11/04/2023 Dr.T.V.Rao MD @ Hospital care 1

INTRAVENOUS MEDICATION Care and Complications

Dr.T.V.Rao MD

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Indications for IV Medication• Indications:

• Intravenous access to patient’s circulatory system. • Administration of Meds. & Fluids, as well as

blood collection

• Contraindications:• IV access should be attempted as distal as

possible. • Avoid veins that cross over joints, local

infection/injury• Extremities with renal shunts or fistulas

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Procedure for Insertion of Peripheral IV Catheter

1. Obtain and review the order2. Ascertain allergies3. Gather Equipment4. Verify patient’s identity using two patient

identifiers5. Explain procedure, benefits, care

management, and potential complications to patient

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Procedure for Insertion of Peripheral IV Catheter (cont)

6. Perform hand hygiene7. Assemble equipment8. Apply Tourniquet9. Assess veins, keeping in mind the rational for

therapy and duration of therapy10. Apply Non sterile gloves11. Wash intended insertion site with antiseptic

soap and water. (as needed)

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Procedure for Insertion of A Peripheral IV Catheter (cont)

13. Clean intended insertion site with antiseptic solution, working outward using back-and-forth motion

14. Allow site to dry15. Perform venipuncture while

stabilizing skin with the nondominate hand

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Procedure for Insertion of A Peripheral IV Catheter (cont)

16. Enter skin at a 10- to- 30 degree angle. Decrease angle when the skin has been penetrated. When blood is obtained in the flash back chamber, advance catheter 1/16 inch, and then slightly pull stylet back, advancing catheter gently into vessel. Continue to advance catheter into vein until the catheter hub is against the skin.

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Procedure for Insertion of A Peripheral IV Catheter (cont)

17. Release tourniquet18. Occlude tip of catheter by pressing

finger of non dominant hand over vein to prevent blood spillage.

19. Activate needle safety device before removing stylet. Connect IV administration set or injection cap/needless device. Begin infusing solutions slowly.

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Procedure for Insertion of A Peripheral IV Catheter (cont)

22.Discard stylet in sharps container

23. Remove gloves. Perform hand hygiene

24. Document procedure in the patient’s medical record.

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Choosing IV catheter Size• Age

< 1 year: 22, 24 gauge (g)

1-8 years: 18, 20, 22 gauges

> 8 years: 16. 18, 20 gauges

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IV Procedure

• Use universal precautions (glove and eye protection)

• Allergies (beta dine or latex)• Explain procedure to Pt.• Prepare all material• Select vein. Apply tourniquet above the

elbow.• Prepare site

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IV Procedure (cont.)

• Warn the patient of possible pain • Bevel up at 30 degree above horizontal• Look for flashback of blood into catheter• Upon seeing flashback, advance catheter

another millimeter or two• Advance the sheath completely into the vein

and release tourniquet

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IV Procedure (cont.)

• Connect the IV tubing/heplock

• Secure catheter and tubing

• Dispose of needles in sharps container

• Document the IV site, catheter size and date on the patient’s chart

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Complications of IV Therapy

• Classified according to their location–Local complication: at or near the

insertions site or as a result of mechanical failure–Systemic complications: occur within

the vascular system, remote from the IV site. Can be serious and life threatening

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Local complications• Occur as adverse reactions or trauma to the

surrounding venipuncture site• Assessing and monitoring are the key

components to early intervention• Good venipuncture technique is the main

factor related to the prevention of most local complications associated with IV Therapy.

• Local complications include: hematoma, thrombosis, phlebitis, post infusion phlebitis, thrombophlebitis, infiltration, extravasation, local infection, and veno spasm.

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Hematoma• Subcutaneous hematoma is the most common

complication• Can be a starting point for other

complications: thrombophlebitis and infection• Related to:– Nicking the vein– Discontinuing the IV without apply adequate

pressure– Applying the tourniquet to tightly above a

previously attempted venipuncture site.

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Hematoma• Signs and symptoms:– Discoloration of the skin– Site swelling and

discomfort– Inability to advance the

cannula all the way into the vein during insertion

– Resistance to positive pressure during the lock flushing procedure

• Document

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HematomaPrevention

• Use of an indirect method• Apply tourniquet just before

venipuncture• Use a small need in the elderly and

patients on steroids, or patients with thin skin.

• Use blood pressure cuff to apply pressure• Be gentle

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HematomaTreatment

• Apply direct, light pressure for 2-3 minutes after needle removed

• Have patient elevate extremity

• Apply Ice

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Thrombosis• Catheter-related obstructions can be

mechanical or non-thrombotic• Trauma to the endothelial cells of the venous

wall causes red blood cells to adhere to the vein wall, forms a clot or Thrombosis

• Drip rate slows, line does not flush easily, resistance is felt

• Never forcible flush a catheter

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Thrombosis• Signs and Symptoms

– Fever and Malaise– Slowed or stopped infusion

rate– Inability to flush

• Prevention– Use pumps and controllers

to manage flow rate– Micro drip tubing for rate

below50mL/hr– Avoid areas of flexion– Use filters– Avoid lower extremities

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Thrombosis• Treatment– Never flush a cannula

to remove an occlusion

– Discontinue the cannula

– Notify the physician and assess the site for circulatory impairment

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Phlebitis• Inflammation of the vein

in which the endothelial cells of the venous wall become irritated and cells roughen, allowing platelets to adhere and predispose the vein to inflammation-induced phlebitis– Tender to touch and

can be very painful

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Phlebitis• Mechanical: – To large a catheter for the size of the vein– Manipulation of the catheter: improper stabilization

• Chemical: vein becomes inflamed by irritating or vesicant solutions or medication– Irritation medication or solution– Improperly mixed or diluted– Too-rapid infusion– Presence of particulate matter

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Phlebitis• Chemical (cont):– The more acidic the IV solution the greater the risk– Additives: Potassium – Type of material– Length of dwell:• 30% by day 2, 39-40% by day 3 (Macki and Ringer)

– The slower the rate of infusion the less irritation

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PhlebitisBacterial

• Also called Septic phlebitis: least common• Inflammation of the intima of the vein • Contributing factors– Poor aseptic technique– Failure to detect breaks in the integrity of the equipment– Poor insertion technique– Inadequate stabilization– Failure to perform site assessment– Aseptic preparation of solutions– Hand washing and preparing the skin

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PhlebitisPost infusion

• Inflammation of the vein 48-96 hr after discontinued• Factors that contribute:– Insertion technique– Condition of the vein used– Type, compatibility, pH of solution used– Gauge, size, length, and material– Dwell time– Infrequent dressing change– Host factors: age, gender, age and presence of disease

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Phlebitis• Immune system causes leukocytes to

gather at the inflamed site• Pyrogens stimulate the hypothalamus to

raise body temperature• Pyrogens stimulate bone marrow to

release more leukocytes• Redness and tenderness increase

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Phlebitis• Signs and Symptoms– Redness at the site– Site warm to touch– Local swelling– Palpable cord along the vein– Sluggish infusion rate– Increase in basal temperature of 1degree C or more

• Prevention– Use larger veins for hypertonic solutions– Central lines for Infusions lasting longer than 5 days

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Thrombophlebitis• Thrombophlebitis denotes a twofold

injury: thrombosis and inflammation• Related to:–Use of veins in the lower extremity–Use of hypertonic or highly acidic infusion

solutions–Causes similar to those leading to phlebitis

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Thrombophlebitis• Signs and Symptoms– Sluggish flow rate– Edema in the limbs– Tender and cord like vein– Site warm to the touch–Visible red line above venipuncture site–Diminished arterial pulses–Mottling and cyanosis of the extremities

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Thrombophlebitis• Prevention– Use veins in the forearm rather than the hands– Do not use veins in a joint– Assess site q 4 hr in adults, q 2 hr in children– Catheter securement– Infuse at rate prescribed– Use the smallest size catheter to do the job– Proper dilution

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Thrombophlebitis• Septic thrombophlebitis can be

prevented:–Appropriate skin preparation–Aseptic technique in the maintenance of

infusion–Proper hand hygiene• 60% from patients skin• 35% from the line itself• 5% from hands

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Extravasations• Signs and Symptoms– Complaints of pain or burning– Swelling proximal to or distal to the IV site– Puffiness of the dependent part of the limb– Skin tightness at the venipuncture site– Blanching and coolness of the skin– Slow or stopped infusion– Damp or wet dressing

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Extravasations• Prevention:– Use of skilled practitioners– Knowledge of vesicants– Condition of the patients veins

– Drug administration technique• If continuous give in CVAD• Only with brisk blood return of 3-5 cc• Use of a free flow IV• Do not use a pump on vesicants given peripherally• Assess for blood return frequently

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Personal safety of Health Care Workers

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Steps to prevent needle sticks

• Wear gloves• Do Not Bend or Break Needles • Never RECAP!!! • If you must, use the One Handed technique • Take your time • Dispose of contaminated needles immediately

in puncture-resistant containers

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Risks to you - if Careless

• Risks after needle Sticks Exposure

• Hepatitis B: 10-30% • Hepatitis C: 2%• HIV: 0.4 %

• Other blood borne pathogens

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POLICY ON ACCIDENTAL NEEDLE STICKS

• Immediately wash injured area.• Report all needle sticks immediately to your instructor or

immediate supervisor. • Complete an incident report and report to employee health

or ED.• Determine if the needle was clean or dirty.• Cleansing wound with antiseptic.• Request that the identified patient be tested for Hepatitis B

surface antigen and HIV antibodies.• Have your blood tested for Hepatitis B and HIV antibodies as

soon as possible. • Begin drug treatment (if necessary) & counseling.

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• Programme Created by Dr.T.V.Rao MD for Medical and Paramedical

Professionals in the Developing World• Email

• doctortvrao@gmail.com