Electrolyte Replacement Solutions
Electrolyte replacement solutions provide both electrolytes (like sodium, potassium, and so forth) and fluid to the patient. Special electrolyte replacement solutions can be prepared in order to meet the needs of particular patients.
Examples of Electrolyte Replacement Solutions. Below are two of the solutions commonly used to replace electrolytes.
Nutrient Solutions (Hyperalimentation Products)
These products provide total parenteral nutrition for those patients who cannot, should not, or will not ingest the nutrients they need to live. It should be noted that a hyperalimentation solution can supply all the patient's nutritional needs by administration through the circulatory system. However, these solutions are quite expensive and, because of their nutrient content, are highly susceptible to bacterial growth. Most of the solutions contain high concentrations of carbohydrates (for example, dextrose). Because of this high concentration, the solutions must be administered through a large-bore vein. Just placing the needle or catheter into such a large-bore vein is a surgical procedure in itself. The hyperalimentation solution is prepared in the Pharmacy Sterile Products Section by a specially trained person. You must be very careful to prevent bacterial contamination. The preparation of the product itself is quite a job because the preparer must add ingredients in a certain sequence. Many of the components of a hyperalimentation solution are incompatible in certain concentrations. The components of most hyperalimentation solutions are water, dextrose, amino acids, electrolytes, and vitamins. One product, IntralipidR, is an oil in water emulsion. IntralipidR is one hyperalimentation product that can be administered through a small-bore vein such as those found in the arm.
Requirements for Intravenous Solutions/Intravenous Admixtures
Any solution administered through a patient's veins must be:
Precautions for Using Fluid Therapy
You will likely be in a position to administer or supervise administration of fluid therapy. Some precautions will be beyond your control, but most will be your responsibility. Carefully watch for the pitfalls shown below, to make sure that the intravenous infusion does the patient more good than harm.
a. Contamination. A solution intravenously administered to a patient must be free from living microorganisms. You have a responsibility for using the aseptic technique. When there is doubt about the sterility of the admixture (or intravenous solution), the product should be discarded. Microorganisms are present in the environment of the hospital room. They are on the hands of the person who will start (that is, begin the administration) the intravenous product. Therefore, this person is responsible for using care and aseptic technique to make the venipuncture.
b. Irritating Drugs. The veins are very sensitive. Therefore, any intravenous product which has an extreme pH or which is very concentrated can irritate the veins. In some cases, the physician can decide to place the drug in another intravenous solution resulting in a pH that will not irritate the veins as much. In other cases, the site can be changed frequently to allow the part of the vein just used to recover.
c. Particulate Matter. Hold a bottle or bag of intravenous solution up in front of a light. See how it is sparkling clear. Actually, small particles called particulate matter are present in the solution. Standards allow extremely small particles to be present in the solution in certain concentrations. Intravenous solutions or admixtures should never be administered to a patient when the products contain visible particulate matter. A product that is cloudy might actually be cloudy because of suspended particulate matter. Even though filters are available which can filter most particulate matter from intravenous products, do not use a cloudy solution.
Site for Venipuncture
a. Selection. Site selection for venipuncture depends on:
b. Preferred Sites. The following sites are generally used and preferred for use by most physicians in the clinical setting it is possible to select preferable veins for puncture. On the battlefield and keeping with the tenants of Tactical Combat Casualty Care (TC3), you should puncture a high percentage vein such as antecubital or external jugular.
CAUTION: Select the largest vein, if possible, when injecting intravenous drugs that may produce sloughing/necrosis injury to the tissues.
Principles of Intravenous Therapy
a. Check all bottles or bags of infusion solution for these specific requirements and discard any that show:
Precipitation (particles on the bottom of the bag or bottle). Foreign contaminants.
b. Always, use sterile equipment and wash your hands thoroughly.
c. Disinfect the patient's skin at and around the injection site. Apply antiseptic solution using friction at and around the venipuncture site.
d. For long term therapy patients.
The complications of intravenous therapy may be mild or life threatening, but they are always uncomfortable for the patient. Many can be prevented with proper care.
a. Infiltration. Infiltration (the most frequent complication) is caused by dislodgement of the needle or catheter or by puncture of the vein. This allows the fluid to collect in the surrounding tissue. Signs or symptoms include, slowing or stopping of the intravenous flow and reduced skin temperature in the venipuncture area. This is not usually serious but can be very uncomfortable for the patient. You can restart the intravenous at another site. The danger of this happening can be reduced by securely taping the intravenous line and providing arm boards for stability.
b. Speed Shock or Circulatory Overload. The "average" person has a blood volume of about five to six quarts. Blood is approximately ninety-one percent fluid. The body has intricate mechanisms for making up for changes in blood volume. For example, when you donate blood, some fluid from the inside of the cells and fluid surrounding the cells enters the circulating blood volume. There is a reverse flow when the blood volume is normal and intravenous fluids are administered. Unfortunately, when too much fluid and/or too much medication is administered too rapidly, circulatory overload can result. Signs and symptoms include patient complaints of pounding headache and chills, a flushed look, irregular pulse, and dyspnea.
c. Sepsis and Pyrogenic Reactions. Sepsis and pyrogenic reactions are usually caused by the introduction of pyrogenic organisms or their toxins into the bloodstream. In addition to these organisms, febrile reactions can be caused by various chemicals and certain types of particles. If an infection results, the reaction can be localized or systemic. A systemic reaction can occur about thirty minutes after starting the intravenous infusion. Long-term therapy patients can develop sepsis from the growth of microorganisms on the skin after a two to three day period. Signs and symptoms include an unexpected rise in temperature preceded by chills, nausea, vomiting, backache, and malaise. To reduce the possibility of developing sepsis, use aseptic techniques when starting the infusion and change the infusion site, bottle, and tubing at least every two to three days on long term intravenous therapy patients.
d. Phlebitis. Phlebitis is an irritation or injury to the vein. It can be caused by mechanical, chemical, or bacterial irritation. Signs and symptoms include redness, pain, and swelling at the infusion site and patient complaints of fatigue together with fever and a rapid pulse. If signs appear, change the needle to another site and apply warm moist compresses to relieve discomfort and aid healing. Do not rub or massage the affected area. You could cause thrombus or emboli and add to the vein damage. A thrombus is a clot that is formed in the blood vessels. A thrombus is usually a further complication of phlebitis. A clot formed in the vessels can produce damage to tissue below the stoppage.
e. Air Embolism. An air embolism is a very serious intravenous therapy complication. It can occur when a sizeable amount of air gets into the circulatory system through the intravenous administration set. It can block a vessel so that tissues are unable to get oxygen. Nutrients and waste products cannot be removed. The air bubble can cut off cardiac, cerebral, or pulmonary circulation. Symptoms include a fall in blood pressure, tachycardia (rapid pulse), and loss of consciousness. If a patient has these symptoms, take his vital signs, place patient on his left lateral side, administer oxygen, and get immediate medical help. Air embolism can be prevented by removing all air (bleeding) from intravenous lines, using venipuncture sites below heart level, and never allowing an intravenous line to run dry before disconnecting or adding another bottle. The larger the embolus, the greater the danger. Death could result.
f. Solution's Incompatibility. The signs of incompatibility will differ according to the solution or drug being administered. The effects can vary from neutralizing the effects of a drug to causing circulatory collapse. Some solutions, such as over 10 percent dextrose or potassium chloride, are very irritating in concentrated doses. Sterile water, saline, or special dilutants are required for certain drugs and substitutions should not be made. Incompatible drugs frequently form a precipitate and cause fever, nausea, vomiting, and intense itching.
Calculating the Intravenous Drip Rate
In order to infuse a solution ordered by the physician, it is necessary to calculate the infusion rate. A drip rate calculation may be desired for maintenance of trauma patients that you may not be able to immediately evacuate. During the care under fire phase of tactical care the appropriate hypovolemic fluid protocols should be followed for the benefit of your patient and triage of your available supplies.
a. The physician who ordered the infusion for the patient will give you the following information:
b. From the infusion set, you will learn how many drops per ml the set is capable of providing. You must determine how many drops per minute are required in order to set this delivery rate on the infusion set. The formula for determining the drip rate is given below.
Explanation of Drip Rate Formula
The above formula can be used by following these steps.
Example of a Drip Rate Calculation
Let us use an example to illustrate this process. The physician has ordered you to infuse 2000 ml of normal saline. The fluid is to be infused over eight hours. Your infusion set delivers 15 drops per milliliter. How many drops per minute should be administered?
|David L. Heiserman, Editor||
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Revised: June 06, 2015