Eileen Whitehead 2010 East Lancashire HC NHS Trust 1
Patients receive intravenous fluids when they are unable to maintain an adequate fluid balance and need fluid replacement This may be due to the inability to take oral hydration or as the result of excess losses, leading to dehydration if left untreated 2
Despite getting plenty of fluids intra-operatively, most patients are usually dehydrated after an operation. There are several reasons for this: Poor oral intake prior to fasting for theatre Fluid and blood loss intra-operatively Direct blood loss Exposure of large internal surfaces to the heat and light of the theatre lights Fluid loss from respiration while incubated 3
Other possible causes of dehydration: Swallowing problems CVA / Maxfax problems GI problems eg perforation / obstruction Excessive vomiting / diarrhoea Haemorrhage 4
What are the physical signs of dehydration? Hypotension Tachycardia Reduced Urine Output Increased Respiration Headache If a patient is dehydrated the blood results show an increase in sodium and urea 5
Crystalloid V Colloid 6
Crystalloid solutions are solutions of ions (usually sodium and chloride) and or sugars (glucose) contained in water. Solutions commonly used are isotonic with plasma; therefore they do not alter the osmotic movement of water across cell membrane: Normal saline Dextrose solutions Ringer s lactate Hartmann s solution 7
Colloid solutions Gelatinous solutions containing large particles resulting in the fluid being hypertonic. They exert an osmotic pull on fluids from the interstitial spaces into the intravascular space increasing the circulatory volume: Albumin Dextrans Haemaccel Gelofusine 8
Colloids can produce dramatic fluid shifts and place the patient in considerable danger if they are not administered in a controlled settings Not recommended for normal post op fluid replacement 9
Potassium is a commonly infused electrolyte in or added to crystalloid fluids. However excessive serum potassium (hyperkalaemia) can cause cardiac arrhythmias and is therefore potentially life threatening What are the normal levels? 3.5 5.0 meq/l (Should we be adding 20 mmol per litre post op) 10
Most common post op fluid replacement: 0.9% Normal Saline Think of it as Salt and Water Principal fluid used for intravascular resuscitation and replacement of salt loss e.g diarrhoea and vomiting 5% Dextrose Think of it as Sugar and Water Primarily used to maintain water balance in patients who are not able to take anything by mouth; Often prescribed as 2 L x 5% Dextrose and 1 L Normal Saline x 24 hours? Recent research identifies Hartman's as the gold standard in place of Normal Saline 11
Fluid Prescription Chart You must fill in all the details requested familiarise yourself with those of the Trust (Manchester Charts) 12
Useful to record the patient s weight if known All fluid charts should be reviewed every 24 hours Different colours may identify allergy 13
Infusion Calculations: A standard IV giving set delivers 20 drops /ml Blood giving sets deliver 15 drops / ml 14
To calculate the infusion rate in ml /hr Volume of solution (ml) = ml/hr Number of hours e.g. A patient requires 1 litre of fluids administered over 8 hours 1000 = 125 ml / hr 8 15
To calculate the drip rate in drops/min Volume (ml) X drops per ml Time (in minutes) e.g. A patient requires 1 litre of fluids administrating over 8 hrs. How many drops per minute is this? 1000 X 20 = 42 dpm 8 x 60 16
A patient requires 1 L of 5% Dextrose to be given over 12 hours. If you were using an infusion pump how many ml/hr would it be set on? 1000 = 83.3 ml/hr 12 17
285 ml of blood needs to be given over 2 hours. How many drops/min would this be? 285 X 15 = 36 drops/min 2 X 60 18
1L of 5% Dextrose needs to be given via a pump over 16 hours, what rate would it need to run at? 1000 = 62.5 ml/hr 16 19
Procedure 20
Before you start: Check patients details Check prescription - infusion & transfusion chart 21
Prescription Chart Black indelible ink - legible Contain patient s name, DOB, clinical area, hospital & hospital number, named consultant. If <16yrs sex/weight (legal obligation) Only one prescription chart in use at any one time unless items prescribed exceeds available spaces Prescription should state type and strength of IV fluid and duration of infusion Time of administration must be clearly identified using 24 hour clock Check that the patient has not already received the infusion. 22
Select correct fluid Inspect outer packaging, any breach of packaging do not use Check clarity of contents cloudiness, discolouration or particles may indicate contamination Check expiry date on the bag 23
Which IV Administration Set? Standard Set Blood Set 24
Administration (Giving Sets) Check expiry date of administration set Check packaging intact prior to use Clear fluid sets change after 72 hours, providing set has not been disconnected during that time Blood transfusion set during transfusion change admin set every 12 hours 25
The Patient Identify correct patient Final wrist band check. Explain the procedure & answer any concerns or queries the patient may have. Visual Infusion Phlebitis Score (VIPS/VAD)- every day including before and after each medication / IV fluid administration 26
Priming the Administration Set Don apron & WASH YOUR HANDS!!!!! Clean work surface/trolley Wear gloves Remember to use ANTT- identify and protect the key parts Open fluid bag and lay on flat surface (minimise risk of puncturing bag) 27
Remove bung/cover from fluid bag with a twisting movement Open administration set & check integrity 28
Holding the administration set in both hands - close the roller clamp 29
Carefully remove sheath from IV administration set taking care not to touch the sterile spike this is a key part! 30
Gently but firmly insert the spike of administration set into the bag of fluid using a twisting movement. Ensuring the main bag is punctured 31
Hang bag onto drip stand Gently squeeze the drip chamber until it is half full DO NOT OVERFILL difficult to see drops forming 32
Open roller clamp fast to prime the line ensuring no air is trapped around roller clamp Close roller clamp when fluid reaches the end of the set Remove any air bubbles by flushing 33
Remove priming bung from end of administration set Remember the end is sterile so do not touch!- ANTT 34
Check cannula site as previous Apply pressure on vein - above cannula site in order to prevent blood back flowing out of cannula when bung removed Wrong Right 35
Whilst maintaining pressure over the vein with other hand remove the bung on the end of the cannula Take care not to touch key parts If blood flows out from cannula your pressure application is inappropriate!! 36
Attach primed administration set to cannula Discontinue pressure on vein Make sure the connection is secure 37
Open roller clamp Check drip chamber to ensure fluid running Check cannula site for signs of leakage! 38
Secure trailing administration set Documentation 39
Complete Infusion and Transfusion Chart 40
References: Powell-Tuck et al (2009) Guidelines on IV fluid therapy for surgical patients http://www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdf Clinical Education Group (2003) Delivering Intravenous Fluids Undergraduate Dept Lancashire Teaching Hospitals 41