1. Anatomy, Physiology & Basic Concepts of IV Fluids Dr.Ravindar Bethi, MD Specialist, Anesthesia & ICU, Al Rass General Hospital, KSA. IV THERAPY - AN OVERVIEW

2. Intravenous therapy or IV therapy is the giving of liquid substances directly into a vein.

3. IV THERAPY - AN OVERVIEW Compared with other routes of administration, the intravenous route is the fastest way to deliver fluids and medications throughout the body.

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5. Types of IV Needles Steel needles: Butterfly catheters, named for the plastic tabs that look like wings. Used for small quantities of medicine, infants, and to draw blood although the small size of the catheter can damage blood cells. Usually small gauge needles. Over-the-needle catheters: Peripheral-IV catheters are usually made of various types of Teflon or silicone materials which determines how long the catheter can remain in your vein. These typically need to be replaced about every 1 to 3 days. Inside-the-needle catheters: Larger than Over-the- needle catheters, typically used for central lines.

6. Gauges Needles & Catheters are sized by diameters which are called gauges. Smaller diameter = larger gauge IE: 22-gauge catheter is smaller than a 14- gauge Larger diameter = more fluid able to be delivered If you need to deliver a large amount of fluid, typically 14- or 16-gauge catheters are used.

7. Intravenous Catheter Complications About 25 million Americans have intravenous catheters placed each year. Intravenous catheters (or IVs) are a very important part of medical treatment for acute illnesses, cancer, surgery, anesthesia, and trauma, allowing medications to reach as quickly and effectively as possible, via the bloodstream, the parts of the body where they work.

8. Intravenous Catheter Complications IV catheters can be placed in a hand, arm or leg. These are known as "peripheral" IVs. IVs placed in the central circulation, like the internal jugular vein (neck) or subclavian vein (just beneath the collar bone), are known as "central lines". The rest of this article will deal with peripheral IVs, the most common type of IV.

9. Intravenous Catheter Complications During the placement of an IV, a needle is inserted through the skin and into an accessible blood vessel. A Teflon (plastic) cannula is then slid over the needle, which is withdrawn. No needle remains in your body. (So-called "butterfly" needles are an exception to this). Some healthcare providers use a little bit of local anesthetic beforehand, with a very tiny needle, to numb the area of skin where the IV is inserted. Local anesthetic cream is sometimes applied 45-60 minutes beforehand to achieve the same effect. This is particularly helpful in the care of children.

10. Complications Local Infection In any case where there is an open wound on the body, disrupting the protective lining of skin, an infection can occur. A microscopic organism may use the tiny hole in the skin created by the IV catheter to find its way into the body, and cause an infection. Common signs of local infection ("abscess") include a large lump that is painful and hot to touch. Treatment - If you suspect an infection, see your healthcare provider immediately. Antibiotics may be used to control the bacterial infection.

11. Complications Infiltration This occurs when the catheter unintentionally enters the tissue surrounding the blood vessel. In this case the IV fluid and associated medications will go into the tissues and there will be a lump where the IV has been inserted. It would be cool to touch (this differentiates it from inflammation due to infection, which is warm to the touch). Treatment - If you notice this inform your healthcare professional and they will administer appropriate care immediately. Infiltrated IVs are not a big problem usually unless the medication being administered is very irritant, such as certain chemotherapy and circulatory medicines. The intravenous infusion must be stopped, obviously, to avoid putting any more fluid or medication into the tissues. Another IV may need to be started elsewhere.

12. Complications Hematoma A hematoma is a collection of blood caused by internal bleeding. This happens when the catheter punctures through the vein and causes a hematoma. Hematomas generally occur with unsuccessful IV insertion but can also happen when an IV is taken out. This is why pressure must be applied to the insertion site, to try to make the hematoma as small as possible. A hematoma may appear as a visible bruise or a lump. Treatment - A hematoma normally recovers over time (a few hours or days) without treatment.

13. Complications Nerve Damage It is also possible for the IV needle to penetrate and injure a nerve, and for bruising and bleeding to irritate a nerve. Nerves are invisible from the skin surface so it?s easy to understand how this could happen. If you feel a sudden sharp pain radiating along your arm as the IV is inserted, let your healthcare provider know immediately as this may be a sign that the needle has come into contact with a nerve. A 1996 study of 419,000 blood donations showed that 1 in every 6300 donors had a nerve injury. Fortunately, most got better within a month. The symptoms included excessive or radiating pain, and loss of arm or hand strength. Fifty-two of 56 donors achieved a full recovery, and 4 other donors had only a mild, localized, residual numbness. Treatment - Nerve damage tends to repair itself in a few weeks to a few months. If you suspect a nerve injury contact your doctor. In rare instances (such as persistent weakness) specific treatment, even surgery, may become necessary.

14. In classical terms, thrombosis is caused by abnormalities in one or more of the following (Virchow's triad):thrombosis The composition of the blood (hypercoagulability) Quality of the vessel wall (endothelial cell injury) Nature of the blood flow The formation of a thrombus is usually caused by Virchow's triad. To elaborate, the pathogenesis includes: an injury to the vessel's wall (such as by trauma, infection, or turbulent flow at bifurcations); by the slowing or stagnation of blood flow past the point of injury (which may occur after long periods of sedentary behavior—for example, sitting on a long airplane flight); by a blood state of hypercoagulability (caused for example, by genetic deficiencies or autoimmune disorders).

15. IV THERAPY - AN OVERVIEW It is commonly referred to as a drip because it employs a drip chamber, which prevents air entering the blood stream (air embolism) and allows an estimate of flow rate. Neat and clear diagram needed

16. FLUIDS AND ELECTROLYTES ANATOMY AND PHYSIOLOGY IV THERAPY - AN OVERVIEW More clear pictures needed

17. ANATOMY AND PHYSIOLOGY Dorsal venous arch See ACLS print out material for text and pictures

18. ANATOMY AND PHYSIOLOGY Basilic vein

19. ANATOMY AND PHYSIOLOGY Cephalic vein

20. ANATOMY AND PHYSIOLOGY dorsal veins of forearm

21. ANATOMY AND PHYSIOLOGY

22. Medial cubital vein

23. ANATOMY AND PHYSIOLOGY Medial cubital vein Brachial artery

24. ANATOMY AND PHYSIOLOGY Medial cubital vein Brachial artery Median Nerve

25. ANATOMY AND PHYSIOLOGY Dorsal venous arch Great Saphenous Vein Femoral Vein

26. ANATOMY AND PHYSIOLOGY Scalp Veins

27. …the new access site has to be proximal to the "blown" area to prevent extravasation of medications through the damaged vein… Extra-vasation pictures needed

28. …for this reason it is advisable to site the first cannula at the most distal site on the vein.

29. Interosseous Route What is next best ? ACLS The only alternative in emergency that is equally reliable

30. ANATOMY AND PHYSIOLOGY

31. Central Venous Lines Central Lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart.

32. Central Venous Lines Central Lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart.

33. Central Venous Lines Central Lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart. ADVANTAGES Fluids irritating to peripheral veins can be given Chemotherapy Total parenteral nutrition Medications reach the heart immediately, and are quickly distributed to the rest of the body. Central venous pressure can be measured

34. Central Venous Lines Central Lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart. DISADVANTAGES Risks of bleeding, infection, air embolism. Technically difficult– needs experienced clinician knowing the appropriate landmarks and/or using an ultrasound probe to safely locate and enter the vein. Pleura and carotid artery are at risk of damage with the potential for pneumothorax or puncture/ cannulation of the artery.

35. Central Venous Lines Central Lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart. INTERNAL JUGULAR Nursing care Be cautious with potassium

36. Central Venous Lines Central Lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart. SUBCLAVIAN Nursing care is easier Open even in shock Incompressible

37. Central Venous Lines Central Lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart. FEMORAL Emergency situations where it is difficult to cannulate Internal jugular vein or Subclavian vein High risk of infection Preferred for potassium infusions

38. Central Venous Lines Central Lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart. Some more photos are to be collected and placed here

39. Central Venous Line Vs Pulmonary Artery Catheter

40. Central Venous Lines Central Lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart. Peripherally inserted central catheter ADVANTAGES Safer to insert with a relatively low risk of uncontrollable bleeding no risks of damage to the lungs or major blood vessels. With proper hygiene, care, can be left in place for several weeks for patients who require extended treatment. Some special types of

41. Central Venous Lines Central Lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart. Peripherally inserted central catheter DISADVANTAGES Must travel through a relatively small peripheral vein which can take a less predictable course on the way to the superior vena cava. Hence, more technically difficult to place in some patients. Travels through the axilla. Hence, can become kinked causing poor function. Some special types of

42. Central Venous Lines Central Lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart. Tunneled Lines Hickman line or Broviac catheter “Tunneled" under the skin to emerge a short distance away. from the central vein Reduced risk of infection, since bacteria from the skin surface are not able to travel directly into the vein; Catheters are also made of materials that resist infection and clotting. A Hickman line in a leukemia patient. It is tunneled under the skin to the jugular vein Some special types of

43. Central Venous Lines Central Lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart. Implantable ports Silicone rubber reservoir, implanted under the skin. Medication is injected via its silicone cover, into the reservoir. The cover can accept several hundreds of needle sticks during its lifetime. It is possible to leave the ports in the patient's body for years. Some special types of

44. Central Venous Lines Central Lines flow through a catheter with its tip within a large vein, usually the superior vena cava or inferior vena cava, or within the right atrium of the heart. Implantable ports Needs regular maintenance. If it is plugged a thrombus can form with the accompanying risk of embolisation Commonly used for patients on long- term intermittent treatment. Some special types of

45. IV Fluids Crystalloids Colloids Replace with actual photos of our hospital

46. IV Fluids Colloids

47. IV Fluids Crystalloids

48. IV Fluids Colloids Contain larger insoluble molecules, such as albumen. Preserve a high colloid osmotic pressure in the blood Blood itself is a colloid.

49. IV Fluids Colloids

50. IV Fluids Crystalloids Aqueous solutions of water- soluble molecules. The most commonly used crystalloid fluid is normal saline=, a solution of sodium chloride at 0.9% concentration, which is close to the concentration in the blood (isotonic). What is isotonic? What is Iso-osmolar ?

51. IV Fluids Crystalloids

52. IV Fluids Crystalloids

53. IV Fluids Crystalloids Fluid of choice in multiple situations Trauma Metabolic alkalosis Not to be given in hyperchloremic acidosis isotonic Replace with actual photos of our hospital

54. IV Fluids Crystalloids hypotonic Replace with actual photos of our hospital

55. IV Fluids Crystalloids ? Isotonic/ Hypotonic Isotonic in vitro Hypotonic in vivo Iso-osmolar, compared to Normal Saline Hypotonic to the human cells due to Insulin Hypertonic in insulin deficiency

56. IV Fluids Crystalloids ? Isotonic/ Hypertonic ?

57. IV Fluids Crystalloids Contains calcium, potassium and Lactate Don’t give in alkalosis Don’t give in hyperkalemia Don’t give with Blood Mind its Calcium content, when giving with Mg therapy Nearly Isotonic Replace with actual photos of our hospital

58. Don’t give potassium therapy with Dextrose containing solutions IV Fluids Crystalloids Replace with actual photos of our hospital When giving Dextrose containing solutions, add KCl to prevent hypokalemia When giving KCl in the treatment of hypokalemia, don’t add it to solutions containing Dextrose.

59. Distribution of fluid in human body Colloids stay here Crystalloids move up to here DRAW NERVE CELLS PICTURE OF WATER GAMES IN WATER

60. Risks and complications of IV THERAPY 1.Infection 2.Phlebitis 3.Infiltration and extravasation 4.Embolism 5.Fluid overload 6.Electrolyte Imbalance

61. Electrolytes Sodium 135 – 145 mmol/L Potassium 3.5 – 5.0 mmol/L Calcium 2.12 – 2.75 mmol/L ( Ionised calcium 1.0-1.3 mmol/L) Magnesium 1.5 – 2.2 m Eq/L Phosphorous 0.81 – 1.20 mmol/L

62. Electrolytes Sodium 135 – 145 mmol/L Potassium 3.5 – 5.0 mmol/L Calcium 2.12 – 2.75 mmol/L Magnesium 1.5 – 2.2 m Eq/L Phosphorous 0.81 – 1.20 mmol/L Low sodium – lower osmolality High sodium – higher osmolality

63. Sodium 135 – 145 mmol/L Potassium 3.5 – 5.0 mmol/L Calcium 2.12 – 2.75 mmol/L ( Ionised calcium 1.0-1.3 mmol/L) Magnesium 1.5 – 2.2 m Eq/L Phosphorous 0.81 – 1.20 mmol/L More DETAILS AND MORE PICTURES needed, ABOUT ALL THE ELECTROLYTES Is it ACLS 2005? Electrolytes Hypokalemia Hyperkalemia

64. Sodium 135 – 145 mmol/L Potassium 3.5 – 5.0 mmol/L Calcium 2.12 – 2.75 mmol/L ( Ionised calcium 1.0-1.3 mmol/L) Magnesium 1.5 – 2.2 m Eq/L Phosphorous 0.81 – 1.20 mmol/L BE GOOD IN CLINICAL SKILLS KEEP DRUGS AWAY Bicarbonate Glucose + Insulin Calcium Sorbitol Keyexalate Dialysis Albuterol ACLS - 2006 More DETAILS AND MORE PICTURES needed, ABOUT ALL THE ELECTROLYTES Is it ACLS 2005?

65. Electrolytes Sodium 135 – 145 mmol/L Potassium 3.5 – 5.0 mmol/L Calcium 2.12 – 2.75 mmol/L ( Ionised calcium 1.0-1.3 mmol/L) Magnesium 1.5 – 2.2 m Eq/L Phosphorous 0.81 – 1.20 mmol/L

66. EVERYTHING IS RELATED TO EVERYTHING ELSE