Which complication involves the entry of an IV solution containing a Vesicant drug?

Abstract

Administering intravenous (IV) fluid is one of the most common interventions in the intensive care unit (ICU). Although IV fluid can be used to replace free water, electrolytes, glucose, and plasma constituents (e.g., albumin), most IV fluid in the ICU is given to increase intravascular volume. Critically ill adults frequently experience either absolute hypovolemia (resulting from blood loss, diarrhea, decreased oral intake) or effective hypovolemia (increased venous capacitance resulting from sepsis, medications, adrenal insufficiency). IV fluid resuscitation can increase ventricular preload, cardiac output, and oxygen delivery, restoring hemodynamic stability and tissue perfusion. This chapter discusses the physiologic rationale for fluid therapy in the ICU; the volume, rate, and end points of fluid resuscitation; choice of fluid; and areas of ongoing controversy.

Oral Resuscitation

Intravenous fluids may be limited, and the victims may be advised to take oral fluids consisting of balanced salt solutions and maintain a large urine output. Studies in humans and animal models have shown that intestinal absorption remains intact in burn patients. Kramer et al. reviewed the use of oral resuscitation therapy in burn care and found 12 reports, most of which show equal outcomes to IV infusions. This solution should be readily available, cheap, easy to transport, and palatable (Table 41.5).28,29 A study published by one of the authors shows a reduction in IV fluid requirements by 58% on average when Parkland formula-driven protocols are supplemented with oral resuscitation (Fig. 41.1).30

Contamination

Intravenous (IV) fluid is typically composed of water containing various electrolytes, glucose, and occasionally other substances. Therefore, contamination of a specimen with this fluid falsely elevates concentrations of these analytes, but at the same time, contamination causes dilution of the specimen. Thus, values of analytes that are not present in the IV fluid should be decreased [47]. Skin antisepsis is typically accomplished with isopropanol or iodine compounds [3,48]. Isopropanol is generally recommended. The site should be allowed to dry for 30–60 s to minimize the risk of interference with alcohol assays. Iodine compounds have been noted to affect some assays and probably should be avoided for chemistry studies. In particular, povidone iodine can falsely elevate potassium, phosphorous, and uric acid in specimens collected by skin puncture [3].

Thermal Burns

Intravenous fluids and humidified oxygen via a nonrebreathing reservoir mask are a useful starting point, but early intubation is mandatory if signs of upper airway injury are present. Burn treatment includes moistening with cool sterile saline, open blister debridement, wrapping of single fingers and toes, cleaning of other parts with mild soap and gentle scrubbing, and partial thickness wound covering with antibiotic ointment.35 Escharotomy is needed in case of full-thickness neck burns, chest burns limiting respiratory excursion, and circumferential full-thickness burns involving extremities and the chest.36

Fluid and Electrolyte Management

IV fluids serve multiple purposes in the perioperative patient: they replace fluid losses, maintain tissue perfusion, and cover maintenance fluid requirements.54 Patients enter the surgical suite with fluid deficits from preoperative fasting and renal or gastrointestinal losses, more significant if a bowel preparation was administered. In patients undergoing ambulatory surgical procedures whose major fluid loss is from preoperative dehydration, maintenance fluid requirements should provide adequate hydration, and the child can resume oral rehydration once fully awake from anesthesia. Patients undergoing major abdominal surgical procedures, especially in the setting of bowel preparation, may present with significant dehydration. Working with the anesthesiologist to ensure adequate hydration overcomes the deficits incurred by general anesthesia and possibly third-space losses and losses from hemorrhage.

Postoperatively, standards for maintenance IV therapy are derived from studies examining weight-dependent metabolic rates among children. The most commonly used regimens are listed in Table 55-2. Additional fluids may be required to replace losses from diarrhea or nasogastric suction. Simply increasing the fluid rate may inadequately cover electrolyte losses specific to the fluid composition of gastric fluid and diarrhea. Gastric fluid is high in chloride content and low in potassium; diarrhea is high in potassium content and low in sodium and chloride concentration. Attention to these particular fluid losses may require an adjustment in the composition of the IV fluids.

Evidence suggests that the maintenance rate and electrolyte compositions shown may predispose patients to hyponatremia, hyperglycemia, and loss of core body temperature. The calculations listed in Table 55-2 overestimate the fluid requirements of the child and can potentially exacerbate hypotonic fluid-induced hyponatremia. This situation can be compounded by the postoperative syndrome of inappropriate antidiuretic hormone with an inability to concentrate urine. Although this condition is more common in cardiac surgery and neurosurgery, it can occur in patients undergoing urologic surgical procedures. Similarly, findings from randomized controlled trials suggest that physicians overdose glucose in maintenance fluids. Use of fluids with dextrose concentrations as low as 1% prevents hypoglycemia with reduced rates of the hyperglycemia associated with 5% solutions. Although no consensus has defined optimal maintenance IV fluids, recommendations for changes in standard regimens include the use of 2.5% concentrations of dextrose or lower and close follow-up of serum sodium concentrations in patients receiving maintenance IV fluids for an extended period of time.

Resuscitation

Intravenous fluids are required, with correction of electrolyte disturbances (particularly hypokalemia and hyponatremia). In the anemic or bleeding patient, blood is given. Hypoprothrombinemia is treated with vitamin K.

A central venous cannula is often inserted early in the patient's hospital stay. This is useful in the early resuscitation of hypovolemic patients, but more often serves as a route for hyperalimentation during the intensive medical treatment that follows, and in the early postoperative period if the patient requires surgery. Nasogastric suction is not used routinely but is employed if there is vomiting or the development of colonic dilatation.

Before administration

Intravenous fluids offer special scope for interactions (incompatibilities). Drugs commonly are weak organic acids or bases, produced as salts to improve their solubility. Plainly, the mixing of solutions of salts can result in instability, which may or may not be visible in the solution, i.e. precipitation. While specific sources of information are available in manufacturers’ package inserts and formularies, issues of compatibility are complex and lie within the professional competence of the hospital pharmacy, which should prepare drug additions to infused solutions. In any situation involving unfamiliar drugs their help and advice should be sought.

Abstract

Intravenous fluid delivery can be achieved from pressure generated by gravity, passive forces (spring, elastic), and active (electromechanical) means. The common mechanisms of operation of electromechanical pumps are peristaltic, cassette-based, and syringe-driven. Each have their own advantages and disadvantages, particularly related to accuracy at low flows and cost. Improving infusion safety, usability, and interoperability is a key driver behind modern infusion pump technology. While technologic safeguards increase safety of infusion delivery, there are still pump limitations and clinical best practices that are important to understand when using infusion pumps.

Intravenous Solutions Administered to the Patients

Intravenous fluids, drugs, and nutrition have become an indispensable part of modern therapy, and large quantities of commercially and locally manufactured fluids are used in treatment daily.47,48

In modern medical practice, up to 80% of hospitalized patients received intravenous (IV) therapy at some point during their admission.48 The parenteral route of administration is generally adopted for medicaments that cannot be given orally, either because of patient intolerance, drug instability, or poor absorption via the enteral route. In the unconscious patient, parenteral administration is the only safe and most effective means of administering medicaments through the IV route. Contamination of IV products is a recurrent problem and can have fatal consequences.

Microbial contamination of injections, infusions, and other fluids often results from poor sterilization management, inadequate analytical facilities, lack of properly trained personnel, obsolete equipment, inappropriate production environment, poor-quality packaging, or indeterminate errors during the quality control process.48–50

It has been reported that microorganisms can gain access to IV infusions during administration, by external sources of contamination such the influx of unfiltered air, the addition of drugs, and the migration of microorganisms through the cannulae of the administration set.48 Infusion fluids requiring compounding or the addition of medications to the fluid container were found to produce 7% of primary bloodstream infections when those fluids were prepared.51 The hands of health-care workers could be the major transmission vehicle and contamination is probably attributable to induction of needle puncture in the body of IV fluid bags by nursing staff.50 Parenteral nutrition and IV fat emulsions can become contaminated during preparation and infusion, with fungal pathogens,52 especially Candida species, which account for 20–30% of systemic infections associated with central venous catheters.53 C. albicans has the ability to either grow very well or sustain prolonged viability in all nutritional IV products and C. parapsilosis grows very well in parenteral solutions rich in glucose. Intraluminal spread of infection may also result from intrinsic contamination of the infusion fluids. Pathogenic fungi such as Aspergillus, Candida, Fusarium, and Paecilomyces have been isolated from “commercially sterile” fluids, with no visible fungal growth, suggesting that these products can be potential health hazards.50 Fungi may also contaminate intact bottles of fluid. The colony of fungus is usually found growing on the underside of the rubber stopper and may be very difficult to see on cursory inspection.47

Crystalloid Versus Colloid

Fluid infusion is best begun with boluses of 20 mL/kg isotonic saline or colloid, and initial volume resuscitation commonly requires 40 to 60 mL/kg but can be as much as 200 mL/kg.119,122,131,135–145 Of note, large volumes of fluid for resuscitation in children have not been shown to increase the incidence of acute respiratory distress syndrome122,146 or cerebral edema.122,147 The use of either crystalloid or colloid is acceptable, because three randomized controlled trials have compared the use of colloid versus crystalloid resuscitation in children with dengue shock and found no difference in mortality.144,145,148