Intravenous Fluid Therapy Paramedic Class

5 Purposes Provide maintenance requirements for F&E Replace previous losses Replace concurrent losses Provide a mechanism for administration of medications/blood products Provide nutrition

Intravenous Solutions Colloids Crystalloids Blood products

Colloids Large protein molecules Can’t cross capillary membrane Draw fluid from interstitial and intracellular compartments into vascular compartment. Work well in reducing edema while expanding vascular compartment

Colloids Too costly Difficult to store Never used as first solution Albumin, steroids

Crystalloids Contain electrolytes Move across capillary membranes

Crystalloids Need 2-3 times the volume lost

Tonicity A solutions’ salt balance compared to plasma Around 300 mOsm/L

Isotonic Nearly the same as serum NS: 0.9% Sodium Chloride LR Generally, initial fluid replacement should not exceed three liters before blood is infused

Isotonic Balanced salt solutions Isotonic crystalloids Remember! 3 ml of isotonic crystalloid are needed to replace 1 ml of blood

Hypertonic Higher osmolarity Pulls F&E from intracellular and interstitial compartments into intravascular compartment.

Hypertonic, cont. Can help stabilize BP, increase urine output, reduce edema Rarely used in prehospital setting. Dangerous if cell dehydration exists D-5%-W in Lactated Ringers, 10% NS Example: Albumin

Less osmolarity than serum 0.45% NaCl Hypotonic Less osmolarity than serum Dilutes serum 0.45% NaCl D5NS.45 (5% Dextrose in ½ normal saline)

Hypotonic, cont. Water is pulled from vascular compartment into interstitial fluid compartment, then into adjacent cells Helpful when cells are dehydrated Dialysis pt on diuretics Hyperglycemia - DKA Can be dangerous – sudden fluid shift can cause cardiovascular collapse and ICP

REMEMBER - WATER GOES WHERE THE SALT IS Isotonic no movement initially Hypertonic attracts water Hypotonic gives up water

Isotonic crystalloid EMT’s first choice Normal Saline 0.9% Lactated Ringers, Plasmalyte-A, Normosol-R

Hypertonic Solution Higher concentration of ions 1.8% NaCl, D5%W/LR

Hypertonic Solution Usually no prehospital application Crenation

Hypotonic Solution Lower concentration 0.45% NaCl, 0.25% NaCl

Hypotonic Solution No prehospital application Lysis

Administration Sets Microdrip (60 drops per ml) Macrodrip (10–15 drops per ml)

Administration Sets Others (12, 20 drops/ml, adjustable) Soluset (pediatric set)

Microdrip Usually for secondary IV or limited fluid administration Used for IV mixed medications

Microdrip Lidocaine, Bretylium Dopamine, Epinephrine

Macrodrip or regular set For initial or primary IV Runs fluid faster

Cannulas Hollow needles (butterfly) Angiocath (catheter over the needle) Intracath (needle over the catheter)

Angiocath Usual prehospital device Smaller number is larger size 14, 16, 18, 20, 22 gauge

Peripheral You can see it or touch it Brachial, cephalic, saphenous

Peripheral Dorsal plexus, antecubital fossa External jugular

Central Femoral is allowed in Oregon

Central Internal jugular (physician only) Subclavian (physician only)

Butterfly / Scalp vein Scalp veins in infants Draw blood Small gauge (23 gauge)

Complications of IV Therapy Pain Extravasation Hematoma

Complications of IV Therapy Infiltration Local infection Pyrogenic reaction

Complications of IV Therapy Catheter shear Arterial puncture Circulatory overload

Complications of IV Therapy Thrombophlebitis Air embolism Sepsis

Flow rates TKO (to keep open) KVO ( keep vein open) WFO (wide full open)

Flow rates Drops per minute = Volume in mls x drops/ml of the set

Flow rates Divided by the time in minutes

120 ml/hour using a 10 drop set 120 x 10 Divided by 60 min. = 20 drops per minute

Subcutaneous catheters Portacatheter Most common Hickman catheter PICC line

IV Pumps Allows primary line, secondary line and piggyback line 1 – 999 ml/hr KVO – 1 ml/hr Battery operation – 8 hrs at 125 ml/hr or 1000 ml total

Procedure demonstrated

IV starts – Improve your odds! A calm start Confidence Gravity and position Three-point landing Universal precautions

IV starts, cont. Failed? Shaving? Removing tape Removing the cannula The best tourniquet Clean well NTG venodilation

IV starts, cont. Can’t see? Trust your fingers Hard veins Ask the patient Float it in Less often used veins Right or Left? The Stroke Side?

Moving with the target Drip or Lock? What size cannula? Loose skin? Tape well Use a light? It’s NOT about your ego!