Hazards of IV therapy

1. Hazards of IV therapy • Aim: To raise awareness of hazards • Learning outcomes: Recall the role of the nurse in IV therapy List the main risk factors of IV therapy List complications to the patient of IV therapy Howard Griffiths, SHS

2. Underpinning knowledge • Basic anatomy and physiology of the cardiovascular system • Principles of asepsis • Pharmaceutical knowledge of different fluids • Drip factors and different giving sets, their purpose • Technical knowledge of different pumps that may be used Howard Griffiths, SHS

3. Role of the nurse • Identifying and verifying prescription • Checking for contamination and faults • The 5 R,s of drug administration • Controlling the prescribed flow rate • Monitoring and reporting patient’s condition • Ensuring that IV device remains patent • Inspecting the insertion site, reporting any abnormalities • Maintaining records Howard Griffiths, SHS

4. Nursing interventions • Good hand washing and universal precautions • Drug administration calculation • Vital signs measurement during therapy (BP, pulse, respiration, temperature) • Degree of consciousness of the patient • Observe urinary output and maintain fluid balance chart • Report blood results of urea and electrolytes to doctor • Observe for local signs of infection at the cannula site Howard Griffiths, SHS

5. Methods of administration • Intermittent fluids • Continuous fluids • Parenteral nutrition • IV bolus medication • IV intermittent injection of medication Howard Griffiths, SHS

6. Managing Risks • Infection control • Drug interactions • Correct use of syringe and infusion equipment • Correct checking procedures for drug administration Howard Griffiths, SHS

7. Therapeutic use of Intravenous fluids • To maintain hydration • To correct fluid and electrolyte balance • To administer bolus IV systemic medication, such as prescribed antibiotics • To maintain haemodynamic stability during surgery, and or maintain stability during pathological crisis, e.g shock Howard Griffiths, SHS

8. Factors to consider when administrating drugs • Does it require reconstitution • storage • stability • expiry date • drug action and side-effects • what is it incompatible with • physiological considerations, serum levels? • is protective clothing required? Howard Griffiths, SHS

9. Drug interactions • inadequate mixing of drugs • fluid may have an affect on the stability of the drug • drug degradation through light (frusemide, nitroprusside, vitamin A and K) • inadequate mixing of drug additives • specific gravity of the added drug may be different from fluid used, resulting in layering Howard Griffiths, SHS

10. Patient related factors in drug administration • The 5 R’s • allergies • body mass • vital signs • informed consent • clinical status • do they understand the side-effects • is the device patent? Howard Griffiths, SHS

11. IV administration sets • Use aseptic technique when handling • Latex bungs and injection ports, clean with 70% alcohol, and allow to dry before administrating drugs • Clear fluids/ stored plasma/ drug infusion should have: • standard administration sets (5-15 micron filter, 20 drops per ml). • Burette or buretol (15 micron filter, 60 drops/ml) Howard Griffiths, SHS

12. Transfusions • blood administration sets (15 drops/ml) should be used for blood and fresh frozen plasma (FFP) • Albumin Solution, Hetastarch and Haemacell can be given through clear fluid sets, as they contain no cells • Platelets and Cryoprecipitate is administered through a platelet set (15 drops/ ml) Howard Griffiths, SHS

13. Factors affecting flow rates • Fluid composition, viscosity and concentration of fluid • Height of fluid container will alter the hydrostatic pressure of fluid • Change in the position of the client’s access site • Administration sets • distortion of tubing may render the clamp ineffective • diameter of the lumen • inclusion of in line devices such as filters • Vascular access • condition and size of vein • cannula gauge • occlusion • pressure Howard Griffiths, SHS

14. Infusion devices • Medical Device Agency has identified one of the most serious of medication errors involve the use of infusion pumps • One of the main areas where human error occurs is in drug calculation • The MDA has categorised infusion devices in terms of risk: Howard Griffiths, SHS

15. Neonatal risk infusionrequires high accuracy and consistency of flow, used in neonatal intensive care and paediatric services • High-risk infusionsimilar to above but not as accurate over the short term (within 1 hour). More suitable for older children and adults. • Low-risk infusion infusion of simple electrolytes, antibiotics and total parenteral nutrition. Devices will not need to have accurate or consistent output, only rudimentary alarm and safety systems • Ambulatory infusion infusion devices worn to allow normal activities during infusion, often battery powered Howard Griffiths, SHS

16. Infusion device checklist • Uncontrolled flow • occur from gravity drips, volumetric and syringe pumps • Selecting the right infusion pump for transfer • is it necessary to take all infusion devices, does the pump meet the risk classification?, is the operator trained to use it • Changing the infusion during transit • avoid, calculate infusion requirements and prepare so that the infusion will last the journey • Security and safety • ensure that all devices are fixed or clamped secured Howard Griffiths, SHS

17. Flushing and maintaining patency • Ensures that the whole drug is given • Ensures that the device remains patent • 0.9% NaCl is effective in maintaining patency in peripheral devices • Flushing should be undertaken after each dose or at least every 24 hours Howard Griffiths, SHS

18. Issues of infection control • Transparent film dressings over catheter or cannula site • Change local dressings according to local protocols • Keep change of IV infusion bags, giving sets, disconnection or interruption to a minimum • Hand washing and asepsis should be maintained before manipulating the IV system • With minimal breaks in IV circuit, change administration sets every 72 hours. • With frequent breaks in IV circuit, change administration set every 24-48 hours. For blood products change after infusion. Howard Griffiths, SHS

19. Fluid and blood product administration • DO NOT ADD DRUGS TO: • blood products • mannitol • sodium bicarbonate • parenteral nutrition • Ensure individual drugs and solutions are given by the optimal route Howard Griffiths, SHS

20. Chemistry of body fluids • Electrolytes • it is common to measure electrolytes in ECF, chiefly the plasma. • The term ‘plasma’ and ‘serum’ are used interchangeably • Na+ is the main cation in ECF and controls the volume of fluid in ECF • K+ is the main concentration of ICF. Howard Griffiths, SHS

21. Intravenous fluids • Correcting and maintaining fluid and electrolyte balance • isotonic fluids are prescribed fluids that do not alter the osmotic movement of water across cell membranes. • 0.9% Sodium chloride is used to sustain extra cellular fluid volume by compensating for volume lost be • dehydration • urinary excretion of sodium • fluid drains following surgery Howard Griffiths, SHS

22. Hypertonic fluids are fluids that expand intravascular volume by moving endothelial and intracellar water into the intravascular space • These fluids contain a high concentration of particles when compared to plasma, has potential therefore to cause fluid overload. • These fluids also has the potential to irritate peripheral veins, administration should be slow Howard Griffiths, SHS

23. Hypotonic saline (0.45%) is used to replenish electrolytes. Complications can include over hydration, sodium overload and potassium defecit. • Hypotonic fluids drive fluid from the plasma into the interstitial space, and therefore are used to re-hydrate the cells Howard Griffiths, SHS

24. Potassium electrolyte infusion is used for patients with severe hypokaelaemia. • Conditions leading to hypokalaemia are- • vomiting, diarrhoea, use of potent diuretics, malnutrition, some forms of renal diseases and metabolic acidosis • Careful infusion is required in order to avoid cardiac arrhythmias and death. Howard Griffiths, SHS

25. Peripheral site complications • Phlebitis • caused by mechanical rubbing of cannula, or chemical irritation from fluid, or through contamination through poor hand washing by the nurse • Occlusion • caused by incorrect flushing, empty bags, kinking of line, precipitation, poor cannula site • Infiltration • a none blistering drug leaks into the surrounding tissue • Extravasation • blistering drug that leaks into surrounding tissue Howard Griffiths, SHS

26. Potential systemic complications of IV therapy • Circulatory overload • Systemic infection • Air embolism • Allergic reaction Howard Griffiths, SHS

27. Types of central venous access • Peripherally inserted catheters (PICCs)- for patients requiring several weeks of IV access • Short term tunnelled catheters- days to several weeks of IV access • tunnelled cuffed catheters- for long term intermittent continuous or daily IV access • Implanted venous access- for long term, intermittent, continuous or daily IV access Howard Griffiths, SHS

28. Immediate Complications of central venous catheters • venous air embolism • tamponade • catheter embolus/rupture • arterial puncture • dysrhythmias • pneumothorax Howard Griffiths, SHS

29. Delayed complications of central venous catheters • Infection of tunnel • infection within catheter • occlusion • drug precipitation • thrombosis • air embolism • anaphylaxis • broken hub, broken clamp, split catheter • catheter pulled or fallen out Howard Griffiths, SHS

30. Safety issues in Critical Care • Labelling of sets • Functions of different sets must be clearly labelled • above will help prevent mal-administration of drugs and avoid haemodynamic monitoring sets • Identify both proximal and distal end of a giving set • Use uninterrupted tubing, free of junctions and access ports • Only use high pressure tubing for haemodynamic measurements • If stopcocks have to be used on administration sets, clean with 70% alcohol beforehand Howard Griffiths, SHS

31. Blood products • Whole blood transfusion • Packed RBC • Platelets- • Fresh frozen plasma • Cryoprecipitated antihemophilic factor • Granulocytes • Serum albumin and plasma protein fraction (PPF) Howard Griffiths, SHS

32. Therapeutic use of blood products • Whole blood transfusion • for massive blood loss in neonates • Packed RBC • for inadequate oxygen carrying capacity • Platelets • for treatment of thrombocytopenia, acute lukaemia, and marrow aplasia, and to restore platelet count preoperatively inpatients with a count of <100,000/mm3 or less Howard Griffiths, SHS

33. Fresh frozen plasma • for expansion of plasma volume, treat post-op haemorrhage or shock and correct coagulation factor deficiencies • Cryoprecipitated antihaemophilic factor • for haemophilia A, von Wilerbrand’s disease, hypofibrinogenemia • Granulocytes • for severe gram negative infection or severe neutropenia unresponsive to routine forms of therapy in immunosuppressed patient. Also indicated in severe granulocyte dysfunction. • Serum albumin and plasma protein fraction • in hypovolaemia and hypoproteinemia (burns) Howard Griffiths, SHS

34. Managing Clinical Risk • Human error has been recognised as a cause of transfusion fatality for several decades (BMJ 1953) • Errors can occur : • time of blood sample collection (incorrect labelling, blood taken from the wrong patient) • within the laboratory (use of incorrect sample or patient record; release of wrong unit from the store) • practice settings (administration to the wrong patient) Howard Griffiths, SHS

35. Managing Clinical Risk • There is no mandatory reporting system in the U.K. • A voluntary system operates through Serious Hazard of Transfusion (SHOT) initiative • Anyone can report a blood transfusion error, adverse incident or error to SHOT Howard Griffiths, SHS

36. Good Practice required for blood transfusions • All blood products should be correctly prescribed by the doctor: • specify quantity and note any allergies • duration of the transfusion, special requirements of the blood or blood product and precautions • reason for transfusion should be documented in the medical notes • Other methods should be considered: • autologous blood transfusion • intra-operative blood salvage • No formal consent is required in the UK but information provided should cover: • reasons for transfusion • details of the benefit and risks of such treatment Howard Griffiths, SHS

37. Good Practice required for blood transfusions • Follow local policy when collecting blood: • compatability reports filed in the patient’s notes • signatures of authorized staff collecting the blood • time of collection • storage of blood should be in a refrigerator at -2.6c • blood transfusion should commence within 30 minutes of its removal • blood transfusion should be completed within 5 hours (proliferation of bacteria in blood components) Howard Griffiths, SHS

38. Good Practice required for blood transfusions • BCSH 1999 guidelines state that a single practitioner (midwife, nurse or doctor) can verify details at the bedside, in order to reduce risk of errors. • Pre-transfusion checks should include: • expiry date • leakage • unusual colour (brown or red plasma indicates haemolysis) • patients details, and ABO and Rhesus group • unique donation number • The blood unit details should be checked against the doctor’s prescription, compatibility report and identification number Howard Griffiths, SHS

39. Good Practice required for blood transfusions • Patients should have an I.D. band containing accurate information • The bag should be gently squeezed for leaks, and gently rocked to mix the contents • A standard 19 gauge IV cannula and a blood giving set should be set up which has filter to prevent small clots entering the blood stream. • Administration of platelets should be through a platelet giving set, not a blood transfusion set (special paediatric sets are for infants). • Giving sets should be primed only with N/Saline Howard Griffiths, SHS

40. Good Practice required for blood transfusions • A blood warmer is indicated: • a flow rate of >50mL / Kg / hour in adults • a flow rate of 15 mL/ Kg/ hour in children • exchange transfusions in infants • transfusing patients with clinically significant cold agglutins • No other drug or fluids should be added to the transfusion set which may cause red cells to clot or lyse • The giving set should be changed: • after 12 hours • if another infusion is to continue after the transfusion Howard Griffiths, SHS

41. Good Practice required for blood transfusions • Nursing observation required according to BCSH guideline 1999 are: • baseline observations to include temperature, pulse and BP • pulse and temperature are additionally observed within 15 minutes of the start of each unit of blood. • nurse all patients receiving blood in a location where they can readily be observed • additional observations are only necessary when a patient is unwell or noted to have deteriorated. • observe urinary output and maintain fluid balance chart Howard Griffiths, SHS

42. Good Practice required for blood transfusions • observe patient’s behaviour during transfusion • observe the appearance of the patient during transfusion • check cannula for signs of infection • adverse reactions should be reported immediately • acute haemolytic reactions, transfusion must be stopped and further assessments carried out. • After completion of transfusion: • the transfusion should be disposed of according to local policy for disposal of clinical waste. • Retention of blood bags for 48 hour period as been recommended by BCSH 1990, in case there may be a severe reaction some hours after discontinuation Howard Griffiths, SHS

43. Potential complications of blood transfusions • Infection • Febrile reaction • Allergic reaction • Transfusion hypothermia • Fluid overload Howard Griffiths, SHS

44. Adverse reaction • Increase in temperature • Hypotension • Tachycardia • Headaches • Rashes • Swelling around cannula site • Pain in abdomen or chest • Patient feeling agitated or unduly apprehensive • STOP TRANSFUSION, CONTACT DOCTOR AND FILL DOCUMENTATION Howard Griffiths, SHS

45. Reporting adverse incident • recheck the blood against the patient’s notes • check the patient’s urine for blood • blood needs to be cross matched again • all equipment (blood bag, giving set and urine ) should be sent to the lab for testing • keep the iv line open with 0.9% normal saline • complete the employer’s adverse clinical incident form, and document in care plan Howard Griffiths, SHS

46. Conclusion • IV therapy must be prescribed by a medical practitioner • Cannulation and insertion of catheters, together with administrating IV medication is regarded as extended Professional Scope of Practice. • Always check that equipment, the fluids and the flow rate with another R.N. Howard Griffiths, SHS

47. The bedside check is the final opportunity to prevent a mis-transfusion • Each hospital will have a formal policy which must be followed for blood transfusion • Every patient should have an uniquely identified wristband • Each R.N must ensure responsibility regarding their competency . Howard Griffiths, SHS

48. REFERENCES • British Committee for Standards in Haemotology, Blood Transfusion Task Force (1999) The administration of blood and blood components and the management of transfused patients; Transfusion Medicine 9:227-238 • Jane Mallet and Lisa Dougherty (2000) Manual of Clinical Nursing Procedures (5th edition); Blackwell Science, London • Fox, Nick (2000) Managing risks posed by intravenous therapy; Nursing TimesVol.96 (30), pp37-39 • R.C.N. ( ) Guidance for Nurses Giving Intravenous Therapy • Serious Hazards of Transfusion (SHOT) Annual Report 1999-2000:Availavble from; htpp://www.shot.demon.co.uk/ • Quinn, C. (2000)Infusion devices: risks, functions and management; Nursing Standard Vol. 14 (26):35-41 • Wilkinson, J. (2001) Administration of blood transfusions to adults in general hospital settings: a review of the literature; Journal of Clinical Nursing Vol. 10 (10):161-172 Howard Griffiths, SHS