INDICATIONS AND RATIONALES FOR IV THERAPY

The indications or rationales for using IV therapy fall into three categories: maintenance therapy, replacement therapy, and restoration therapy. Additional indications for initiating and maintaining restoration IV therapy include the establishment of access to a vein for administration of medications and fluids required to maintain fluid, electrolyte balance, or both and for administration of medications that cannot be ingested by oral route. IVs also provide a ready-available access for treatment by keeping the vein open. An IV that is administered at a very slow rate to maintain access to the vein is often referred to as keep open (KO) so it is available for immediate access for emergency situations or for administration of medications. This is important because it refers to the ability to have a route for medication administration when rapid response is required. Further indications include administration of blood and blood components, administration of chemotherapy, administration of anesthesia or diagnostic reagents, and administration of medication using a bolus or piggyback setup. IV administration of drugs and fluids is useful in patients who are unconscious or are unable to ingest food.

Maintenance therapy involves providing necessary nutrients for daily needs of water, electrolytes, and nutrition for the patients having reduced or no intake of oral fluids and nutritional elements. IV infusions provide a method for the health care provider to maintain hydration in the patient with dehydration from gastrointestinal disorders, such as diarrhea, and in those who cannot take fluids by the oral route. The maintenance of fluid balance is essential to maintain the body’s state of equilibrium.

Replacement therapy is indicated when the patient has experienced a deficit in the intake of fluids and nourishment, usually over a period of 48 hours or more. As previously mentioned in Chapter 2, a large part of the body’s fluid is water that is divided into two main compartments: intracellular and extracellular. To assist the body in the maintenance of homeostasis and fluid balance, IV fluids and electrolytes are administered.

The amount of water in the body is a response to fluid intake and fluid output. Normally, an average-size adult will have a daily intake of approximately 3000 mL of fluid. Many factors influence the normal intake of fluids, including the intake of liquids, the consumption of food, and the oxidization of nutrients during metabolism. Fluid output is normally about the same amount as the intake. Normally, body fluids are lost in urine, feces, perspiration, and respiration. Vomiting, diarrhea, hemorrhage, profuse sweating, and exposure to excessive heat may cause excessive fluid loss and consequent dehydration. During these processes, electrolytes also are depleted. When disease conditions and emergent situations are responsible for extensive fluid loss, fluid replacement must be accomplished by alternative means, usually IV infusion.

Restorative therapy involves daily restoration of fluids and electrolytes. Laboratory testing is necessary to determine the amount of electrolytes and fluids lost and what is required to replace them on a daily basis. Therefore, this therapy is most often performed in an inpatient setting.

In the event that medication cannot be administered orally, because of the inability to swallow the medication, the detremental effects of the gastrointestinal secretions, or the drugs, the IV infusion or injection becomes an essential route for the drug therapy. For any medication, including electrolytes, to be effective, it must reach the blood for distribution throughout the body. Oral medications are absorbed through the digestive tract, and parenteral medications other than those given intravenously cross tissue barriers before absorption. With IV therapy, these barriers do not exist and the entire amount of medication is distributed in the bloodstream immediately after administration. Thus, one of the major indications and advantages of IV therapy is the rapid absorption of medication, but this too could become a major disadvantage when errors or adverse reactions occur.

Certain drugs cannot be administered orally or by other routes. Contents of the gastrointestinal (GI) tract often interact with oral medications, rendering them less effective or useless. Others cannot be absorbed in the GI tract. Some patients are unable to take medications by mouth because of an inability to swallow or level of consciousness. Others may be vomiting or may be uncooperative and thus unable to have oral medications administered. IV therapy becomes an important asset for the health care provider and the patient to provide drugs in emergency situations and when rapid absorption of a medication is needed.

Common medications that are administered intravenously include antimicrobial agents such as cephalosporins, aminoglycosides, and penicillins. Other classifications of drugs that may be administered by the IV route include anticoagulants, antifungals, antiviral agents, bronchodilators, hypoglycemic drugs, insulin, immunosuppressants, biotherapy drugs, and neuromuscular blocking agents. Chemotherapy drugs may also be administered by IV therapy, usually as an infusion. Opioid drugs may be delivered in a bolus form for intermittent pain relief or continuous analgesia. Refer to Chapter 7 for more information about IV medication.

METHODS OF ADMINISTERING IV MEDICATIONS

IV therapy involves the administration of medications or drug therapy using the following methods: continuous infusion, either as intermittent infusion, bolus injection, or piggyback infusion. IV fluids themselves are considered a type of drug therapy in the form of isotonic, hypotonic, or hypertonic solutions. Additionally, chemical replacements such as electrolytes may be added to the solution to manage homeostasis and fluid balance. Medications such as bronchodilators or a hypoglycemic agent (insulin) may be added for administration at a controlled and slow drip rate. Narcotics used for pain relief may be added to the fluids for patient-controlled analgesia with the patient dispensing anesthesia as needed for pain relief.

Controlled drip rates, as ordered by the physician, must be maintained when medications are added to the primary bag of solution. This is a necessary action to prevent an overdose of the medication. Methods of controlling the drip rate are discussed in Chapter 4 under the discussion of equipment.

Bolus injections may be administered through an existing IV line or directly into a vein. Bolus injections are often drawn up in a syringe and administered through an access port by way of slow or rapid push. When giving the bolus into an existing IV line, the health care provider inserts the medication-filled syringe into the access port and pushes the plunger of the syringe at the prescribed rate. If a bolus injection is introduced directly into a vein, care should be taken to dilute the medications as indicated and provide at a rate necessary for patient safety. CAUTION: This type of IV medication administration is beyond the scope of an untrained health care professional. Physicians, paramedics, specially trained registered nurses, and radiology technicians are the health care professionals who administer drugs by the IV bolus push route. Refer to practice acts and legislation of your state and community and to facility guidelines found in the policy manual for information on administration by bolus push.

IV piggyback (IVPB) is a secondary set that is attached to the primary administration set. As previously mentioned, medications dissolved in the smaller amount of solution can be administered using this route without disconnecting the primary IV line. This type of administration is often used for dosages to be administered at regular intermittent intervals (i.e., every 8 hours). Different from IV bolus, IVPB provides medications that have been diluted but the ordered flow rate for the fluids must be carefully followed. Refer to Chapter 4 for additional information.

ADVANTAGES AND DISADVANTAGES OF IV THERAPY

Although IV therapy is often a necessary intervention in the treatment of a patient, the procedure carries some risk even when all precautions are taken and no break in sterile or medical aseptic techniques occur. The health care professional must be alert of possible complications at all stages of IV therapy. The inherent dangers and the methods that can reduce the complications of IV therapy are discussed as complications of IV therapy to follow. Individuals who are dehydrated; vomiting; experiencing electrolyte imbalance; unconscious; in shock; or unable to take medications, fluids, or nourishment orally benefit from IV therapy as fluids and electrolytes are replaced. The more rapid absorption of antibiotics and other medications is another advantage. Many antibiotics require specific blood levels to be maintained to reach optimum benefits. Other medications also often require that blood levels remain constant to be effective. Because of many factors, oral intake is not always the route that will achieve the constant levels required for maximum benefit to the patient.

DANGERS OF IV THERAPY

Most dangers are associated with human error, whereas complications are from the IV fluids. An obvious danger of IV therapy is the possible introduction of microorganisms directly into the bloodstream when aseptic technique is not followed precisely. Because fluids are introduced directly into the bloodstream for transport throughout the body, the strictest of aseptic techniques is necessary. Any possible loss of asepsis must be confronted and the equipment must be discarded to protect the patient. Remember sterility is not measured in degrees. Please refer to Chapter 3 on asepsis for additional information on the prevention of sepsis and the importance of sterile technique.

Other dangers include safety issues related to human errors that are associated with the medication calculations. Chapter 5 addresses the importance of calculating the correct dosage of medication for infusion. Review of basic concepts of infection control; correct dosage; and calculations, including of weight and volume of the metric system, are necessary for patient safety and the prevention of dangerous conditions. Information including the importance of the correct flow rate ensures that fluids are administered during the specific prescribed time. The use of the seven rights and three befores helps to ensure that the patient is receiving the correct medication, the danger to the patient is reduced, and patient safety is reinforced.

The health care professional has the responsibility of continually observing the infusion site and the patient’s general status to detect any complications that may arise and caring for these complications in a timely manner to prevent further insult. Patient safety must always be of primary importance. A discussion of complications and risks of IV therapy follows.

COMPLICATIONS OF IV THERAPY

Complications of IV therapy can be of different origins. They may be local at the infusion site or generalized and systemic. Local complications include mechanical problems such as infiltration into the surrounding tissue, a leak of fluid at the site, or a displaced catheter. Localized infection within the vein or phlebitis can result from a break in asepsis. Systemic complications include circulatory overload, phlebitis, thrombus formation, pulmonary embolism, air embolism, or generalized infection. The possibility of drug overdose and toxicity exists with the introduction of medication directly into the bloodstream. Because of the many chances of complications and possible dangers of IV therapy, careful monitoring of patients receiving medication is crucial. After the infusion is discontinued, possible complications may include bleeding at the site–excessive bleeding or even hemorrhaging–that demands prompt management. Mechanical problems related to the infusion system or trauma to the veins may be the causes of delayed local adverse reactions.

Local Complications

Local complications may occur at the initiation of the IV, during the IV infusion, and after the IV catheter or needle is removed. Some of the problems include infiltration of fluids into the surrounding tissues caused by improper placement of the needle, trauma to the vein on insertion of the needle, or leaving the tourniquet in place following the initiation of the flow of fluids.

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Pharmacology Related to Intravenous Therapy Introduction to Intravenous Therapy Review of Asepsis Review of Anatomy and Physiology Starting an Intravenous Infusion Review of Dosage Calculations

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