its osmolarity decreases, which draws water into the adjacent cells. Hypotonic fluids can be helpful when cells are dehydrated, such as those of a dialysis patient on diuretic therapy. They may also be used for hyperglycaemic conditions such as diabetic ketoacidosis, in which high serum glucose levels draw fluid out of the cells and into the vascular and interstitial compartments.

IV fluids are usually provided to achieve the following: provide volume replacement; administer medications, including electrolytes; and monitor cardiac functions;

BUSINESS BRIEFING: LONG-TERM HEALTHCARE STRATEGIES 2003

Intravenous Therapy
Hypotonic fluids can be dangerous to use because of the sudden fluid shift from the intravascular space to the cells. This can cause cardiovascular collapse and increased intracranial pressure in some patients. An example is provided in Figure 6.
Hypertonic Fluids Figure 1: Butterfly Catheter

Hypertonic fluids have a higher osmolarity than serum. They pull fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartment and can help stabilise blood pressure, increase urine output and reduce oedema. They are rarely used in the pre-hospital setting and care must be taken with their use. Hypertonic fluids can be dangerous in the setting of cell dehydration. An example is provided in Figure 7. There are two main groups of fluids: crystalloid; and colloid.

Figure 2: Inside-the-needle Catheter

Figure 3: Midline and Extended-dwell Catheters Crystalloid

Crystalloids are isotonic and remain isotonic and are, therefore, effective volume expanders for a short period of time. However, both the water and the electrolytes in the solution can freely cross the semipermeable membranes of the vessel walls (but not the cell membranes) into the interstitial space and will achieve equilibrium in two to three hours. They are ideal for patients who need fluid replacement. When using an isotonic crystalloid for fluid replacement to support blood pressure from blood loss, it should be borne in mind that three millilitres of isotonic crystalloid solution are needed to replace one millilitre of patient blood. This is because approximately two-thirds of the infused crystalloid solution will leave the vascular spaces by about one hour.
Figure 4

Generally, a good rule of thumb is that initial crystalloid replacement should not exceed three litres before whole blood is instituted. Continued use of crystalloids runs the very real risk that the fluid that has leaked into the interstitial space will result in oedema, primarily in the lungs (pulmonary oedema). Examples are Lactated Ringers, normal saline.
Colloid

interstitial and intracellular compartments into the vascular compartment. They work well in reducing oedema (as in pulmonary or cerebral oedema) while expanding the vascular compartment. Colloids can produce dramatic fluid shifts and place the patient in considerable danger if they are not administered in a controlled settings. Examples are albumin and steroids.

Colloids contain molecules (usually proteins) that are too large to pass out of the capillary membranes and therefore remain in the vascular compartment. The large protein molecules give colloid solutions a very high osmolarity. As a result, they draw fluid from the

BUSINESS BRIEFING: LONG-TERM HEALTHCARE STRATEGIES 2003

Reference Section

Figure 5: Lactated Ringers, Normal Saline or 0.9% Saline in Water

should be chosen and areas where the vein crosses over joints should be avoided. If the IV treatment is for a life-threatening illness or injury, choice may be limited to an area that remains open during hypoperfusion. Otherwise, IV access needs to be limited to the more distal areas of the extremities.
Dorsal Digital Veins

Isotonic fluids contain an approximately equal number of molecules (blue dots) as serum so the fluid stays within the intravascular space. Fluid flows from an area of lower concentration of molecules to an area of high concentration of molecules (osmosis) to achieve equilibrium (fluid balance). In this example, there is no fluid flow into or out of the intravascular space.

Dorsal digital veins flow along the lateral portion of the fingers and are joined to each other by communicating branches. They are available for IVs accommodating a small-gauge IV catheter (22- or 24-gauge) and need to be properly supported with a tongue blade or hand board. Dorsal digital veins are usually not very stable and not a primary site choice.
Metacarpal Veins

Vein Selection

Generally speaking, the vein section with the straightest appearance should be selected. A vein that has a firm, round appearance or feel when palpated
Figure 6: D5NS.45 (5% Dextrose in 1/2 Normal Saline)

Metacarpal veins are formed by the union of digital veins (dorsal venous area) and are ideally positioned for IV use primary choice IVs. Venipuncture

Hypotonic fluids contain a lower number of molecules than serum so the fluid shifts from the intravascular space to the interstitial space (represented by the green arrows). This decreases the interstitial space osmolarity (because of the increase of fluid and constant number of molecules within it), which then causes fluid to move into the cells. Note that the green arrows represent fluid movement, not molecule movement.

Figure 7: Nine Per Cent Normal Saline, Blood Products and Albumin

Hypertonic fluids contain a higher number of molecules than serum so the fluid shifts from the interstitial space to the intravascular space (green arrows). This increases the interstitial space osmolarity (because of the loss of fluid and constant number of molecules within it), which then causes fluid to leak out of the cells.

BUSINESS BRIEFING: LONG-TERM HEALTHCARE STRATEGIES 2003

Intravenous Therapy
should be started at the most distal point on the extremity and proper support is needed after IV infusion is initiated to prevent movement of the IV catheter. The veins are thin with inadequate tissue and muscle support in the elderly.
Cephalic Veins

For the person administering the IV, it is imperative that these four points are remembered: Do Do Do Do I I I I have have have have the the the the right right right right patient? solution? drug? route?

The cephalic vein flows upwards along the radial border of the forearm producing branches to both surfaces of the forearm. Due to its size and location, it provides an excellent site for IV infusion. The cephalic veins readily accommodate large-gauge IV catheters and are available for venipuncture in the upper-arm region.
Accessory Cephalic Veins

Flow Rates

Administration sets are available to calculate IV flow rates. The administration sets are available in two basic sizes microdrip and macrodrip. Microdrip sets are good for medication administration or paediatric fluid delivery, while macrodrip sets are great for rapid fluid delivery. Also used for routine fluid delivery and keep the vein open (KVO). Fluids may be ordered at a KVO rate or run in very slowly, enough to keep the vein open, but not really deliver much volume. At times, a faster flow rate may be desired. This is usually expressed in millilitres per hour. In other words, how much fluid do you want your patient to receive each hour? A common maintenance amount, for instance, would be to run it in at 125 millilitres an hour, thus, the patient would receive 125 millilitres of fluid every hour. Electronic pumps will deliver the fluid at precise amounts, however, if these are not used, the nurse/doctor will need to learn how to set a flow rate. Setting the flow rate is usually done by counting the number of drops that fall into the clear drip chamber on the IV administration set in one minute. Using the following formula it is possible to calculate the flow rate: (volume in ml) x (drip set) = (time in minutes) gtts min.

The accessory cephalic vein originates from either a plexus on the back of the forearm or dorsal venous network, branching off from the cephalic vein just above the wrist and flowing back into the main cephalic vein at a higher point. Accessory cephalic veins readily accommodate large gauge IV catheters.
Basilic Veins

The basilic vein originates in the ulnar portion of the dorsal venous network. It ascends along the ulnar portion of the forearm, curves towards the anterior surface of the arm just below the elbow and meets with the median cubital vein below the elbow. It is available for venipuncture above the antecubital fossa in the upper-arm region. The basilic vein is often overlooked because of its inconspicuous position.
Median Antebrachial Veins

The median antebrachial vein rises from the venous plexus on the hand and extends along the ulnar side on the anterior surface of the forearm. It empties into the basilic vein or median cubital vein and is not always easily seen.
Median Cephalic and Median Basilic veins

If a patient is to receive 250 millilitres of normal saline over a 90-minute time period and it is decided to use a macrodrip (10gtt/millilitre) administration set, the formula will now look like this: (250ml) x (10 gtts/min.) = (90 min.) which becomes: 2,500 = 90 gtts 1 gtts 1 min.

Located in the antecubital fossa, the median cephalic and median basilic veins should be a last-resort site for blood draws and are not a favourable site for prolonged infusions.
Technique

then solving for gtts: It is important to point out that starting an IV is an art form that is learned with experience accumulated after performing many IVs. Some patients are easy to administer but many are difficult. 27.7 = or, gtts = 28 gtts 1
4

BUSINESS BRIEFING: LONG-TERM HEALTHCARE STRATEGIES 2003