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Intravenous therapy Introduction Administering medications and fluids via intravenous route has become common In the pediatric setting. Intravenous injections are the most effective way for quick response and are the only acceptable route for some drugs. They also provide less traumatic administration. Purpose of IV therapy To maintain fluid and electrolyte balance To administer antibiotic therapy To provide nutritional support To administer anticancer drugs To administer pain medications Candidates for IV medication administration Children with poor absorption due to vomiting or diarrhea Children who require higher serum concentration in a short period of Time eg; sepsis, meningitis etc) Children with resistant infections who require IV medications over a long period Children with acute problems Children who require continuous pain relief Intravenous access Intravenous therapy can be administered via peripheral catheter, peripherally Inserted central catheter or central catheter. Common and easy access is via peripheral catheter. Guidelines for selection of IV site and catheter 1. The rate and type of fluid to be infused, the projected length of time and availability of veins determine the site selection in children. 2. Consider the developmental level. The placement of an IV line in the toddler’s foot will inhibit the child’s walking which is a newly acquired skill 3. Avoid inserting IV line into a dominant hand if possible, because it interferes with activities of daily living.Also; avoid insertion into antecubital fossa as it restricts movement. 4. Scalp veins are sometimes used in children. Scalp veins have no valves and can be used in either direction.iv catheters can be secured to allow infant to move without dislodging the catheter. 5. Vein size and type of fluid to be infused or the nature of medication to be injected often guides the selection of catheter. 1 6. Generally the smallest catheter through which fluids and medications can be safely infused should be used. A 20 to 24 gauge provides adequate access. 7. IV fluids are infused through over the needle catheter or butterfly cannula, preferably over the needle catheter. Guidelines for IV medications 1. Properly dilute the medication using the package directions 2. Check the length of time over which h it is safely administered 3. Check compatibility of different medication and fluids 4. Assess cumulative effect of drugs 5. Consider the rate of infusion the child may tolerate 6. Assess IV site prior to infusion 7. Medication labels to be placed on the IV bag, tubing.buretrol and infusion pump to indicate that medicine is added 8. Follow IV medication with appropriate flush solutions to ensure that all medication has been infused 9. Use an IV pump whenever possible to ensure a constant rate of drug infusion Calculating the daily maintenance fluid requirement The daily fluid requirement is calculated on the basis of body weight Up to 10 kg 10-20 kg More than 20 kg 100ml/kg body weight 1000ml+50ml/kg for each additional kg 1500ml+20ml/kg for each additional kg over 20 kg To determine the hourly rate divide the daily requirement by 24 Example: the daily maintenance fluid requirement for a child weighing 15 kg is 1000ml for the first 10kg +50ml/kg for each kg between 10-20 kg =1000+ (50 X 5) =1000+250=1250ml/day Hourly rate =Daily amount = 1250 = 52mls/hr ---------------- -----24 hrs 24 Commonly used administration sets 1. Burette set-macro drip---15drops/ml 2. Solusetmicro drip---60 drops/ml 3. Hemoset 10drops/ml 2 4. Syringepump /infusion pump Calculating the infusion flow rate Using the drop factor method Flow rate =total volume of infusion X drop factor --------------------------------------------Time of infusion in minutes Example: a 2 year old infant is ordered 200 ml of DNS to be infused over 8 hours using soluset. Calculate the rate of infusion/hr Flow rate=total volume of fluid X drop factor -------------------------------------------Time in minutes Flow rate = 200 X 60 -------------= 25 drops/minute 8 X 60 Equipments for IV therapy 1. Local anaesthetic: Topical agent like EMLA cream, Numby Stuff, or injectable buffered lidocaine unless in emergency 2. IV catheter of appropriate size and length 3. Tourniquet or rubber band 4. Nonsterile gloves 5. Alcohol swab 6. Sterile saline filled 3 ml syringe 7. Short T infusion primer set 8. Dressing material: cotton or gauze and tape, semipermeable transparent dressing 9. Heparinised saline if heplock to be used 10. Prescribed IV fluid 11. IV tubing 12. Infusion pump 13. Material to secure line: tape, secure lock device, surgical net, padded arm board Procedure Steps rationale Check the physicians order for IV fluids/ Prevent medication errors 3 Medication, verify the accuracy Identify the patient by ID band Identify the vein and insertion site. Apply EMLA cream 1 hour before venipuncture Wash hands Assemble equipments Prime T infusion set with sterile saline and Keep syringe attached to primer set Prepare infusion pump if needed and prime with IV fluid Prepare the IV medication if any according to instruction Prepare for the IV therapy in the medication room Take the equipments to the bedside Put on non sterile gloves Apply tourniquet above the proposed site For scalp veins in infants a large rubber band around the head with a gauze pad under the band Cleanse the area around insertion site with antiseptic swab in circular motion If local anesthetic is used clean with soft cloth before cleaning with alcohol swab Hold extremity of insertion with Non dominant hand. Using dominant hand remove the protective sheath over the catheter and puncture skin at a 45 degree angle with the bevel up, parallel to vein Reduce the angle of the catheter needle Insert 1/8 to ¼ inch into vein until blood appears in the catheter Release tourniquet Advance catheter into vein while gently Removing inner needle from catheter, Leaving only catheter in place Stabilize the catheter with non dominant Hand and connect primed extension tube to Hub of the catheter Initiate flow and assess for signs of Prevent administration to wrong patient Reduce pain during insertion Reduces transmission of infection Efficient and quick insertion Prevent air embolism Prevents anxiety due to the sight of needle Standard precaution Increase venous pressure and Better visualization of the vessel Decrease number of organisms Keeps the extremity steady Allows insertion into lumen without puncturing the posterior wall of the vein Prevents rupture of vein Establish catheter in place Provides direct entry for IV fluids and assesses patency of catheter 4 Infiltration Secure catheter with gauze and tape or Semipermeable transparent dressing Connect the extension to the IV tubing Begin IV fluids/ IV medication. Heparin lock or saline lock for intermittent delivery Secure line with additional tape and arm board Label the site with date time and initials of person Discard used supplies Remove gloves and wash hands Comfort the child Record the procedure according to hospital Policy Prevents accidental dislodgement Transparent dressing provide better visualization Prevent accidental dislodgement Identifies proper change timings Standard precaution Prevents transmission of infection Reduce the effect of painful procedures Prevents duplication and is legal document Maintenance of infusion Assess the IV site every hour for complication Discontinue if indicated Hang no more than 4 hours of fluids at any one time during infusion.Use volume control chamber Change IV tubing using aseptic technique every 72 hrs or when contamination is suspected Label tubing with date time and initials of person who hung the tubing Change IV site dressing when the site is soiled damp or loose using aseptic technique Label the dressing with date time and initials of person who did the dressing Removal of peripheral IV catheter Wash hands Collect all equipments Explain the procedure Put on non sterile gloves Close clamp on IV set and extension Remove tape and dressing from site Ensures early detection of complication Prevents accidental overload Limits bacterial contamination Identifies proper change timings Limits bacterial contamination Identifies proper change timings Reduce transfer of organisms Reduces anxiety Standard precaution Stops flow and prevents potential infiltration while removing Allow access to site 5 Using gauze pad, apply slight pressure over insertion site while withdrawing catheter Apply pressure over the site after catheter is removed for 1-2 minutes Remove gauze, assess for bleeding, infection infiltration or phlebitis Apply bandage over insertion site Discard used supplies Remove gloves and wash hands Comfort the child Prevents bleeding Ensures detection of complication Standard precaution Prevents transmission of infection Reduce the effect of painful procedures Record the procedure according to hospital Policy 6