8.2 Intravenous Fluid Therapy

Intravenous therapy is treatment that infuses intravenous solutions, medications, blood, or blood products directly into a vein (Perry, Potter, & Ostendorf, 2014). Intravenous therapy is an effective and fast-acting way to administer fluid or medication treatment in an emergency situation, and for patients who are unable to take medications orally. Approximately 80% of all patients in the hospital setting will receive intravenous therapy.

The most common reasons for IV therapy (Waitt, Waitt, & Pirmohamed, 2004) include:

1. To replace fluids and electrolytes and maintain fluid and electrolyte balance: The body’s fluid balance is regulated through hormones and is affected by fluid volumes, distribution of fluids in the body, and the concentration of solutes in the fluid. If a patient is ill and has fluid loss related to decreased intake, surgery, vomiting, diarrhea, or diaphoresis, the patient may require IV therapy.
2. To administer medications, including chemotherapy, anesthetics, and diagnostic reagants: About 40% of all antibiotics are given intravenously.
3. To administer blood or blood products: The donated blood from another individual can be used in surgery, to treat medical conditions such as shock or trauma, or to treat a failure in the production of red blood cells. The infusion restores circulating volumes, improving the ability to carry oxygen and replace blood components that are deficient in the body.
4. To deliver nutrients and nutritional supplements: IV therapy can deliver some or all of the nutritional requirements for patients unable to obtain adequate amounts orally or by other routes.

Guidelines Related to Intravenous Therapy

The following are general guidelines for peripheral IV therapy:

• IV fluid therapy is ordered by a physician or nurse practitioner. The order must include the type of solution or medication, rate of infusion, duration, date, and time. IV therapy may be for short or long duration, depending on the needs of the patient (Perry et al, 2014).
• IV therapy is an invasive procedure, and therefore significant complications can occur if the wrong amount of IV fluids or the incorrect medication is given.
• Aseptic technique must be maintained throughout all IV therapy procedures, including initiation of IV therapy, preparing and maintaining equipment, and discontinuing an IV system. Always perform hand hygiene before handling all IV equipment. If an administration set or solution becomes contaminated with a non-sterile surface, it should be replaced with a new one to prevent introducing bacteria or other contaminants into the system (Centers for Disease Control [CDC], 2011).
• Understand the indications and duration for IV therapy for each patient. Practice guidelines recommend that patients receiving IV therapy for more than six days should be assessed for an intermediate or long-term device (CDC, 2011).
• If a patient has an order to keep a vein open, or “TKVO,” the usual rate of infusion is 20 to 50 ml per hour (Fraser Health Authority, 2014).
• Complications may occur with IV therapy, including but not limited to localized infection, catheter-related bloodstream infection (CR-BSI), fluid overload, and complications related to the type and amount of solution or medication given (Perry et al., 2014).
• For an infusing peripheral IV, the site must be assessed every 2 hours and p.r.n.
• A saline lock site must be assessed every 12 hours and p.r.n.

Types of Venous Access

Safe and reliable venous access for infusions is a critical component of patient care in the acute and community health setting. There are a variety of options available, and a venous access device must be selected based on the duration of IV therapy, type of medication or solution to be infused, and the needs of the patient. In practice, it is important to understand the options of appropriate devices available. This section will describe two types of venous access: peripheral IV access and central venous catheters.

Peripheral IV

A peripheral IV is a common, preferred method for short-term IV therapy in the hospital setting. A peripheral IV (PIV) (see Figure 8.1) is a short intravenous catheter inserted by percutaneous venipuncture into a peripheral vein, held in place with a sterile transparent dressing to keep the site sterile and prevent accidental dislodgement (CDC, 2011). Upper extremities (hands and arms) are the preferred sites for insertion by a specially trained health care provider. If a lower extremity is used, remove the peripheral IV and re-site in the upper extremities as soon as possible (CDC, 2011; McCallum & Higgins, 2012). The hub of a short intravenous catheter is usually attached to IV extension tubing with a positive pressure cap (Fraser Health Authority, 2014).

PIVs are used for infusions under six days and for solutions that are iso-osmotic or near iso-osmotic (CDC, 2011). They are easy to monitor and can be inserted at the bedside. CDC (2011) recommends that PIVs be replaced every 72 to 96 hours to prevent infection and phlebitis in adults. Most agencies require training to initiate IV therapy, but the care and preparation of equipment, and the maintenance of an IV system can be completed each shift by the trained health care provider. For more information on how to initiate IV therapy, see the resources at the end of the chapter.

PIVs are prone to phlebitis and infection, and should be removed (CDC, 2011) as follows:

• Every 72 to 96 hours and p.r.n.
• As soon as the patient is stable and no longer requires IV fluid therapy
• As soon as the patient is stable following insertion of a cannula in an area of flexion
• Immediately if tenderness, swelling, redness, or purulent drainage occurs at the insertion site
• When the administration set is changed (IV tubing)

Several potential complications may arise from peripheral intravenous therapy. It is the responsibility of the health care provider to monitor for signs and symptoms of complications and intervene appropriately. Complications can be categorized as local or systemic. Most complications are avoidable if simple hand hygiene and safe principles are adhered to for each patient at every point of contact (Fraser Health Authority, 2014; McCallum & Higgins, 2012). Table 8.1 lists the potential local and complications and treatment.

Systemic complications can occur apart from chemical or mechanical complications. To review the systemic complications of IV therapy, see Table 8.2.

Central Venous Catheters

A central venous catheter (CVC) (see Figure 8.2), also known as a central line or central venous access device, is an intravenous catheter that is inserted into a large vein in the central circulation system, where the tip of the catheter terminates in the superior vena cava (SVC) that leads to an area just above the right atrium. CVCs have become common in health care settings for patients who require IV medication administration and other IV treatment requirements. CVCs can remain in place for more than one year. Some CVC devices may be inserted at the bedside, while other central lines are inserted surgically. Central lines are inserted by a physician or specially trained health care provider, and the use of ultrasound guided placement is recommended to reduce time of insertion and complications (Safer Healthcare Now, 2012).

A CVC has many advantages over a peripheral IV line, including the ability to deliver fluids or medications that would be overly irritating to peripheral veins, and the ability to access multiple lumens to deliver multiple medications at the same time (Fraser Health Authority, 2014). Central venous catheters can be inserted percutaneously or surgically through the jugular, subclavian, or femoral veins, or via the chest or upper arm peripheral veins (Perry et al., 2014). Femoral veins are not recommended, as the rate of infection is increased in adults (CDC, 2011; Safer Healthcare Now, 2012). To have a CVC inserted or removed, an order by a physician or nurse practitioner must be obtained. Site selection for a CVC may be based on numerous factors, such as the condition of the patient, patient’s age, and type and duration of IV therapy.

The majority of patients in an ICU will have a CVC to receive fluids and medications. A chest X-ray is given to determine correct placement before inserting, or to confirm a suspected dislodgement (Fraser Health Authority, 2014). An IV pump must be used with all CVCs to prevent complications.

CVCs are typically inserted for patients requiring more than six days of intravenous therapy or who:

• Require antineoplastic medications
• Are seriously or chronically ill
• Require vesicant or irritant medications
• Require toxic medications or multiple medications
• Require central venous pressure monitoring
• Require long-term venous access or dialysis
• Require total parenteral nutrition
• Require medications with a pH greater than 9 or less than 5, or osmolality of greater than 600mOsm/L
• Have poor vasculature
• Have had multiple PIV insertions/attempts (e.g., two attempts by two different IV therapy practitioners)

A central line is made up of lumens. A lumen is a small hollow channel within the CVC tube. A CVC may have single, double, triple, or quadruple lumens (Perry et al., 2014). Depending on the type of CVC, it may be internally or externally inserted, and may have an open-ended or valved tip. Open-ended devices are those in which the catheter tip is open like a “straw.” These have a higher risk for complications, such as hemorrhage, air embolism, and occlusion from fibrin or clots. Valved devices are those in which the tip is configured with a three-way pressure-activated valve (Perry et al., 2014). It is important to know what type of central line is being used, as this will impact how to care for and manage the equipment for specific procedures. Table 8.3 lists various types of central lines.

Table 8.3 Types of Central Venous Catheters (CVCs)
Safety considerations: CVC care and maintenance requires specialized training to prevent complications. Central lines heighten the risk for patients to develop a nosocomial infection. Strict adherence to aseptic technique is required for all CVC care.
Type		Location and Additional Information
Percutaneous central venous catheter (CVC)		Tip location: The tip of the catheter is located in the SVC. The entry site is the exit site. Can be inserted at the bedside by specially trained physician or nurse. The percutaneous CVC is inserted directly through the skin. The internal or external jugular, subclavian, or femoral vein is used. Most commonly used in critically ill patients. Can be used for days to weeks, and the patient must remain in the hospital. Usually held in place with sutures or a manufactured securement device.
Peripherally inserted central catheter (PICC)		Tip location: The tip is located in the SVC. A PICC (see Figure 8.3) may be inserted at the bedside, in a home or radiology setting. The line is inserted through the antecubital fossa or upper arm (basilic or cephalic vein) and is threaded the full length until the tip reaches the SVC. Can provide venous access for up to one year. The patient may go home with a PICC. PICCs can easily occlude and may not be used with dilantin IV. It is held in place with sutures or a manufactured securement device.
Subcutaneous or tunnelled central venous catheter		A tunnelled CVC, also known as a Hickman, Broviac, or Groshong, is a long-term CVC with a proximal end tunnelled subcutaneously from the insertion site and brought out through the skin at an exit site. Insertion is a surgical procedure, in which the catheter is tunnelled subcutaneously under the skin in the chest area before it enters the SVC. A tunnelled catheter may remain inserted for months to years. These CVCs have a low infection rate due to a Dacron cuff, an antimicrobial cuff surrounding the catheter near the entry site, which is coated in antimicrobial solution and holds the catheter in place after two to three weeks of insertion.
Implanted central venous catheter (ICVC, port a cath)		The implanted central venous catheter (ICVC) is inserted into a vessel, body cavity, or organ and is attached to a reservoir or “port,” located under the skin. The ICVC is also referred to as a port a catheter or port a cath. A surgical procedure is required to insert the device, which is considered permanent. The device may be placed in the chest, abdomen, or inner aspect of the forearms. It is often better for body image. The ICVC can be accessed using a non-coring needle. A patient may return home with this type of CVC.
Data source: Fulcher & Frazier, 2011; Perry et al., 2014

CVCs have specific protocols for accessing, flushing, disconnecting, and assessment. All health care providers require specialized training to care for, manage complications related to, and maintain CVCs as per agency policy. Never access or use a central line for IV therapy unless trained as per agency policy. For more information on CVC care and maintenance, see the suggested online reference list at the end of this chapter.

Health care providers should assess a patient with a central line at the beginning and the end of every shift, and as needed. For example, if the central line has been compromised (pulled or kinked), ensure it is functioning correctly. Each assessment should include:

• Type of CVC and insertion date: reason for CVC
• Dressing: is it dry and intact?
• Lines: secure with stat-lock, sutures, or Steri-Strips?
• Review: patient still requires a CVC?
• Insertion site: free from redness, pain, swelling?
• Positive pressure cap: attached securely?
• IV fluids: running through an IV pump?
• Lumens: number of lumens and type of fluids running through each?
• Vital signs: fever?
• Respiratory/cardiovascular check: any signs and symptoms of fluid overload?

See Table 8.4 for a list of complications, signs and symptoms, and interventions.