Safe administration of intravenous fluids.
A sterile technique is necessary. A vein that is easy to feel and straight is selected.
The vein has to feel full, soft and easy to feel instead of hard and rubbery or inflamed or painful to touch. The selection should avoid a vein recently used (Safe administration of medicines, 1997). The infusion should be administered through the vein slowly or as a bolus push. For a continuous infusion, the emptying bags are changed with new bags without disturbing the site of venepuncture. Precautions needed when administering medicine require checking the medication order and whether it is compatible with the intravenous solution being administered (Safe administration of medicines, 1997). Labelling the bag with the patient’s name, medicine added and whether in correct dosage are important. The time the infusion was started, the flow rate and the nurse’s name are to be written on the bag. Checking for reaction to the administration of drug is essential. The drug given and time of administration need to be recorded. Adverse reaction is marked by a change in the pulse rate, chills, nausea, vomiting, headache or breathing problems. The medication is pushed into an already existing IV line (Safe administration of medicines, 1997)
A blood transfusion
Cross matched and compatible blood is transfused. A sample of the patient’s blood is sent to the laboratory for cross matching. When the blood for transfusion arrives, the bottle must be checked for the patient’s name, blood type and RH factor. If the information is the same, the blood may be transfused (Safe administration of medicines, 1997)
The patient’s vital signs are checked before starting. The blood must be started within 30 minutes of being brought to the ward in order to prevent infection. The drip chamber should be the type which filters clots. Transfusion is only compatible with normal saline.
(Safe administration of medicines, 1997). The patients must be observed at the start for 15 minutes. The sooner the reaction, the greater the severity. The transfusion is stopped and the doctor notified. If no reaction occurs, the vital signs are checked every fifteen minutes. The drip rate and details of the blood being given is recorded (Safe
administration of medicines, 1997)
Safe administration of cytotoxic drugs or chemotherapy
Management of central venous access.
The patency of this access has to be checked before and after administration of cytotoxic drugs. Initially a fluid is used through the access. Only on ensuring that it is patent and there is no extravasation should you start the drug (Ener, 2004). The flashback or aspiration when a needle is entered, the easy flow of fluid and the absence of swelling or pain or redness at the site confirm the correct positioning (Safe administration, GONG). A fresh site, not punctured within the previous 12hours, is selected, keeping free of joints or bony prominences. The side of dissection of the axillary lymph nodes is avoided as it would have impaired circulation. The smallest gauge catheter appropriate for and a vein large enough to cope with the volume of fluid administered are selected (Safe administration, GONG). Vesicants are not given into the cubital fossa through a peripheral cannula. The cannula must be secure enough not to get dislodged. The site of puncture must be in a site well visualized. This access is always the one used when continuous infusions of vesicant drugs are used (Safe administration, GONG)
Intravenous administration
This requires syringes and lines with Luer lock connections, lines having one-way or non return valves and add-a-lines. A 3-way tap (multiple access connection) is best used as a precaution to administer medicines in case of hypersensitivity reactions.
Before and after administration of cytotoxic drugs, the back-priming technique is used to check that the medicines had entered into the veins and not extravasated. Cytotoxic medicines are handled at waist level so that the best view is obtained and the chances of spillage are less (Safe administration, GONG). The patient is monitored carefully. After completion of administration, the equipment is disposed of intact into the bin for disposal. Hands must be washed to eliminate chances of hypersensitivity reactions in the nursing staff and contamination of other equipment (Safe administration, GONG).
Many cytotoxic drugs are vesicants. They cause blistering, pain, inflammation and then tissue necrosis. The result could be a dystrophy or atrophy or scarring or damage to nerves and muscles or loss of limb function. Extra caution needs to be taken when administering them (Safe administration, GONG).. Vesicant medicines should always be given before the non vesicant ones. Continuous infusions must be given through central venous access devices and short infusions through a fast flowing intravenous line (not infusion pumps). The nursing surveillance for the patient must last throughout the infusion (Safe administration, GONG).
Intact connection of the line
Occassionally inadequate surveillance on the part of the nurse can cause a great problem. Central venous lines are more used these days for providing total parenteral nutrition and central venous pressure monitoring (Ostrow, 1981). A discrepancy in the connection can lead to a fatal complication of air embolism. Leakage of fluid at the catheter site must be immediately attended to. Proper surveillance of the infusion period is extremely important. The air embolism occurs when an air bubble enters the systemic vein and travels to the heart through the vena cava and enters the right ventricle (Ostrow, 1981). The bubble of air hinders the pumping of the heart, reducing the output to the pulmonary vasculature. The large bubble becomes smaller ones and blocks
the pulmonary arterioles. The flow of blood into the body from the heart becomes
obstructed. Cyanosis occurs followed by syncope and the patient collapses. The central venous line which involves the use of a large needle allows large air bubbles to enter if care is not taken. The emergency procedure includes putting the patient in the Trendelenburg and left lateral positions and supplying oxygen. It is necessary to keep these patients under proper observation.
Reducing the cost of infusion treatment and providing a safer service.
Fairfax Hospital near Washington D.C. has a unique arrangement which drastically reduces the cost of treatment where infusions are needed (Poretz, 1991)
With close cooperation among the physicians, members of the hospital administration, nurses and pharmacists an infusion centre type programme was developed. Initially patients were admitted, given their infusions and discharged. Now they are getting their infusions as outpatient treatment. Criteria for admission include patient’s educatability, amenability of the disease to outpatient therapy, stability of the medical condition and absence of contraindications (Poretz, 1991). Personnel are trained in cardiopulmonary resuscitation. The centre caters to the comfort of the patient with private rooms , convenient examining rooms, chairs, television sets and phones. Ramps and ample parking are patient friendly. Adverse effects are few, 3 % each of rashes and diarrhea. Phlebitis was only 1%. 24 hour surveillance is done here (Poretz, 1991).
Hospital acquired infections in Intravenous administrations
Intrinsic contamination of fluids is rare, 1 in 1000 units ( Stamm, 1978).
Intrinsic contamination can occur due to cracks or holes in the container or faulty sterilization. Organisms responsible are Klebsiella, Enterobacter and Serratia and it would be a large infection.(Maki, 1976). Fever, chills and other symptoms would be seen. Phlebitis is common (50%). Mortality is 15 -20%. Extrinsic occurs in 5-10% of cases with infusion for less than 48 hours and in 15-20% cases where infusions last more than 48 hours (Stamm, 1978). In a small percentage, sepsis occurs. In both prompt remedial measures must be done. All hospital patients harbour organisms. Some may be pathogenic to other people. Isolation of organisms in staff should not cause alarm and must be corroborated with evidence (Hargiss and Larson, 1981).
Complications seen in intravenous administration of fluids
Modern day medical practice invariably uses intravascular catheters especially in the Intensive Care Units. The risk of local and systemic complications, local wound site infection, septic thrombophlebitis, catheter related blood stream infections(CRBSI) , endocarditis and other metastatic infections like osteomyelitis, lung abscess, brain abscess and endophthalmitis does occur occasionally (O’Grady, 2002), more in the ICU setting. The central venous access may be required for long periods, patients may be harbouring hospital-acquired infections and the catheter may be frequently manipulated for the administration of drugs, blood and fluids. Sometimes catheters may be hurriedly placed in an emergency and caution on asepsis is thrown to the winds (O’Grady, 2002). Occassionally catheters maybe frequently tampered with to obtain samples for analysis. In the United States, 15 million CVC days occur in the ICUs alone. About 80000 CRBSI occur in US. Mortality is increased and resources expended. Strategies to prevent the infection rates and to reduce health care costs must be implemented. Different catheters have different types of complications (O’Grady, 2002).
How to reduce catheter related infections.
Having ‘Specialised 4’ teams is the best technique to reduce the incidence of catheter-related infections. Associated complications and effective costs are simultaneously reduced. Risk is further decreased by reduction of nursing staff too (Soifer, 1998)
Extravasation
Extravasation of vesicant cytotoxic drugs in to the subcutaneous tissues
is one of the most disastrous of reactions that can occur during administration of intravenous chemotherapeutic agents. Different drugs cause varying degrees of local tissue injury. Incidence of extravasation in systemic infusional chemotherapeutic agents is 0.1-6.5% of cases (Ener, 2004). Most extravasations can be prevented by careful administration techniques and closely adhering to the guidelines for administration of vesicant drugs. Apart from the systematic maintenance of intravenous lines, application of local cooling or warming for different extravasations, the use of antidotes to prevent the local toxic action make up the basis of medical management.
Extravasation is recognized by the pain 1-2 weeks after the drug administration and localized tissue inflammation going onto full thickness necrosis and ulceration (Ener, 2004). Sloughing of the skin and underlying structures occur. The degree of destruction will depend on the health of the local tissue and concentration and volume of the vesicant drug. The healing process takes months (Ener, 2004). Plastic surgery may have to be done to remove the trapped drug and for skin grafting.
Some chemotherapeutic drugs bind to the anthracyclines, the nucleic acids in the DNA. These are absorbed initially leading to direct cell death or endocytolysis. Then the death of the surrounding cells occurs by the release of the drug from the dead cells (Ener, 2004). The repetition of the process impairs healing and leads to vast necrosis. Drugs like doxorubicin can be detected in the skin months afterwards. Less irritant drugs undergo metabolism and the tissue damage is limited.
The central venous access devices that are used now are fairly better than olden days’equipment. They are the subcutaneously implanted ports or peripherally inserted central catheter lines. However they still cause leakage due to catheter separation from the port, a nick in the outflow catheter, a rupture in the port septum, excessive back pressure around the needle due to a fibrin sheath at the outflow tip of the catheter, incomplete or no penetration of the needle through the port septum or retraction of the catheter tip from the vein. Extravasation injuries can even invite litigation problems (Schulmeister, 2008). Proper documentation on all aspects of the administration should be made by the nursing staff in charge.
Phlebitis in Infusions
A survey done by Isabel Kay and Sally S.Roberts (1967) showed that one out of five patients receiving intravenous fluids developed phlebitis. 974 infusions were given . Of these 17% (167) had phlebitis. This survey included the use of the regular catheter, radio-opaque catheter, buffalo needle, Rochester needle, straight needle and scalp vein needle. There was a suggestion that a particular type of radio-opaque catheter produced less phlebitis than the regular plastic one (18.3%). However the radio-opaque catheters produced 23% of phlebitis. Phlebitis occurred not because of bacterial invasion (Kay and Roberts, 1967). Many patients had to have their infusion restarted for various reasons. They were the ones who had more phlebitis. The incidence of phlebitis was directly proportional to the number of injections received. Phlebitis was also seen in longer lasting infusions. This study suggested that phlebitis occurred due to a mechanical reason rather than bacterial (Kay and Roberts, 1967).
References.
Ener, R.A.; (2004), “Extravasation of haemato-oncological therapies” Annals of
Oncology, Vol 15. Pgs 858-862, 2004, European Society for Medical Oncology.
Hargiss, Clarice O. and Larson, Elaine ; (1981), “Guidelines for prevention of hospital
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Kay, Isabel and Roberts, Sally S.; (1967), “Infusions and Phlebitis”, The American
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Infections”, Clinical Infectious Diseases, Vol. 35, No.11, pgs. 1281-1307,
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Ostrow, Lynne Stanton, (1981), “Air embolism and central venous lines:, The American
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Poretz, Donal M.; (1991), “ The Infusion Centre: A model for outpatient parenteral
antibiotic therapy”, Reviews of Infectious Diseases, Vol.13, Supplement 2, The
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Safe administration of cytotoxic medications, Gippsland Oncology Nurses Group,
http://www.gha.net.au/Uploadlibrary/393586908safeadmin_cytotoxic_guidelines
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http://www.wpro.who.int/NR/rdonlyres/8AD3E358-AD6C-46CA-9E27-
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