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Safe Intravenous

Therapy &
Hazards of
ABDUL WALI KHAN UNIVERSITY Intravenous
MARDAN
Therapy
DEPARTMENT OF PHARMACY

Clinical Pharmacy
Assignment # 01

Submitted By:
Sayeda Ambreen
Roll Number: 10

Final Professional (Pharm-D)

Submitted to: Dr. Saleemullah

Date: March, 15th 2019


INTRAVENOUS THERAPY
Intravenous therapy is a treatment that infuses intravenous solutions, medications,
blood, or blood products directly into a vein (Perry, Potter, & Ostendorf, 2014).
Intravenous therapy is an effective and fast-acting way to administer fluid or
medication treatment in an emergency situation, and for patients who are unable to
take medications orally. Approximately 80% of all patients in the hospital setting will
receive intravenous therapy.

INDICATIONS
1. To replace fluids and electrolytes and maintain fluid and electrolyte balance: If a
patient is ill and has fluid loss related to decreased intake, surgery, vomiting,
diarrhea, or diaphoresis, the patient may require IV therapy.
2. To administer medications, including chemotherapy, anesthetics, and diagnostic
reagents: About 40% of all antibiotics are given intravenously.
3. To administer blood or blood products: in situations such as shock or trauma, or to
treat a failure in the production of red blood cells.
4. To deliver nutrients and nutritional supplements: IV therapy can deliver some or all
of the nutritional requirements for patients unable to obtain adequate amounts
orally or by other routes.
5. To monitor hemodynamic function.
6. To administer fluids to keep a vein open

GUIDELINES FOR SAFE I/V THERAPY:


For safe I/V therapy the following protocol is to be observed:
 While prescribing I/V therapy the prescriber shall include type of solution or
medication, rate of infusion, duration, date, and time. IV therapy is an invasive
procedure, and therefore significant complications can occur if the wrong amount
of IV fluids or the incorrect medication is given.
TYPES OF IV FLUIDS
IV fluids can be categorised according to their physical composition:
 Crystalloids are solutions of small molecules in water (e.g, sodium chloride,
glucose, Hartmann’s)
 Colloids are dispersions of large organic molecules (e.g, Gelofusin, Voluven)
The different types of fluid distribute into the various fluid compartments in different
ways. In general, colloids remain in the intravascular space, while crystalloids
distribute more readily into other tissues.
Types of Venous Access
 Peripheral IV
A peripheral IV is a common, preferred method for short-term IV therapy in the
hospital setting. A peripheral IV (PIV) is a short intravenous catheter inserted by
percutaneous venipuncture into a peripheral vein, held in place with a sterile
transparent dressing to keep the site sterile and prevent accidental dislodgement.
Upper extremities (hands and arms) are the preferred sites for insertion by a
specially trained health care provider. If a lower extremity is used, remove the
peripheral IV and re-site in the upper extremities as soon as possible
PIVs are used for infusions under six days and for solutions that are iso-osmotic or
near iso-osmotic (CDC, 2011). They are easy to monitor and can be inserted at the
bedside.
PIVs are prone to phlebitis and infection, and should be removed as follows:
 Every 72 to 96 hours and p.r.n.
 As soon as the patient is stable and no longer requires IV fluid therapy
 As soon as the patient is stable following insertion of a cannula in an area of flexion
 Immediately if tenderness, swelling, redness, or purulent drainage occurs at the
insertion site
 When the administration set is changed (IV tubing)
 Central Venous Catheters
A central venous catheter (CVC), also known as a central line or central venous access
device, is an intravenous catheter that is inserted into a large vein in the central
circulation system, where the tip of the catheter terminates in the superior vena
cava (SVC) that leads to an area just above the right atrium. CVCs have become
common in health care settings for patients who require IV medication
administration and other IV treatment requirements. CVCs can remain in place for
more than one year. Some CVC devices may be inserted at the bedside, while other
central lines are inserted surgically.
Advantages:
The ability to deliver fluids or medications that would be overly irritating to
peripheral veins, and the ability to access multiple lumens to deliver multiple
medications at the same time.

 While writing an order, the type of patient is determined. Typically, there four
types of medical patients when it comes to administering IV fluids:
 Hypovolemic patient (pneumonia, sepsis, haemorrhage, Gastroenteritis)
 Hypervolemic patient (CHF, renal failure, cirrhosis)
 NPO patient, surgical patient, euvolemic (awaiting surgery)
 Eating/drinking normally
 Aseptic technique must be maintained throughout all IV therapy procedures,
including initiation of IV therapy, preparing and maintaining equipment, and
discontinuing an IV system.
 Always perform hand hygiene before handling all IV equipment.
 If an administration set or solution becomes contaminated with a non-sterile
surface, it should be replaced with a new one to prevent introducing bacteria or
other contaminants into the system
 Rate of Infusion shall be controlled. Usually 20-50 ml/h
 Site of infusion shall be checked and assessed after each 2 hours.
 Repeated puncturing may be avoided for long term use by using cannulas etc.
 Needles or catheters should never be re-used.
 Irritant medicines shouldn’t be administered through IV route.
 Cardiac and renal patients have increased risk of systemic complications, hemce
they should be monitored carefully.
 Paediatric patients, neonates, and elderly people have increased risk of systemic
complications

ADVANTAGES OF IV THERAPY:
1. Provides a route for unconscious patients
2. Provides a route for emergency access, where quick response is required and
other routes are not available.
3. Provides a route during decompression of the stomach or bowel.
4. Provides a route for the patients with inflammatory bowel disease
5. Drugs that are unstable and cannot be administered orally due to degradation
in the stomach or first-pass metabolism can be administered intravenously.
6. In IV therapy entire administered dose reaches the systemic circulation.
Hence, Bioavailability= 100%
7. Diagnosis
Widely used for the administration of tracers and other diagnostic reagents in
radiographic diagnosis.
8. Large volume of fluids can be administered through IV route.
9. I/V therapy ensure controlled, steady supply (concentration) of drug into
blood and hence plasma concentration is easy to maintain during therapy.
10. I/V therapy is useful in administering nutrients in conditions where patient is
unable to take food orally.
11. Serious illness (Palliative care/ Hospice care)
I/V therapy is very helpful in conditions associated with serious illness for the
improvement of patient life.

HAZARDS ASSOSIATED WITH INTRAVENOUS THERAPY:


1. Physical/ physiological complications
2. Mechanical hazards
3. Therapeutic hazards

Physical complications associated with I/V therapy may be local or systemic.


LOCAL COMPLICATIONS:

1. Phlebitis:
Phlebitis is an inflammation of one or more layers of the vein.

Possible Causes Management


Mechanical phlebitis  Remove IV cannula and reinsert
 Cannula too large for vein appropriate vascular access
 Cannula inserted near a joint, creating device in new location.
piston motion against vein wall when  Apply warm moist compress (ie.
patient moves body temperature) to site for 20
 Inadequate dressing and securement minutes, 6 hourly for 24 hours
Chemical Phlebitis (non-cytotoxic drugs only)
 Infusion of Alkaline solutions: - e.g.  Use smallest gauge cannula in
acyclovir, azathioprine, ganciclovir, largest vein possible (refer to IV
phenytoin or Acid solutions - cannulation package)
vancomycin, thiamine, glucagon,  Re secure or redress as required
cyclizine, haloperidol  Dilute irritating solutions to
 Infusion of hyper/hypotonic solutions acceptable dilutions
(link to IV certification package)  Decrease infusion rate
 Speed and method of infusion delivery

2. Infiltration
Infiltration is the infusion of fluid and/or medication outside the intravascular
space, into the surrounding soft tissue.

Clinical signs & symptoms: Management:


 Localized redness  Immediately stop infusion
 Pain & swelling  remove cannula
 Cold  Check site for reuse
 Flow rate changes

3. Extravasation
Extravasation of vesicant drugs / fluids into the tissues is a complication that
can occur due to:
 Vein injury during cannula insertion
 Too large a cannula for the vein
 Cannula dislodgement during infusion
 Inadequate securement of the cannula
 Constriction of the vein above infusion site. e.g. clothing, patient ID bracelet

Signs and symptoms Management Prevention


 Swelling  Do not flush the line  Ensure the cannula is the
 Burning and or pain  Attempt to aspirate appropriate size and well
at the insertion site. drug from the secured
Pain may be severe cannula  Blood return on aspiration is
if the IV solution is  Remove the cannula observed before flushing
hypertonic (e.g. once aspiration is cannula
solutions greater complete  The insertion site must be
than 5%  Re-cannulate away visible at all times during
 Dextrose), acid or from the affected administration
alkaline area  Check cannula site at least
 Slowing of the hourly or more often if there
infusion rate is any concern during an
 Lack of blood return infusion
from cannula Note: the insertion site should
never be over an area of flexion.
Splints are never to be used

4. Local Infection
Infection can be the result of cannula insertion or during management and care
of a cannula when aseptic non touch technique is not adhered to. It is usually a
local infection at the catheter-skin entry point. Infection can also be the result of
unresolved phlebitis. Local infection at IV site is indicated by purulent drainage
from site, usually two to three days after an IV site is started.

Clinical signs and symptoms Management


 Redness  Take swab from insertion site for culture
 Swelling  Clean insertion site with antimicrobial wipe
 Skin discolouration before removing cannula
 Purulent discharge  Remove cannula and culture
 Pain  Place sterile dressing over site
 Systemic antibiotics may be necessary
 Monitor site 8 hourly for signs and
symptoms of systemic infection.
5. Hemorrhage
Hemorrhage is defined as bleeding from the puncture site.
Treatment: Apply gauze to the site until the bleeding stops, then apply a sterile
transparent dressing.

SYSTEMIC COMPLICATIONS:
1. Pulmonary edema
Accumulation of fluid in the lungs due to excessive fluid in the circulatory system
Clinical signs & symptoms: Management:
 Decreased oxygen saturation  Prompt medical attention
 Increased respiratory rate  Raise head of the bed
 Restlessness  Monitor vital sign
 Breathlessness  Call the physician
 Dyspnea
 Coughing up pinky frothy sputum

2. Air Embolism:
Air embolism refers to the presence of air in the vascular system and occurs when
air is introduced into the venous system and travels to the right ventricle and/or
pulmonary circulation. An air embolism is reported to occur more frequently
during catheter removal than during insertion, and the administration of up to 10
ml of air has been proven to have serious and fatal effects. Small air bubbles are
tolerated by most patients.
Clinical signs and symptoms Management
Air embolism is characterised by If there is evidence that considerable air has
abrupt onset of signs and entered the vascular compartment:
symptoms.  Stop the infusion by clamping the line
 Sudden shortness of breath,  Place patient in left trendelenburg position
continued coughing, (head down on left side by tipping the bed).
breathlessness, shoulder or Theoretically this action keeps the air in the
neck pain, agitation, feeling of pulmonary out flow tract to a minimum. Traps
impending doom, air in the right chamber of heart and great veins
lightheadedness, hypotension, proximal to the pulmonic valve and may be
wheezing, increased heart withdrawn via a central catheter inserted into
rate, altered mental status, the ventricle. Notify medical staff immediately.
and jugular venous distension.  Administer oxygen
 Loss of consciousness  Hyperbaric treatment may be considered
 Focal seizures
 Complete collapse
Prevention
 Ensure air is removed from administration set and the set is primed with the
infusion fluid before commencing infusion
 Never leave the rate control fully open unless the fluids are continuously
visually monitored.
 Observe the fluid level in the bag frequently and prepare the next prescribed
bag when the level is low
 Ensure all connections are tight (Should they be loose, fluid usually leaks out
rather than air entering the system)
 Remove air from the side arm reservoir before injection of intravenous drugs.

3. Allergic Reaction / Anaphylaxis:

Clinical Signs and symptoms: Management


Systems that may be involved include:  Cease treatment.
 Skin producing urticaria  Implement resuscitation
 Respiratory producing bronchospasm procedures depending on
 Oedema severity
 Cardiovascular producing signs of  Notify doctor immediately
shock.
 i.e. Low BP, tachycardia.
 Gastrointestinal producing cramps and
diarrhoea

Prevention
It is the responsibility of all staff, ie. both the person prescribing and the person
administering to be aware of previous reactions and possible medication interactions

4. Hypervolaemia
Those particularly at risk are:
1. The elderly
2. Children and infants
3. Patients with cardiac or pulmonary disease
4. Patients with significant cerebral or renal disease/injury
5. Pregnant women

Clinical signs and symptoms Management


 Deteriorating respiratory status –  Stop the infusion.
tachypnoea, dyspnoea, decreased  Notify Medical staff
oxygen saturations  Administer treatment
 Tachycardia. as ordered
 Hypertension.
 Raised CVP measurement and
distended neck veins.
 Pulmonary oedema may also occur,
leading to dyspnoea and cyanosis
 Weight increase >2kg over 24 to 48hrs

5. CATHETER RELATED PROBLEMS


Catheter embolism:
When part of the cannula tip breaks and enter the blood stream
After removing the cannula the tip shall be observed for possible break.
Cather related infection:
Infection caused by microorganisms introduced at puncture side through catheter or
needle causing bacteremia or sepsis.
REMEDY
Recommended antibiotics shall be sued to avoid further complications

6. Electrolyte Imbalance:
Administration of electrolytes may disturb the electrolyte balance especially when
hypertonic or hypotonic solutions are used.
Monitoring of important electrolytes may overcome the problem

7. Shock
When the infusion is introduced with higher speed usually the patient may suffer a
shock leading to dizziness, hypotension, light headedness, chest pain and shock
Adjustment of rate of infusion may overcome the problem.

Mechanical Hazards
1. Infusion pump or controller failure can lead to runaway infusion, fluid
overload or incorrect dosage.
2. IV tubing can become kinked, split, or cracked. It may also produce particulate
contamination or interfere with the infusion.
3. Glass containers may break/ causing injury.
4. Rubber vial closures may interact with the enclosed product.
Therapeutic hazards
1. Drug instability, which may lead to therapeutic ineffectiveness.
2. Incompatibilities may result in toxicity or reduced therapeutics effectiveness
3. Labelling error can cause administration of an incorrect dose or drug.
4. Drug overdose can be caused by runaway IV infusion, failure of an infusion
pump or controller.
5. Preservative and solubilizing agent toxicity can be a serious complication,
especially in children. Rapid administration of phenytoin and diazepam both
utilize propylene glycol as a solubilizing agent, has been associated with
cardiovascular collapse.

CONCLUSION
Although there are numerous risks associated with accessing the venous system for
administering any product directly into the circulating blood, the intravenous route is
often the best, or only, route of choice.