Peripheral Intravenous Access Resuscitation fluid Intraosseous Infusion

Peripheral Intravenous Access

Peripheral IV cannulation is performed to provide access to the patient's circulatory system. Establishment of IV access is essential during cardiac arrest and major trauma.

Because of the potential for fluid extravasation or inadequate volume flow, peripheral IV lines should not be started in an extremity in which massive edema, burns, traumatic injury, sclerosis, phlebitis, or thrombosis are present. In patients with chest, abdominal, or proximal extremity trauma, the vein selected for an IV line should not empty into the affected area, because the integrity of the proximal veins cannot be ensured. For example, it is preferable for patients with gunshot wounds to the abdomen to have IV lines started in their upper extremities, rather than in the lower extremities.

In the upper extremity, on the dorsal surface of the hand, in the forearm , in the lower extremity, on the dorsal surface of the foot. Materials : 70% alcohol pads Tourniquet or blood pressure cuff Arm board Tape Antibiotic ointment or film barrier Intravenous catheter 1-inch tape Latex gloves IV fluid, an IV tubing set, and a primary administration set are selected appropriately for the clinical situation.

Complication
Air embolism Catheter embolism Cellulitis Hematoma Infiltration, possibly tissue necrosis Phlebitis Sepsis Thrombophlebitis Thrombosis Volume overload

Almost all circulatory shock states require largevolume IV fluid replacement, as does severe intravascular volume depletion . ntravascular volume deficiency is acutely compensated by vasoconstriction, followed over hours by migration of fluid from the extravascular compartment to the intravascular, maintaining circulating volume at the expense of total body water. However, this compensation is overwhelmed after major losses.

Choice of resuscitation fluid depends on the cause of the deficit: -Crystalloid -Colloid -Blood substitutes -Blood

Crystalloid
Are typically isotonic (eg, 0.9% saline or Ringer's lactate [RL]). H2O freely travels outside the vasculature, so as little as 10% of isotonic fluid remains in the intravascular space. With hypotonic fluid (eg, 0.45% saline), even less remains in the vasculature and thus is not used for resuscitation. Both 0.9% saline and RL are equally effective; RL may be preferred in hemorrhagic shock because it somewhat minimizes acidosis.

The Ca in RL may interfere with concurrently infused drugs and may trigger clotting in transfused blood unless the ratio of blood:RL is > 2:1. For patients with acute brain injury and hemorrhagic shock, 0.9% saline is preferred. Hypertonic saline (7.5%) is also an effective crystalloid; it shifts more volume from the extravascular space and therefore requires lower absolute volume, which has practical advantages in a pre-hospital setting.

Colloid
Are also effective for volume replacement during major hemorrhage. Despite theoretical benefits over crystalloid, no differences in survival have been proven. Albumin is the colloid of choice, although it may have a negative inotropic effect. Both dextrans and hydroxyethyl starch may adversely affect coagulation when > 1.5 L is given.

Blood substitutes

Are O2-carrying fluids that can be Hb-based or perfluorocarbons , these substances do not require cross-matching. They also can be stored > 1 yr, providing a more stable source than banked blood.

Blood

Blood typically is given as packed RBCs, which should be cross-matched, but in an urgent situation, 1 to 2 units of type O Rh-negative blood are an acceptable alternative. When > 1 to 2 units are transfused (eg, in major trauma), blood is warmed to 37° C.

Endotracheal Drug Administration
Endotracheal (ET) administration of selected medications is a simple, rapid, and effective method of drug delivery to the central circulation. However, this technique of drug administration should be reserved for use in situations in which a patient's condition warrants immediate pharmacologic intervention and when more conventional means of drug delivery, such as by intravenous (IV) or intraosseous (IO) access, are not readily available.

Most studies on the subject indicate that higher doses are needed endotracheally than intravenously to obtain the therapeutic efect. It seems reasonable in adults to start with a dose 2.0 to 2.5 times then usual IV dose. If this appears ineffective, higher doses may be used on subsequent administration.

Endotracheally administered drugs shown to be effective : Atropine Diazepam Epinephrine Lidocaine Naloxone Do not administered via ET : Amiodarone , Calcium , Sodium bicarbonate !

Intraosseous Infusion
In light of the need for rapid vascular access in pediatric patients, we could use of IO infusion . It provides a safe, reliable method of accessing the cardiovascular system for administration of fluids and drugs during cardiac arrest and other resuscitations. Comparisons of IO and IV infusion of drugs have demonstrated that the drugs reach the central circulation by both routes in similar concentrations and at the same time .

Long bones are richly vascular structures with a dynamic circulation that is capable of accepting large volumes of fluid and rapidly transporting fluids or drugs to the central circulation. The site of choice is the proximal tibia, followed by the distal tibia and distal femur. Equipment necessary for establishing IO access is a sturdy needle with a stylet and a syringe for aspiration.

Complication IO
The most common infection is cellulitis at the puncture site .Osteomyelitis is less common, but it also usually responds to antibiotics. Inflammatory reactions of the bone may be seen. Another complication that has been reported is necrosis of the skin at the site of infusion. Tibial fractures have also been reported , fat embolism(rare, only in adults).

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