Intravenous Fluid TherapyIntravenous Fluid Therapy

Paramedic ClassParamedic Class

5 Purposes5 Purposes

Provide maintenance Provide maintenance requirements for F&Erequirements for F&E

Replace previous lossesReplace previous losses Replace concurrent lossesReplace concurrent losses Provide a mechanism for Provide a mechanism for

administration of administration of medications/blood medications/blood productsproducts

Provide nutritionProvide nutrition

Intravenous SolutionsIntravenous Solutions

ColloidsColloids

CrystalloidsCrystalloids

Blood productsBlood products

ColloidsColloids

Large protein moleculesLarge protein molecules– Can’t cross capillary membraneCan’t cross capillary membrane

– Draw fluid from interstitial and Draw fluid from interstitial and intracellular compartments into intracellular compartments into vascular compartment.vascular compartment.

– Work well in reducing edema Work well in reducing edema while expanding vascular while expanding vascular compartmentcompartment

ColloidsColloids

Too costlyToo costly

Difficult to storeDifficult to store

Never used as first solutionNever used as first solution

Albumin, steroidsAlbumin, steroids

CrystalloidsCrystalloids

Contain electrolytesContain electrolytes

Move across Move across

capillary membranescapillary membranes

CrystalloidsCrystalloids

Need 2-3 times the volume Need 2-3 times the volume lostlost

TonicityTonicity

A solutions’ salt balance A solutions’ salt balance compared to plasmacompared to plasma

Around 300 mOsm/LAround 300 mOsm/L

IsotonicIsotonic

Nearly the same as serumNearly the same as serum NS: 0.9% Sodium ChlorideNS: 0.9% Sodium Chloride LRLR Generally, initial fluid Generally, initial fluid

replacement should not exceed replacement should not exceed three liters before blood is three liters before blood is infusedinfused

IsotonicIsotonic

Balanced salt solutionsBalanced salt solutions Isotonic crystalloidsIsotonic crystalloidsRemember! 3 ml of isotonic Remember! 3 ml of isotonic

crystalloid are needed to crystalloid are needed to replace 1 ml of bloodreplace 1 ml of blood

HypertonicHypertonic

Higher osmolarityHigher osmolarityPulls F&E from intracellular Pulls F&E from intracellular

and interstitial compartments and interstitial compartments into intravascular into intravascular compartment.compartment.

Hypertonic, cont.Hypertonic, cont.

Can help stabilize BP, increase urine Can help stabilize BP, increase urine

output, reduce edemaoutput, reduce edema

Rarely used in prehospital setting.Rarely used in prehospital setting.

Dangerous if cell dehydration existsDangerous if cell dehydration exists

D-5%-W in Lactated Ringers, 10% NSD-5%-W in Lactated Ringers, 10% NS

Example: AlbuminExample: Albumin

HypotonicHypotonic

Less osmolarity than serumLess osmolarity than serum–Dilutes serumDilutes serum

0.45% NaCl0.45% NaClD5NS.45 (5% Dextrose in ½ D5NS.45 (5% Dextrose in ½

normal saline)normal saline)

Hypotonic, cont.Hypotonic, cont. Water is pulled from vascular Water is pulled from vascular

compartment into interstitial fluid compartment into interstitial fluid compartment, then into adjacent cellscompartment, then into adjacent cells

Helpful when cells are dehydratedHelpful when cells are dehydrated

– Dialysis pt on diureticsDialysis pt on diuretics

– Hyperglycemia - DKAHyperglycemia - DKA Can be dangerous – sudden fluid shift Can be dangerous – sudden fluid shift

can cause cardiovascular collapse and can cause cardiovascular collapse and ICPICP

REMEMBER - WATER GOES REMEMBER - WATER GOES WHERE THE SALT ISWHERE THE SALT IS

Isotonic no movement Isotonic no movement

initiallyinitially

Hypertonic attracts waterHypertonic attracts water

Hypotonic gives up waterHypotonic gives up water

Isotonic crystalloidIsotonic crystalloid

EMT’s first choiceEMT’s first choice

Normal Saline 0.9%Normal Saline 0.9%

Lactated Ringers, Lactated Ringers,

Plasmalyte-A, Normosol-RPlasmalyte-A, Normosol-R

Hypertonic SolutionHypertonic Solution

Higher concentration of ionsHigher concentration of ions1.8% NaCl, D5%W/LR1.8% NaCl, D5%W/LR

Hypertonic SolutionHypertonic Solution

Usually no prehospital Usually no prehospital applicationapplication

CrenationCrenation

Hypotonic SolutionHypotonic Solution

Lower concentrationLower concentration

0.45% NaCl, 0.25% NaCl0.45% NaCl, 0.25% NaCl

Hypotonic SolutionHypotonic Solution

No prehospital applicationNo prehospital application

LysisLysis

Administration SetsAdministration Sets

Microdrip Microdrip (60 drops per ml)(60 drops per ml)

Macrodrip Macrodrip (10–(10–15 drops per ml)15 drops per ml)

Administration SetsAdministration Sets

Others (12, 20 drops/ml, Others (12, 20 drops/ml, adjustable)adjustable)

Soluset (pediatric set)Soluset (pediatric set)

MicrodripMicrodrip

Usually for secondary IV or Usually for secondary IV or limited fluid administrationlimited fluid administration

Used for IV mixed Used for IV mixed

medicationsmedications

MicrodripMicrodrip

Lidocaine, BretyliumLidocaine, Bretylium

Dopamine,Dopamine,

EpinephrineEpinephrine

Macrodrip or regular setMacrodrip or regular set

For initial or primary IVFor initial or primary IV

Runs fluid fasterRuns fluid faster

CannulasCannulas Hollow needles Hollow needles

(butterfly)(butterfly) Angiocath Angiocath

(catheter over the (catheter over the needle)needle)

Intracath (needle Intracath (needle over the catheter)over the catheter)

AngiocathAngiocath

Usual prehospital deviceUsual prehospital deviceSmaller number is larger sizeSmaller number is larger size14, 16, 18, 20, 22 gauge14, 16, 18, 20, 22 gauge

PeripheralPeripheral

You can see it or touch itYou can see it or touch it

Brachial, cephalic, Brachial, cephalic,

saphenoussaphenous

PeripheralPeripheral

Dorsal plexus, Dorsal plexus, antecubital antecubital fossafossa

External jugularExternal jugular

CentralCentral

Femoral is allowed in Femoral is allowed in OregonOregon

CentralCentral

Internal jugular (physician Internal jugular (physician only)only)

Subclavian (physician only)Subclavian (physician only)

Butterfly / Scalp veinButterfly / Scalp vein

Scalp veins in infantsScalp veins in infants

Draw bloodDraw blood

Small gauge Small gauge

(23 gauge)(23 gauge)

Complications of IV TherapyComplications of IV Therapy

PainPain

ExtravasationExtravasation

HematomaHematoma

Complications of IV TherapyComplications of IV Therapy

InfiltrationInfiltration

Local infectionLocal infection

Pyrogenic Pyrogenic

reactionreaction

Complications of IV TherapyComplications of IV Therapy

Catheter shearCatheter shear

Arterial punctureArterial puncture

Circulatory overloadCirculatory overload

Complications of IV TherapyComplications of IV Therapy

ThrombophlebitisThrombophlebitis

Air embolismAir embolism

SepsisSepsis

Flow ratesFlow rates

TKO (to keep open)TKO (to keep open)

KVO ( keep vein open)KVO ( keep vein open)

WFO (wide full open)WFO (wide full open)

Flow ratesFlow rates

Drops per minute =Drops per minute =

Volume in mls x drops/ml of Volume in mls x drops/ml of

the set the set

Flow ratesFlow rates

Divided by the time in Divided by the time in

minutesminutes

120 ml/hour using a 10 drop 120 ml/hour using a 10 drop setset

120 x 10120 x 10

Divided by 60 min.Divided by 60 min.

= 20 drops per minute= 20 drops per minute

Subcutaneous Subcutaneous catheterscatheters

PortacatheterPortacatheter– Most commonMost common

Hickman catheterHickman catheter PICC linePICC line

IV PumpsIV Pumps

Allows primary line, Allows primary line, secondary line and secondary line and piggyback linepiggyback line

1 – 999 ml/hr1 – 999 ml/hr KVO – 1 ml/hrKVO – 1 ml/hr Battery operation – 8 hrs Battery operation – 8 hrs

at 125 ml/hr or 1000 ml at 125 ml/hr or 1000 ml totaltotal

Procedure demonstratedProcedure demonstrated

IV starts – Improve your IV starts – Improve your odds!odds!

A calm startA calm start

ConfidenceConfidence

Gravity and positionGravity and position

Three-point landingThree-point landing

Universal precautionsUniversal precautions

IV starts, cont.IV starts, cont.

Failed? Failed? Shaving?Shaving? Removing tapeRemoving tape Removing the cannulaRemoving the cannula The best tourniquetThe best tourniquet Clean wellClean well NTG venodilationNTG venodilation

IV starts, cont.IV starts, cont.

Can’t see? Trust your fingersCan’t see? Trust your fingers Hard veinsHard veins Ask the patientAsk the patient Float it inFloat it in Less often used veinsLess often used veins Right or Left?Right or Left? The Stroke Side?The Stroke Side?

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