1. Hazards of IV therapy Aim: To raise awareness of hazards
Learning outcomes: Recall the role of the nurse in IV therapy List the main risk factors of IV therapy List complications to the patient of IV therapy
Howard Griffiths, SHS

2. Underpinning knowledge
Basic anatomy and physiology of the cardiovascular system
Principles of asepsis
Pharmaceutical knowledge of different fluids
Drip factors and different giving sets, their purpose
Technical knowledge of different pumps that may be used
Howard Griffiths, SHS

3. Role of the nurse Identifying and verifying prescription
Checking for contamination and faults
The 5 R,s of drug administration
Controlling the prescribed flow rate
Monitoring and reporting patient’s condition
Ensuring that IV device remains patent
Inspecting the insertion site, reporting any abnormalities
Maintaining records
Howard Griffiths, SHS

4. Nursing interventions
Good hand washing and universal precautions
Drug administration calculation
Vital signs measurement during therapy (BP, pulse, respiration, temperature)
Degree of consciousness of the patient
Observe urinary output and maintain fluid balance chart
Report blood results of urea and electrolytes to doctor
Observe for local signs of infection at the cannula site
Howard Griffiths, SHS

5. Methods of administration
Intermittent fluids
Continuous fluids
Parenteral nutrition
IV bolus medication
IV intermittent injection of medication
Howard Griffiths, SHS

6. Managing Risks Infection control Drug interactions
Correct use of syringe and infusion equipment
Correct checking procedures for drug administration
Howard Griffiths, SHS

7. Therapeutic use of Intravenous fluids
To maintain hydration
To correct fluid and electrolyte balance
To administer bolus IV systemic medication, such as prescribed antibiotics
To maintain haemodynamic stability during surgery, and or maintain stability during pathological crisis, e.g shock
Howard Griffiths, SHS

8. Factors to consider when administrating drugs
Does it require reconstitution
storage
stability
expiry date
drug action and side-effects
what is it incompatible with
physiological considerations, serum levels?
is protective clothing required?
Howard Griffiths, SHS

9. Drug interactions inadequate mixing of drugs
fluid may have an affect on the stability of the drug
drug degradation through light (frusemide, nitroprusside, vitamin A and K)
inadequate mixing of drug additives
specific gravity of the added drug may be different from fluid used, resulting in layering
Howard Griffiths, SHS

10. Patient related factors in drug administration
The 5 R’s
allergies
body mass
vital signs
informed consent
clinical status
do they understand the side-effects
is the device patent?
Howard Griffiths, SHS

11. IV administration sets
Use aseptic technique when handling
Latex bungs and injection ports, clean with 70% alcohol, and allow to dry before administrating drugs
Clear fluids/ stored plasma/ drug infusion should have:
standard administration sets (5-15 micron filter, 20 drops per ml).
Burette or buretol (15 micron filter, 60 drops/ml)
Howard Griffiths, SHS

12. Transfusions
blood administration sets (15 drops/ml) should be used for blood and fresh frozen plasma (FFP)
Albumin Solution, Hetastarch and Haemacell can be given through clear fluid sets, as they contain no cells
Platelets and Cryoprecipitate is administered through a platelet set (15 drops/ ml)
Howard Griffiths, SHS

13. Factors affecting flow rates
Fluid composition, viscosity and concentration of fluid
Height of fluid container will alter the hydrostatic pressure of fluid
Change in the position of the client’s access site
Administration sets
distortion of tubing may render the clamp ineffective
diameter of the lumen
inclusion of in line devices such as filters
Vascular access
condition and size of vein
cannula gauge
occlusion
pressure
Howard Griffiths, SHS

14. Infusion devices
Medical Device Agency has identified one of the most serious of medication errors involve the use of infusion pumps
One of the main areas where human error occurs is in drug calculation
The MDA has categorised infusion devices in terms of risk:
Howard Griffiths, SHS

15. Neonatal risk infusion
Neonatal risk infusion requires high accuracy and consistency of flow, used in neonatal intensive care and paediatric services
High-risk infusion similar to above but not as accurate over the short term (within 1 hour). More suitable for older children and adults.
Low-risk infusion infusion of simple electrolytes, antibiotics and total parenteral nutrition. Devices will not need to have accurate or consistent output, only rudimentary alarm and safety systems
Ambulatory infusion infusion devices worn to allow normal activities during infusion, often battery powered
Howard Griffiths, SHS

16. Infusion device checklist
Uncontrolled flow
occur from gravity drips, volumetric and syringe pumps
Selecting the right infusion pump for transfer
is it necessary to take all infusion devices, does the pump meet the risk classification?, is the operator trained to use it
Changing the infusion during transit
avoid, calculate infusion requirements and prepare so that the infusion will last the journey
Security and safety
ensure that all devices are fixed or clamped secured
Howard Griffiths, SHS

17. Flushing and maintaining patency
Ensures that the whole drug is given
Ensures that the device remains patent
0.9% NaCl is effective in maintaining patency in peripheral devices
Flushing should be undertaken after each dose or at least every 24 hours
Howard Griffiths, SHS

18. Issues of infection control
Transparent film dressings over catheter or cannula site
Change local dressings according to local protocols
Keep change of IV infusion bags, giving sets, disconnection or interruption to a minimum
Hand washing and asepsis should be maintained before manipulating the IV system
With minimal breaks in IV circuit, change administration sets every 72 hours.
With frequent breaks in IV circuit, change administration set every hours. For blood products change after infusion.
Howard Griffiths, SHS

19. Fluid and blood product administration
DO NOT ADD DRUGS TO:
blood products
mannitol
sodium bicarbonate
parenteral nutrition
Ensure individual drugs and solutions are given by the optimal route
Howard Griffiths, SHS

20. Chemistry of body fluids
Electrolytes
it is common to measure electrolytes in ECF, chiefly the plasma.
The term ‘plasma’ and ‘serum’ are used interchangeably
Na+ is the main cation in ECF and controls the volume of fluid in ECF
K+ is the main concentration of ICF.
Howard Griffiths, SHS

21. Intravenous fluids
Correcting and maintaining fluid and electrolyte balance
isotonic fluids are prescribed fluids that do not alter the osmotic movement of water across cell membranes.
0.9% Sodium chloride is used to sustain extra cellular fluid volume by compensating for volume lost be
dehydration
urinary excretion of sodium
fluid drains following surgery
Howard Griffiths, SHS

22. Hypertonic fluids are fluids that expand intravascular volume by moving endothelial and intracellar water into the intravascular space
These fluids contain a high concentration of particles when compared to plasma, has potential therefore to cause fluid overload.
These fluids also has the potential to irritate peripheral veins, administration should be slow
Howard Griffiths, SHS

23. Hypotonic saline (0. 45%) is used to replenish electrolytes
Hypotonic saline (0.45%) is used to replenish electrolytes. Complications can include over hydration, sodium overload and potassium defecit.
Hypotonic fluids drive fluid from the plasma into the interstitial space, and therefore are used to re-hydrate the cells
Howard Griffiths, SHS

24. Conditions leading to hypokalaemia are-
Potassium electrolyte infusion is used for patients with severe hypokaelaemia.
Conditions leading to hypokalaemia are-
vomiting, diarrhoea, use of potent diuretics, malnutrition, some forms of renal diseases and metabolic acidosis
Careful infusion is required in order to avoid cardiac arrhythmias and death.
Howard Griffiths, SHS

25. Peripheral site complications
Phlebitis
caused by mechanical rubbing of cannula, or chemical irritation from fluid, or through contamination through poor hand washing by the nurse
Occlusion
caused by incorrect flushing, empty bags, kinking of line, precipitation, poor cannula site
Infiltration
a none blistering drug leaks into the surrounding tissue
Extravasation
blistering drug that leaks into surrounding tissue
Howard Griffiths, SHS

26. Potential systemic complications of IV therapy
Circulatory overload
Systemic infection
Air embolism
Allergic reaction
Howard Griffiths, SHS

27. Types of central venous access
Peripherally inserted catheters (PICCs)- for patients requiring several weeks of IV access
Short term tunnelled catheters- days to several weeks of IV access
tunnelled cuffed catheters- for long term intermittent continuous or daily IV access
Implanted venous access- for long term, intermittent, continuous or daily IV access
Howard Griffiths, SHS

28. Immediate Complications of central venous catheters
venous air embolism
tamponade
catheter embolus/rupture
arterial puncture
dysrhythmias
pneumothorax
Howard Griffiths, SHS

29. Delayed complications of central venous catheters
Infection of tunnel
infection within catheter
occlusion
drug precipitation
thrombosis
air embolism
anaphylaxis
broken hub, broken clamp, split catheter
catheter pulled or fallen out
Howard Griffiths, SHS

30. Safety issues in Critical Care
Labelling of sets
Functions of different sets must be clearly labelled
above will help prevent mal-administration of drugs and avoid haemodynamic monitoring sets
Identify both proximal and distal end of a giving set
Use uninterrupted tubing, free of junctions and access ports
Only use high pressure tubing for haemodynamic measurements
If stopcocks have to be used on administration sets, clean with 70% alcohol beforehand
Howard Griffiths, SHS

31. Blood products Whole blood transfusion Packed RBC Platelets-
Fresh frozen plasma
Cryoprecipitated antihemophilic factor
Granulocytes
Serum albumin and plasma protein fraction (PPF)
Howard Griffiths, SHS

32. Therapeutic use of blood products
Whole blood transfusion
for massive blood loss in neonates
Packed RBC
for inadequate oxygen carrying capacity
Platelets
for treatment of thrombocytopenia, acute lukaemia, and marrow aplasia, and to restore platelet count preoperatively inpatients with a count of <100,000/mm3 or less
Howard Griffiths, SHS

33. Cryoprecipitated antihaemophilic factor
Fresh frozen plasma
for expansion of plasma volume, treat post-op haemorrhage or shock and correct coagulation factor deficiencies
Cryoprecipitated antihaemophilic factor
for haemophilia A, von Wilerbrand’s disease, hypofibrinogenemia
Granulocytes
for severe gram negative infection or severe neutropenia unresponsive to routine forms of therapy in immunosuppressed patient. Also indicated in severe granulocyte dysfunction.
Serum albumin and plasma protein fraction
in hypovolaemia and hypoproteinemia (burns)
Howard Griffiths, SHS

34. Nursing interventions required for blood transfusions
All blood products should be correctly prescribed
Follow the local employer’s protocol on how to collect blood products from the blood bank
Blood should not be taken from the refrigerator no more than 30 minutes before transfusion, to reduce chances of bacterial growth (Pritchard and David 1990)
Always check with another registered nurse
Howard Griffiths, SHS

35. Correct blood component Blood unit number Expiry date of the blood
Check with the patient the details against the patient’s ID wristband and the component and prescription sheet at the bedside.
A range of details on the blood bag, patient’s identity bracelet and blood form should match:
Patient’s name
Hospital number
Date of birth
Blood group
Correct blood component
Blood unit number
Expiry date of the blood
Howard Griffiths, SHS

36. Check with the patient’s prescription ( any allergies)
The bag should be gently squeezed for leaks, and gently rocked to mix the contents
Check with the patient’s prescription ( any allergies)
A standard 19 gauge IV cannula through a blood giving set, which has filter to prevent small clots entering the blood stream.
Use correct hand washing technique and universal precautions
Howard Griffiths, SHS

37. Check cannula for signs of infection
Maintain baseline observation (BP, pulse, respiration and temperature), initially every 15 minutes.
Continue observations every 15 minutes for 1 hour, thereafter, where no complication remains, every 1 hour
Baseline observations should be repeated before commencing each new unit and 15 minutes after the new unit has commenced (Glover and Powell 1995)
Check cannula for signs of infection
Howard Griffiths, SHS

38. Observe urinary output and maintain fluid balance chart
Observe patient’s behaviour during transfusion
Observe the appearance of the patient during transfusion
Do not leave a unit of blood transfusing more than 5 hours
Howard Griffiths, SHS

39. Potential complications of blood transfusions
Infection
Febrile reaction
Allergic reaction
Transfusion hypothermia
Fluid overload
Howard Griffiths, SHS

40. Adverse reaction Increase in temperature Hypotension Tachycardia
Headaches
Rashes
Swelling around cannula site
Pain in abdomen or chest
Patient feeling agitated or unduly apprehensive
STOP TRANSFUSION, CONTACT DOCTOR AND FILL DOCUMENTATION
Howard Griffiths, SHS

41. Reporting adverse incident
recheck the blood against the patient’s notes
check the patient’s urine for blood
blood needs to be cross matched again
all equipment (blood bag, giving set and urine ) should be sent to the lab for testing
keep the iv line open with 0.9% normal saline
complete the employer’s adverse clinical incident form, and document in care plan
Howard Griffiths, SHS

42. Conclusion IV therapy must be prescribed by a medical practitioner
Cannulation and insertion of catheters, together with administrating IV medication is regarded as extended Professional Scope of Practice.
Always check that equipment, the fluids and the flow rate with another R.N.
Howard Griffiths, SHS

43. Every patient should have an uniquely identified wristband
The bedside check is the final opportunity to prevent a mis-transfusion
Each hospital will have a formal policy which must be followed for blood tranfusion
Every patient should have an uniquely identified wristband
Each R.N must ensure responsibility regarding their competency .
Howard Griffiths, SHS

44. REFERENCES
Jane Mallet and Lisa Dougherty (2000) Manual of Clinical Nursing Procedures (5th edition); Blackwell Science, London
Fox, Nick (2000) Managing risks posed by intravenous therapy; Nursing Times Vol.96 (30), pp37-39
R.C.N. Guidance for Nurses Giving Intravenous Therapy
Serious Hazards of Transfusion (SHOT) Annual Report : htpp://
Quinn, C. (2000)Infusion devices: risks, functions and management; Nursing Standard Vol. 14 (26):35-41
Howard Griffiths, SHS