SAS 9: Parenteral Therapy

Ampul

a single-use container composed entirely of glass.

Cannula

a tube-like needle or catheter used to infuse parenteral fluids and medications into the vascular system or other body spaces.

Electrolyte

dissolved ions that include sodium, potassium, chloride, calcium, phosphate and others

Epidural

• the space superior to the dura mater of the brain and spinal cord and inferior to the ligamentum flavum

• outside the subarachnoid space where the CSF flows

Extravasation

inadvertent administration of vesicant medication or solution into the tissue

surrounding an artery or vein

Incompatibility

incapable of being mixed or used simultaneously without undergoing chemical or physical changes or producing undesirable effects.

Infiltration

the inadvertent administration of non-vesicant medication or solution into the tissue surrounding an artery or vein. It is an ADE unless it is intended.

Intrathecal

the space within the spinal canal.

Parenteral

intended for injection through one or more layers of skin or other external boundary tissue

Sharps

objects in the health care setting that can be reasonably anticipated to penetrate the skin and to result in an exposure incident

Standard Precautions

guidelines designed to protect workers with occupational exposure to blood borne pathogens

Total Parenteral Nutrition

• also known as hyperalimentation

• the IV provision of total nutritional needs for a patient who is unable to take appropriate amount of food enterally

  • carbohydrates

  • proteins

  • fats

  • electrolytes

  • vitamins

  • trace elements

Vehicle

water for injection (USP) is the liquid in which active ingredients are dissolved, suspended, or emulsified for most parenterals

Vial

a plastic or glass container with a rubber closure secured to its top by a metal ring.

Isotonic

concentrations of solute = blood plasma

Hypotonic

concentration of solutes < blood plasma

Hypertonic

concentration of solutes > blood plasma

Isotonic IV Fluids

• most IV fluids are isotonic

• expand both the intracellular and extracellular fluid spaces

• do not alter the osmolality of the vascular component

• total electrolyte content is approximately 310 mEq/L

• total osmolality is close to that of the ECF

• do not cause red blood cells to shrink or swell

Isotonic IV Fluids

• 0.9% NaCl (Normal Saline Solution, NSS)

• Dextrose 5% in Water (D5W)

• Lactated Ringer’s 5% Dextrose in Water (D5LRS)

• Ringer’s Solution

0.9% NaCl (Normal Saline Solution)

• crystalloid ; contains water, sodium (154 mEq/L), and chloride (154 mEq/L)

• osmolality = 308 mOsm/L

• no calories

• the % of NaCl dissolved in the solution is similar to the usual concentration of Na and Cl in the intravascular space

• the isotonic solution of choice for expanding the ECF because it does not enter the ICF

• administered to correct ECF volume deficit

0.9% NaCl (Normal Saline Solution)

• IV fluid used alongside the administration of blood products

• replace large sodium losses such as in burn injuries and trauma

• should not be used for heart failure, pulmonary edema, and renal impairment, or conditions that cause sodium retention

Dextrose 5% in Water (D5W)

• provides free water when dextrose is metabolized (making it a hypotonic solution), expanding the ECF and ICF

• supply water and correct an increase in serum osmolality

• should not be used for fluid resuscitation (can cause hyperglycemia)

• should be avoided in clients at risk for increased intracranial pressure (can cause cerebral edema)

Lactated Ringer’s 5% Dextrose in Water (D5LRS)

• also known as Ringer’s Lactate or Hartmann solution

• near-physiological solution of balanced electrolytes

• contains bicarbonate precursors to prevent acidosis

• does not provide calories or magnesium

• has limited potassium replacement

• the most physiologically adaptable fluid

  • its electrolyte content is most closely related to the composition of the body’s blood serum and plasma

Hartmann Solution

• correct dehydration, sodium depletion, and replace GI tract fluid losses

• used in fluid losses due to burns, fistula drainage, and trauma

• first choice for first-line fluid resuscitation of certain patients

• administered to patients with metabolic acidosis

• metabolized in the liver; thus, it should not be given to patients who cannot metabolize lactate

• used in caution for patients with heart and renal failure

Ringer’s Solution

• content is similar to Lactated Ringer’s Solution but does not contain lactate

• indications are the same for Hartmann’s solution but without the contraindications related to lactat

Hypotonic IV Fluids

• lower osmolality and solutes < plasma

• cause fluid shifts from the ECF into the ICF to achieve homeostasis

  • causes cells to swell (and may even rupture)

• total electrolyte content = <250 mEq/L

• provide free water for excretion of body wastes, treat cellular dehydration, and replace the cellular fluid

Hypotonic IV Fluids

• 0.45% NaCl

• 0.33% NaCl

• 0.225% NaCl

• 2.5% Dextrose in Water (D2.5W)

0.45% Sodium Chloride

• used for replacing water in patients who have hypovolemia with hypernatremia

• excess use may lead to hyponatremia due to the dilution of sodium

0.33% Sodium Chloride

• allow kidneys to retain the needed amounts of water

• typically administered with dextrose to increase tonicity

• used in caution to patients with heart failure and renal insufficiency

0.225% Sodium Chloride

• maintenance fluid for pediatric patients

• the most hypotonic IV fluid available at 77 mOsm/L

• used together with dextrose

2.5% Dextrose in Water

• treat dehydration and decrease the levels of sodium and potassium

• should not be administered with blood products (can cause hemolysis of RBC)

Hypertonic IV Fluids

• concentration of solutes > plasma

• cause fluids to move out of the cells and into the ECF

  • causes cells to shrink

• aka volume expanders as they draw water out of the intracellular space, increasing ECF volume

Hypertonic Sodium Chloride IV Fluids

• acute treatment of sodium deficiency (severe hyponatremia) and should only be used in critical situations

• infused at a very low rate (to avoid the risk of overload and pulmonary edema)

3% NaCl	513 mEq/L of NaCl osmolality = 1030 mOsm/L
5% NaCl	855 mEq/L of NaCl osmolality = 1710 mOsm/L

Hypertonic Dextrose Solutions

• isotonic solutions that contains 5% dextrose

• provide kilocalories for the patient in short term

Hypertonic Dextrose Solutions

• Dextrose 10% in Water (D10W)

• Dextrose 20% in Water (D20W)

• Dextrose 50% in Water (D50W)

D10W

• hypertonic

• treatment of ketosis of starvation and provides calories (380 kcal/L), free water, and no electrolytes

• administered using a central line if possible

• should not be infused using the same line as blood products

D20W

• hypertonic

• an osmotic diuretic

• causes fluid shifts between various components to promote diuresis

D50W

• treat severe hypoglycemia

• administered rapidly via IV bolus

Colloids

• contain large molecules that do not pass through semipermeable membranes

• for expanding the intravascular volume and raising blood pressure

• for patients in malnourished states and cannot tolerate large infusions of fluid

Colloids

• Human Albumin

• Dextrans

  • Low-molecular-weight

  • High-molecular-weight

• Etherified Starch

• Gelatin

• Plasma Protein Fraction

Human Albumin

• derived from plasma

• two strengths: 5% albumin and 25% albumin

• increase the circulating volume and restore proteins in conditions such as burns, pancreatitis, and plasma loss through trauma

• 25% albumin = used together with sodium and water restriction

• blood transfusion products

• contraindicated in the following:

  • severe anemia

  • heart failure

  • known sensitivity to albumin

  • ACE inhibitors (must be withheld for at least 24 hrs)

Dextrans

• polysaccharides that act as colloids

• available in either saline or glucose solutions

• interferes with blood cross-matching, so draw the patient’s blood before administering dextran

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Low-molecular-weight dextran (LMWD)	High-molecular-weight dextran (HMWD)
average MW = 40,000 improve microcirculation in patients with poor peripheral circulation no electrolytes treat shock related to vascular volume loss prevent venous thromboembolism in certain surgical procedures	average MW = 70,000 for patients with hypovolemia and hypotension
contraindications: thrombocytopenia hypofibrinogenemia hypersensitivity to dextran	contraindication: hemorrhagic shock

Etherified Starch

• derived from starch

• used to increase intravascular fluid but can interfere with normal coagulation

Gelatin

• lower MW than dextrans

• remain in the circulation for a shorter period of time

Plasma Protein Fraction (PPF)

• prepared from plasma and is heated before infusion (like albumin)

• infused slowly to increase circulating volume

Syringe

• a sterile, single-use device that has a Luer lock or non-Luer lock tip, which influences its name

• smaller volumes = SC and IM

• larger size = lower pressure flow

• 10 to 12 mL = central lines, catheters, medical tubing

• 20 to 70 mL = irrigation

Needles

• made of stainless steel, are sterile and disposable, and come in various lengths and sizes

• made up of the hub, shaft, and bevel

• bevel = tip of the needle that is slanted to create a slit into the skin

• hub = fits onto the tip of the syringe

• the gauge is the diameter; vary from very small dm (from 25 to 29 gauge) to large dm (18 to 22 gauge)

Needle Use

IV Push

• aka bolus

• rapid injection of medication

• syringe is inserted into the catheter to quickly send a one-time dose of drug in the bloodstream

IV Infusion

• controlled administration over time

  • Pump Infusion = attached to the IV line and sends medication and a solution into the catheter in a slow, steady manner (used when medication dosage must be precise and controlled)

  • Drip infusion = uses gravity to deliver a constant amount of medication over a period of time