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IV study guides

STUDY GUIDE IV THERAPY – WINTER 2010

1. KNOW HOW TO CALCULATE FLOW RATE, DRIP RATE, TIME OF INFUSIONS, ETC.
(it’s basic algebra. I think it all makes sense when given a problem…less so in words, though)
Flow Rate (ml/min): Volume to be Infused (ml) x Drop Factor (drops/ml)
Infusion time (min)
Drip Rate: = Flow Rate expressed as drops/min
Infusion Times (just rearrange the equation)

*”Be sure you understand how to move back and forth between ml/time and drops/time for the Final Exam” (use the drop factor, which is drops/ml, and multiply or divide as required to make your units work out.)

2. KNOW HOW TO CALCULATE OSMOLARITY
Osmolarity is total mOsm of solution (mOsm) x 1000ml = ____ mOsm/L
Total volume (ml) 1L

3. KNOW SIGNS & SYMPTOMS OF IV COMPLICATIONS. BE ABLE TO RECOGNIZE POTENTIALLY EMERGENT SCENARIOS IN PATIENTS RECEIVING IV THERAPY, E.G., WHAT WOULD DEVELOPMENT OF A CATHETER EMBOLUS LOOK LIKE?

COMPLICATIONS OF IV’S –Local and Systemic
LOCAL COMPLICATIONS:
1. ECCHYMOSIS
HEMATOMA: Localized mass of blood outside the vessel wall
Causes:
1. Nicking vein during venipuncture; puncturing posterior vein wall
2. DC IV cannula/needle without pressure over site and
without adequate amount of time – at least 30 seconds
3. Applying a tourniquet too tightly, over previously attempted venipuncture site
Signs and Symptoms:
1. Discoloration at site, due to infiltration of blood into tissues at VP site.
2. Site swelling and discomfort
3. Inability to advance catheter into vein
Prevention:
1. Use indirect method for starting IV – the VP is done in 2 stages – skin 1st, then the vein.
2. Apply tourniquet just before venipuncture
Treatment:
1. Apply pressure after catheter/needle removed
2. Elevate extremity above the patient’s head to maximize venous return
3. Apply cold pack to site.

2. THROMBOSIS: Trauma to the endothelial cells of the venous wall causes platelets to adhere
to the vein wall leading to a formation of a clot.
Signs and Symptoms:
1. Pain at the site
2. Site warm to touch
3. Sluggish or no infusion rate
Causes:
1. Blood backing up into the system; especially in pts. with HTN.
2. Low IV flow rate limiting fluid movement
3. Location of IV
4. Obstruction of flow rate
5. Attempt at restarting fluid flow rate, after IV tubing dry for extended period of time
6. Trauma to wall of vein by the cannula
Prevention:
1. Manage flow rate
2. Check IV often
3. Choose micro drip tubing of 60 gtts/ml
4. Avoid joint flexion areas for IV placement
5. Use filters
6. Avoid cannulation of lower extremities
Treatment:
1. DC IV and restart a new one (different arm is preferable)
2. Apply cold compress
3. Refer for meds such as urokinase.

3. PHLEBITIS: Inflammation of the intima of a vein due to mechanical, chemical injury or bacterial
infection.
Signs and Symptoms:
1. Redness at the site
2. Local swelling, pain
3. Palpable cord along vein
4. Site warm to touch
5. Sluggish infusion rate
6. Increased temperature
Causes:
1. Trauma to the vein with cannula/needle – mechanical phlebitis
2. Irritation due to type of fluid infused – chemical phlebitis
3. Introduction of pathogens related to contaminated needle/site prior to insertion – bacterial phlebitis
Prevention:
1. Don’t use a larger than necessary needle
2. Stabilize IV well
3. Dilute IV solution appropriately, or use larger veins for hypertonic solutions
4. Don’t infuse IV too rapidly
5. Use inline filters – 0.22 microns
6. Use appropriate pH for IV solutions
7. Use sterile technique/hand washing
8. Rotate IV site every 72 hours
Treatment:
1. Stop IV
2. Apply hot/cold compress

4. INFILTRATION: A seepage of non-vesicant IV fluid/medication into surrounding tissues
Causes:
1. Puncture of distal vein wall upon insertion of needle
2. Dislodgment of cannula
3. Phlebitis
Signs and Symptoms:
1. Coolness of the skin around the site
2. Taut skin
3. Edema
4. Pain
5. Backflow absent
6. Infusion rate slowing, but continues to infuse
Prevention:
1. Make sure IV is in vein before infusing IV
2. Stabilize IV well with tape
3. Check IV frequently
Intervention:
1. Stop IV immediately and remove IV
2. Apply ice if infiltration was detected within 30 min., otherwise apply warm compress
3. Elevate site above heart level

5. EXTRAVASATION: Infiltration of a vesicant solution into the tissues
Signs and Symptoms:
1. Edema, taut skin at VP site
2. Formation of blisters and subsequent sloughing of tissue leading to necrosis
3. Pain or burning at site
4. Infusion stopped or slowing
5. Skin blanching or coolness
Prevention:
1. Choose best site for IV i.e.: avoid antecubital space for long-term therapy
2. Secure the cannula/ needle well
3. Avoid rapid infusion
4. Dilute medications
5. Check IV site frequently
6. Make sure you are in the vein before infusing
a. with use of a syringe draw back on needle to check for blood return
b. lower bag and check for back flow of blood into tubing

6. INFECTION AT INSERTION SITE:
Causes:
1. Site not cleaned well enough
2. Needle/cannula contamination
Signs and Symptoms:
1. Pain and tenderness at site
2. Redness at site
3. Swelling at site
4. Possible increased WBC count and fever
Prevention:
1. Aseptic technique
2. Use of anti-microbial ointment at VP site
Treatment:
1. DC the IV
2. Culture needle of catheter, and the insertion site if you observe purulent material
3. Clean site and apply anti-microbial ointment

7. VENOUS SPASM: Vein spasm during insertion of IV and during or after infusion of fluid
Causes:
1. Patient mental anxiety
2. Difficulty inserting cannula/needle
3. Irritation of tunica intima by fluid infused
Signs and Symptoms:
1. Difficulty locating vein after insertion of cannula/needle
2. Pain at site; may travel up the arm
Prevention/Treatment
1. Warm IV site
2. Dilute any medication used
3. Slow IV drip rate
4. Use warm pack prior to IV insertion
5. Release and reapply tourniquet


SYSTEMIC COMPLICATIONS
1. SEPTICEMIA: General systemic infection with chills and fever
Causes:
1. Poor aseptic technique
2. Pathogens entering at IV site
3. Contaminated IV solutions or medications
4. Host factors: age, underlying illness, decreased immune system function
Signs and Symptoms:
1. Abrupt increase in patient temperature; profuse cold sweat
2. N/V/D
3. General malaise
4. Abdominal pain
5. Tachycardia
6. Hypotension
7. Tachypnea
Prevention:
1. Good technique – wash hands vigorously for > 15 seconds and properly prepare VP site
2. Check all equipment and solutions for contamination
Treatment:
1. Restart IV, preferably in opposite extremity
2. Obtain cultures of administration set, IV container, catheter tip, site and blood
3. Initiate anti-microbial treatment
4. Monitor patient closely


4. KNOW EMERGENCY TX FOR IV COMPLICATIONS

EMERGENCY PROTOCOLS FOR IV THERAPY
OBJECTIVE: to recognize the most common emergencies that may occur when administrating IV therapy
PREVENTION:
1. Know your patient well. How they react to new situations, allergies, and medical conditions.
2.Have appropriate medical equipment available: oxygen tank and mask/cannula, airways, epinephrine, smelling salts, glucose, homeopathics
3. Always take VS before, during, and after the treatment. This allows you to be aware of changes.
4. Never take the IV out if the patient has had a reaction until you are sure they are stable.
Hep lock the site.
5. Be current with CPR
a. Start with the basics:
Survey the scene - What has occurred?
Primary survey
1. Airway
2. Breathing - look, listen, and feel
3. Circulation - carotid artery check 5-10 seconds

CALL EMERCENCY MEDICAL SYSTEM (EMS) 911

DIFFERENTIAL DIAGNOSIS IN EMERGENCIES:
1. Cardiac Emergencies:
CHF: Indicated by fluid overload. A chronic condition that may be aggravated by IV
Therapy.
Symptoms:
Anxiety
Diaphoretic, cold & clammy
Agitation,
Cyanosis
Air hunger
Dizziness
Rapid respiratory rate (tachypnea)
Distended neck veins.
Treatment:
Digitalis
Diuretics (herbal if time)
CHF continued:
Oxygen 10-15 L/min
REFER FOR MONITORING AT THE NEAREST HOSPITAL

ANGINA: Secondary to vasospasm of coronary arteries.
Causes:
Electrolyte imbalance
Cardiac disease
Anxiety.
Treatment:
Nitroglycerin (NTG)
Reestablishing fluid balance and correcting electrolyte imbalance
Addressing the stress issue
Homeopathics and botanicals
CARDIAC ARREST: Absent or inadequate ventricular contraction that immediately reulst in systemic circulatory failure.
Causes:
Electrical dysfunction
Mechanical failure
Circulatory shock
Abnormalities in ventilation
Symptoms:
Loss of consciousness
Rapid, shallow breathing leading rapidly to apnea
Nonpalpable pulses
Absent heart sounds
Treatment:
Call 911
External electronic defibrillator is treatment of choice
CPR

2. Respiratory Emergencies
Asthma: a disease of pulmonary obstruction
Causes:
Inflammation and edema due to allergens or viruses
Exposure to cold
Anxiety
Symptoms:
Decreased breath sounds, or expiratory wheezing.
Anxiety makes it worse.
Treatment:
IV magnesium can be a good treatment.
Hydrotherapy, diet changes, botanical, homeopathics etc….
Anaphylaxis: Uncommon with nutritional IV therapy using substances normal to the body, e.g., vitamins, minerals, amino acids. Exception is parenteral thiamine (rare). Glandulars, alpha lipoic acid, and potentially with botanicals (rare).
Cause: A type 1 immune reaction (“immediate hypersensitivity”) that occurs within 1-10 minutes of re-exposure to antigen. Initial exposure to antigen “sensitizes” the patient; re-exposure to the same antigen produces anaphylaxis
Symptoms:
Coughing, sneezing
Dyspnea
Restlessness, palpitations, throbbing sensation in ears
Airway obstruction
Urticaria, pruritis
Vascular collapse
Treatment:
Immediately administer 0.1 to 0.5 mL of Epinephrine 1:1000 dil. SQ or IM. Can repeat in 15-20 min.
Benadryl 25-50 mg capsule
Assess airway
Monitor Vital Signs
O2.
Don’t send home until after several hours of observation.
If not responding transfer
Call 911

Angioedema:
Causes:
Respiratory arrest
Shock
Cardiovascular collapse
Treatment:
Call 911.
Monitor VS
Oxygen

Respiratory arrest: Absence of spontaneous ventilatory movement in an unconscious person.
Causes:
Airway obstruction: emboli, foreign body, tumor etc.
Pulmonary hemorrhage or edema
Pulmonary bronchospasm throughout (severe)
Spasm or edema of the vocal cords
Laryngeal and pharyngeal inflammation
Respiratory weakness
Fluid and electrolyte imbalance/pH imbalance
Secondary to cardiac arrest
Symptoms:
Decreased sensorium, weak, feeble
Irregular or gasping respirations
Tachycardia
Diaphoresis
Treatment:
Airway obstruction foreign material – Heimlich manuever
Lung auscultation
If no airway obstruction-correct as below
Lower airway obstruction-give epinephrine for bronchodilation
Dose of epinephrine 1:1000 dil. Administer 0.3-0.5 cc. SQ
O2 by mask or cannula
Caution with O2 administration in COPD. More than 2L/min for prolonged periods will cause reparatory acidosis and respiratory arrest

Pulmonary embolism: sudden blockage of pulmonary artery or one of its branches
Cause:
Blood clot or fat clot
Symptoms:
Sudden onset of severe unexplained dyspnea
Chest pain
Tachycardia
Hypotension
Treatment:
Call 911
Keep patient sitting up right
Give O2 by mask,
Maintain IV site
Transport to hospital.
.
Nutrient Reactions:
Causes:
Magnesium overdose may result in respiratory arrest
Potassium may lead to arrhythmias.
Treatment:
Antidote for magnesium - use calcium gluconate.
For Potassium, monitor serum levels.

Air Embolism:
Air introduced into the vascular system via IV equipment. Embolus is carried to the right ventricle where it lodges against the pulmonary valve and blocks the flow of blood from the ventricle into the pulmonary arteries. This requires at least 30 cc of air.
Cause:
Allowing IV bag to run dry with a pump continuing to operate
Infusing air from tubing into patient usually requires some mechanism greater then gravity to push it in
Loose tubing connecting to site into patient allowing air to enter
Symptoms/Signs:
Palpitations, light headedness, weakness
Dyspnea, cyanosis, expiratory wheeze, tachypnea, pulmonary edema
Weak thready pulse, tachycardia, hypotension, substernal chest pain, jugular vein distention
Confusion, anxiety, seizure, coma
Treatment:
Place patient in L lateral decubitus with head down (Trendelenburg position)
O2
VS
Transfer to hospital and contact ER doc (doc to doc)
Prevention:
Clear air from tubing, avoid letting the tubing run dry
Check all tubing connections tape if need be
Use of luer lock
Use of 22 micron air eliminating filter

Catheter Emboli:
Cause:
An over the needle system that has a part of the cannula nicked and sheared off
Symptoms:
Sudden sharp pain at IV site
Cyanosis
Hypotension
Weak rapid pulse
Treatment:
Stop infusion
Apply tourniquet above IV site
Start a new IV in other arm
Arrange for an x-ray
Prevention:
Never re-insert a needle in a catheter after removal
Always use radiopaque catheter so that the catheter can be detected by x-ray
Withdraw needle with catheter together if unsuccessful venipuncture

Circulatory Overload: Excess fluid in the patient’s circulatory system
Causes:
Too much volume
Wrong type of solution (e.g., excess sodium)
Too rapid an infusion
Symptoms/Signs:
Rapid respiratory rate (SOB)
Anxiety or restlessness
Distended neck veins
HTN
Rise in central venous pressure
Late signs: Weight gain, edema, puffy eye lids
Treatment:
Decrease IV rate
Raise head and chest area
VS hourly
O2
Keep patient warm – increases peripheral circulation
Consider diuretic – if needed
Prevention:
Monitor infusion rate closely
Know your patients health history
Monitor I&O
Do not “catch up” IV if infusion if hours behind

Speed Shock: Occurs when a foreign substance is rapidly introduced into the system (usually medication).
Causes:
Too rapid an IV push
Medication not properly diluted
Symptoms / Signs:
Dizziness
HA
Tightness in chest
Hypotension
Irregular pulse
Progression of shock
Treatment:
Give antidote or resuscitation medications as needed
Have emergency equipment available
Prevention:
Reduce the size of drops of medication by using a micro drip set
Monitor piggy back solutions closely
Following manufactures advice on how to administer medication
Know what you are giving – and know it well

Syncope (fainting):
Causes:
Impaired circulation,
Decreased cardiac output/Perfusion
Vaso-vagal spasm
Orthostatic hypotension
Hypoglycemia
Hyperventilation.
Treatment:
Lie horizontal
Raise legs
Break ammonia capsule under nose (smelling salts); if awake: rescue remedy
Re-orient patient
Be patient and reassuring
Note: can occur rapidly

Hyperventilation Syndrome:
Causes:
Anxiety states
Carpopedal spasms-a classic symptom
Symptoms:
Good clear breath sounds
Rapid breathing
No cyanosis
Treatment:
Breathe into brown paper bag
O2

Vaso-vagal Episodes: Oonset from fright, pain or trauma (reflex inhibition of sympathetic activity)
Causes:
Increased thoracic pressure
Sensitive carotid sinus mechanism
Petit mal or grand mal seizures
Hypoglycemia
Other concurrent drug therapy (anti – Hypertensives)
Hyperventilation
Symptoms:
Early: Nause, weakness, yawning, blurry vision, sweating
Faintness, dizziness, or lightheadedness indicate progression toward full syncopy
Patient may state that they feel they are going to pass out
Pale face with diaphoresis
Classic drop in BOTH blood pressure and pulse.
Treatment: according to cause
Trendelenberg position (feet higher than heart)
Oxygen 1-2 L
Rescue Remedy: 1-2 dropperfuls prn
Pressure on Frenulum
Appropriate homeopathic (see handout)

Psychogenic States:
Causes:
General anxiety states with apprehension and aversion to needles
Breath holding or shallow breathing (often fear based)
Symptoms:
Light headedness
Visual changes

Shock:
Causes:
Loss of fluids with a result in cardiovascular collapse and hypoxia
Hemorrhage internal or external
Vomiting and or diarrhea
Pump failure- CHF, heart block, reduced perfusion
Causes (continued):
Psychogenic fear/trauma
Angioedema with third spacing of fluid

Symptoms/signs:
Dizziness
HA
Tightness of chest
Hypotension
Increased pulse
Progression of shock
Treatment:
Give antidote or resuscitation medications as needed
Have emergency equipment available
CALL 911

Hypoglycemia:
Causes:
Dysglycemia
Insulin overdose
Fasting
Glucose shifts secondary to IV treatment (Vitamin C)
Symptoms:
Often pale
Diaphoretic
Syncope
May see personality changes
Unsteady gait when standing
Diplopia
Reminder: Anxiety can heighten a hypoglycemic state.
Treatment:
Fruit juice
IV dextrose
Prevent by having patient eat prior to appt., and bring snacks to eat during long IV treatments. Meals and snacks with high protein content are most helpful.

Summary of vital sign changes:
Shock
BP decreased
Pulse increased
Vaso-vagal Reaction
BP decreased
Pulse decreased
Anxiety States
BP slight increase
Pulse increased
Speed Shock
BP decreased
Pulse irregular


5. BE FAMILIAR WITH EMERGENCY PROCEDURES,(see above) AND BE SURE TO PAY ATTENTION TO EPINEPHRINE DOSING.
EPINEPHRINE HYDROCHLORIDE (ADRENALIN)
1:1000 solution contains 1mg/mL of epinephrine; 1:10,000 has 0.1 mg/mL of epinephrine.
DOSAGE: Onset of effects immediately after IV and up to 6-15 minutes after SC route.

Cardiac arrest: ADULT: 0.5 to 1 mL of 1:10,000 via IV or into endotracheal tube
CHILD: 10 micrograms/kg (0.1 mL/kg of 1:10,000) IV
Anaphylaxis ADULT: 0.1-0.5 mL, of 1:1,000 via SC or IM, every 10-15 minutes, prn
CHILD: 10 micrograms/kg (0.01 mL/kg of 1:1,000) SC, every 20 minutes to 4 hrs, prn.

WARNING/ CAUTIONS:
Rapid IV infusion can cause death from cerebral vascular hemorrhage or cardiac arrhythmia.
Use with caution in the elderly, in patients with diabetes mellitis, cardiovascular disease,
hypertension, hyperthyroidism, and neurosis. If administering via IV route, MUST monitor BP,
heart rate, and EKG when therapy is initiated and frequently thereafter.

CONTRAINDICATIONS: Glaucoma (narrow angle); cardiac arrhythmia; cardiac dilation; coronary insufficiency; cardiogenic, traumatic, or hemorrhagic shock; cerebral arteriosclerosis; organic brain damage. SO, ANAPHYLACTIC SHOCK IS THE ONLY TYPE OF SHOCK FOR WHICH EPINEPHRINE IS AN ACCEPTABLE TREATMENT.

ADVERSE REACTIONS: Common reactions in italics; life-threatening in bold italics.
CNS: Nervousness, headache, tremor, euphoria, anxiety, cold extremities, vertigo,
diaphoresis, disorientation, agitation, restlessness, insomnia.
CV: Palpitations; hypertension; tachycardia; ventricular fibrillation; stroke; widened
pulse pressure; angina; arrythmia; EKG changes (e.g., decreased T-wave amplitude); increased
myocardial oxygen demand.
Other: Sweating; nausea; urinary retention; pulmonary edema, dyspnea, pallor;
hyperglycemia; glycosuria.

DRUG INTERACTIONS: MAO inhibitors (hypertensive crisis); Levodopa (arrythmia); digitalis glycosides (ventricular arrythmias); beta blockers (vasoconstriction & reflex
bradycardia); antihistamines, thyroid hormones, tricyclic anti-depressants (severe adverse cardiac effects – avoid giving together); alpha-adrenergic blockers (hypotension).

-Benadryl for allergic/histamine release symptoms
-Calcium Gluconate for Magnesium overload (Mg Overload s/sxs: neuromuscular depression, respiratory depression, paralysis, circulatory collapse or heart block; sweating, drowsiness, depressed reflexes, hypotension…)

6. BE AWARE OF THE SCOPE OF PRACTICE FOR NDs REGARDING IV THERAPY
?? Were there notes on this? We can do vitamin and mineral therapies—with added training, can do amino acids, ALA….Scope will vary state to state. I don’t believe we’re allowed to “treat cancer” at all but can do supportive….

7. KNOW DIFFERENT TYPES OF IV SOLUTIONS, THEIR USES, & POSSIBLE COMPLICATIONS
(From Week 7 Notes)
II. Types of intravenous solutions
A. Crystalloid solutions **what we use**
1. Crystalloids are substances that are capable of forming crystals (e.g., salt, glucose). When placed in a fluid medium, they form “true solutions” because the crystalloid material dissolves completely and cannot be distinguished from the resulting solution. This allows crystalloid solutions the ability to pass through semipermeable membranes. They can be hypotonic, isotonic, or hypertonic. Vascular fluids comprise 25% of the total extracellular fluids and about 25% of crystalloid solutions given will remain in the intravascular space.

2. Examples of crystalloid solutions : Dextrose in water, sodium chloride, balanced electrolyte fluids, vitamins, and minerals.

B. Colloid “solutions”
1.Colloids are substances that are too large to completely dissolve in fluid, yet not large enough to settle out due to gravity – thus they remain suspended in the fluid medium without forming a true solution. Since colloids do not dissolve, they do NOT flow freely between fluid compartments. Examples of colloid “solutions” include those containing protein or starch molecules. When administered via IV, they remain in the intravascular space for several days, provided the patient has intact capillary endothelial cells. Colloids increase the plasma oncotic pressure, and thus draw fluid into the vessels, leading to increased intravascular volume. Thus they are commonly referred to as “plasma volume expanders.”

C. Elements in parenteral solutions
1. Water
a. Adults require roughly 1000 ml/day to maintain water balance. This requirement is increased when water losses are
increased: respirations above 20, low environmental humidity, diaphoresis, loss of kidney concentrating ability, and in the
elderly. Average adult “insensible” water losses are 500-1000 ml/day, so this needs to be replaced in order to maintain
adequate kidney function. Insensible water losses are NOT measurable. Such losses include: 300-500 mL of water per day
eliminated through the lungs; 500 mL per day through the skin as perspiration; and 100-200 mL per day through the GI tract.

b. Water for injection is a hypotonic fluid with an osmolarity of zero (0) since it contains no ions or osmotically active
particles.

c. Water is NEVER injected intravenously without first adding the appropriate constituents to bring the osmolarity up to a
level where red blood cell hemolysis will not occur; the osmolarity value should be 145-160 mOsm/L (corresponding to
0.45% sodium chloride) or greater in normal patients. It may need to be higher in patients with increased red blood cell
fragility.

2. Glucose
a. Glucose (dextrose) is a nutrient used for replacement, restoration, and maintenance therapies. It is converted into glycogen by the liver, thus improving hepatic function. Glucose supplies calories for energy, sparing protein in patients who are unable to eat.

b. D5W is a solution containing 5% dextrose in water. So, how much glucose would be in one liter of D5W? Be familiar
with the following concepts for your final exam: 1 ml of water weighs 1 gram; 1 mL is 1% of 100 mL. With these facts in mind, milliliters, grams, and percentages can be used interchangeably to calculate the strength of an IV solution. For example, 5% dextrose in water equals 5 grams of dextrose in 100 mLof water. So, one liter of D5W would contain 50 grams of dextrose; 2 liters of D5W contains 100 grams of glucose, etc. D5W is an isotonic solution with an osmolarity of 250 mOsm/L

c. D10W is a solution containing 10% dextrose in water, so every liter of D10W contains 100 grams of glucose. D10W is a
hypertonic solution with an osmolarity of 500-560 mOsm/L

d. D5LR is a solution containing 5% dextrose in Lactated Ringer’s solution (see balanced electrolyte solutions below).
e. Cautions: Infusions of dextrose solutions can result in:
Hypokalemia – dextrose infusions result in increased insulin levels, both dextrose and potassium are taken into cells, serum levels of potassium decrease.
Dehydration from osmotic diuresis.
Hyperinsulinism from rapid infusion of hypertonic carbohydrates can result in hypoglycemia after the infusion is completed.
Water intoxication.

3. Sodium chloride or saline solutions
a.0.9% sodium chloride (normal saline) is used for extracellular fluid replacement, treatment of metabolic alkalosis with fluid
b.loss (e.g., due to vomiting), and sodium depletions.
Caution: Normal saline supplies sodium and chloride in excess of individual need and extended use can result in electrolyte
imbalance and circulatory overload.

c.. 0.45% sodium chloride (half-normal saline) is used to replenish sodium and chloride when the amount needed is
questionable; it is preferable to normal saline provided the patient is not hypotensive. It is useful as a carrier fluid for many
vitamin and mineral protocols.

4. Balanced electrolyte solutions
a. In hospital practice the correction of electrolyte imbalances is very important in the prevention of complications associated
with excess or deficit of electrolytes. This requires access to in-house lab testing and a good understanding of acid-base
balance. In naturopathic practice balanced electrolyte solutions are used to correct dehydration and individual minerals are
used to correct deficits or achieve therapeutic effects.

b. LR or lactated Ringer’s solution is a balanced electrolyte formula similar to 0.9% normal saline, but with potassium and calcium substituted for some of the sodium ions to more closely approximate the electrolyte composition of blood plasma. It also contains sodium lactate, a bicarbonate precursor, to assist in reversing mild acidosis. LR should NOT be used in patients with impaired lactate metabolism:
Liver disease
Addison’s disease
Severe metabolic acidosis or alkalosis
Profound hypovolemia, shock, or cardiac failure
c.LR is useful in any type of dehydration, treatment of mild diabetic keotacidosis or mild metabolic acidosis that occurs with early renal insufficiency, treatment of salicylate overdose, and for dehydration secondary to infant diarrhea.
“in alKaLOsis, K-lo. Potassium is usually low”


8. BE FAMILAR WITH PROCEDURES TO PREVENT INFECTION WHILE ADMINISTERING
IV THERAPY
-Proper preparation for IV is necessary. Don’t use betadine because it obscures the field of vision. Were you to ever use betadine/iodine it needs to sit for 30 seconds and will be inactivated if you follow it with isopropyl alcohol.
-Isopropyl alcohol with one minute of friction decreases organisms, removes organic materials. Use first, then follow with chlorhexidine
-Chlorhexidine is used to cleanse central lines and IV sites, after application of isopropyl alcohol, as per CDC
-No shaving the area. Trim hair if necessary.
-PROTOCOL: clean a 2inch radius from proposed needle entry site, first with alcohol (examine cotton ball, repeat if it is dirty) and then with chlorhexidine. If IV/push will last less than 30 minutes, alcohol alone is sufficient.

INFECTION CONTROL IN IV THERAPY

BASIC PREVENTION:
1. Hand washing at least 15 seconds
2. Appropriate cleaning of IV site
3. Proper technique of inserting IV
4. IV equipment is in good order
5. Solution, nutrients not contaminated, equipment and medications are in-date
6. Duration of IV
7. Patient status
Other:
2. OSHA standards
a. understanding concept of clean, disinfected, sterile
Sources of Contamination in Equipment:
1. IV nutrients
2. Injection ports
3. Cannula contact with skin
4. Changing IV bottle tubing
5. Microorganisms entering IV equipment
6. Patient reaction to IV material


9. BE AWARE OF THE MOST COMMON NUTRIENT COMPLICATIONS. Which nutrient must never be given via IV push?
-Review Adverse Reactions from the Wk 6 notes pasted under Question 10 (tho I doubt that’s where she’s going with this one…)
-**Never use Potassium chloride in an IV push
-Iron has potential for lots of complications
CI in all anemias except IDA; use with extreme caution in pts with impaired renal function, hx of allergies or asthma, serious
hepatic damage, inflammatory diseases….
-Mg can cause neuromuscular depression, respiratory depression, paralysis, circulatory collapse or heart block
-The nutrients not listed below are in the Wk 5 notes with full info of how supplied, incompatibilities, indications and contraindications, etc. I think the most common nutrient complications” are the ones above, however.


10. From Denise Burnham’s Lecture (Week 6): Please be familiar with the “pharmacology” section she included for the nutrients. I am not asking this to torture you, but to impress upon you that this information is useful in designing formulas. For example, considering her list of “Basic IV Nutrients,” which ones would you give to a patient to support synthesis of red blood cells? You can thank me later for this big hint……………Also, which nutrient is contraindicated in digitalized patients?
Pharmaceutical Considerations of Basic IV Nutrients
Vitamin B1 (Thiamine)
Pharmacology Thiamine is important in the metabolism of carbohydrates forming a complex with ATP—Thiamine pyrophosphate. This is a coenzyme to help decarboxylation and transketolase in the pentose phosphate pathway.

Dose 100 to 500mg have been administered parenterally with no side effect.

Contraindication hypersensitivity

Incompatabilities Unstable in neutral or alkaline environments and with citrates; carbonates; copper or acetates. Optimal pH 2.5 to 4.5.

Adverse reactions warm sensation; pruritus; urticaria; weakness; sweating; nausea; restlessness; tightness of the throat; angioneurotic edema; cyanosis; pulmonary edema; hemorrhage into the GI tract; cardiovascular collapse; hypersensitivity and anaphylactic shock.

Availability Usually from Vitamin B Complex (contains thiamine 100mg/ml). Also as 100mg/ml

Storage Room temperature; light protected. Preservative-free products should be refrigerated.

Vitamin B2 (Riboflavin)
Pharmacology Riboflavin functions as 2 coenzymes—flavin adenine dinucleotide and flavin mononucleotide. These catalyze reactions including glucose oxidation, amino acid deamination & fatty acid breakdown.

Dose 1 to 10mg daily

Contraindication hypersensitivity

Incompatibilities Unstable at concentrations above 10mg/ml and in acidic environments

Adverse reactions hypersensitivity; turns urine and breast milk yellow

Availability Usually from Vitamin B Complex (contains riboflavin 2mg/ml).
Infrequently used separately.

Storage Vitamin B Complex should be stored under refrigeration and protected from light.

Vitamin B3 (Niacinamide)
Pharmacology Niacin functions as 2 coenzymes—nicotinamide dinucleotide and nicotinamide adenine dinucleotide phosphate. These participate in glycogenolysis, fatty acid metabolism and tissue respiration.

Dose 100mg daily

Contraindication Liver failure

Incompatibilities Compatible with most other additives at normal doses

Adverse reactions Use with caution in patients with liver dysfunction

Availability Niacinamide 100mg/ml and Vitamin B Complex (100mg/ml)

Storage Room temperature; protected from light. Preservative-free products should be refrigerated.

Vitamin B5 (Pantothenic Acid)
Pharmacology Pantothenic acid is a precursor of coenzyme A, which is a cofactor for a variety of enzyme-catalyzed reactions involving transfer of acetyl groups. Metabolism of gluconeogenesis; fatty acids; steroids; carbohydrates; sphingosine; citrate; acetoacetate; and porphyrins.

Dose up to 500mg daily

Contraindications Hypersensitivity

Incompatibilities Compatible with most other vitamin/mineral additives. More alkaline than most B vitamins. pH 6 to 8.

Adverse reactions None noted

Availability Dexpanthenol 250mg/ml and Vitamin B Complex (2mg/ml)

Storage Room temperature; light protected. Preservative-free products should be stored under refrigeration.


Vitamin B6 (Pyridoxine)
Pharmacology Important for many metabolic processes in the body supporting 60 different enzymes. It helps produce neurotransmitters such as norepinephrine, serotonin, and dopamine. Pyridoxine also influences endocrine function, the growth of red blood cells, health of skin and mucous membranes and the immune system.

Dose 50mg to 100mg daily; intermittent 500mg

Contraindications Hypersensitivity

Incompatibilities Incompatible with oxidizing agents; alkaline solutions and iron salts.
pH 2 to 4.

Adverse reactions Sensory neuropathic syndromes

Availability Pyridoxine 100mg/ml and Vitamin B Complex (2mg/ml)
Storage Room temperature; light protected. Preservative-free products should be stored under refrigeration.

Cyanocobalamin
Pharmacology Vitamin B12 is involved in growth, cell reproduction, hematopoiesis, nucleic acid and myelin synthesis.

Dose 0.25mg to 1mg daily; up to 10mg intermittent

Contraindications Hypersensitivity

Incompatibilities Incompatible with strongly acidic and alkaline solutions. pH 3 to 7

Adverse reactions None noted. Turns urine and other body fluids pink

Availability Cyanocobalamin 1 mg/ml to 10 mg/ml

Storage Room temperature; light protected. Preservative-free products should be stored under refrigeration.

Hydroxocobalamin (some studies say better than cyano)
Pharmacology Vitamin B12 is involved in growth, cell reproduction, hematopoiesis, nucleic acid and myelin synthesis.

Dose 0.25mg to 1 mg daily; up to 10mg intermittent

Contraindications Hypersensitivity

Incompatibilities Compatible with most vitamin additives. pH 6 to 8

Adverse reactions None noted. Turns urine and other body fluids pink.

Availability 1mg/ml to 10mg/ml

Storage Refrigerate; light protected.

Methylcobalamin (form most active in the brain)
Pharmacology Vitamin B12 is involved in growth, cell reproduction, hematopoiesis, nucleic acid and myelin synthesis.

Dose 0.25mg to 1 mg daily; up to 10mg intermittent

Contraindications Hypersensitivity

Incompatibilities Compatible with most vitamin additives. pH 6 to 8

Adverse reactions None noted

Availability 1 mg/ml to 10 mg/ml

Storage Refrigerate; light protected.

Folic Acid (Folate)
Pharmacology Folic acid is the precursor to tetrahydrofolate which is a cofactor for transformylation reactions in the biosynthesis of purines and thymidylates of nucleic acids. Folic acid is required for erythropoiesis.

Dose 0.2mg to 1 mg daily. Up to 10mg intermittent

Contraindications None noted. B12 deficiency

Incompatibilities Precipitates at pH below 5.6. pH 8 to 11.

Adverse reactions Patients have experienced skin rash, itching, erythema, malaise and bronchospasm.

Availability Folic acid 5mg/ml to 10mg/ml

Storage Room temperature; protect from light, although light stable up to several days. Preservative-free products should always be kept refrigerated.

Vitamin C (Ascorbic Acid)
Pharmacology Ascorbic acid is essential for the formation of collagen. It is important in oxidation-reduction reactions, tyrosine metabolism, conversion of folic acid to folinic acid, carbohydrate metabolism, synthesis of lipids and proteins, iron metabolism, resistance to infections and cellular respiration.

Dose 100mg to 2gm daily; intermittent high doses

Contraindications Hypersensitivity

Incompatibilities Not stable in alkaline solutions or when exposed to air. pH 5.5 to 7.

Adverse reactions Hot flushes, headache, fatigue, and insomnia. High doses have caused DVTs. Too rapid infusion can cause faintness or dizziness.

Availability Ascorbic Acid/Sodium Ascorbate 500mg/ml and MVI supplements (100mg/dose)

Storage Refrigerate and protect from light. Stable in some studies up to 4 years at room temperature.



Magnesium
Pharmacology Magnesium is a cofactor in numerous enzyme systems and is involved in muscular excitability and neurochemical transmission.

Dose 1gm to 5gm daily. Not to be given at a rate faster than 1gm in 30 minutes. Monitor for serum level 3 to 4.5 mg/dl

Contraindications Patients with severe renal impairment or heart block

Incompatibilities Compatible with most additives. Incompatible with procaine, phosphate salts and carbonates. pH 5.5 to 7.

Adverse reactions Flushing; sweating; hypotension; stupor; depressed reflexes; flaccid paralysis; hypothermia; circulatory collapse; cardiac & CNS arrest.

Availability Magnesium Sulfate 50% (500mg/ml)

Storage Room temperature. Refrigeration may cause crystallization.

Potassium
Pharmacology Potassium is essential for maintenance of intracellular tonicity; transmission of nerve impulses; contraction of cardiac, skeletal and smooth muscle; and maintenance of normal renal function.

Dose According to lab values to be administered at a maximum of 10mEq/hr in no less than 100ml. Maximum dose of 100mEq in 24hours.
Contraindications Renal insufficiency or in cases where hyperkalemia may result
Incompatibilities Compatible with most additives. pH 5.5 to 8.
Adverse reactions Phlebitis; weakness; flaccid paralysis; mental confusion; muscle or respiratory weakness; hypotension; heart block; cardiac arrhythmias and cardiac death.

Availability Potassium Chloride 2meq/ml. Must be diluted for infusion

Storage Room temperature; light stable.

Calcium
Pharmacology Calcium is essential for the function of the nervous system and muscular systems, for normal cardiac function, for cell permeability and for blood coagulation.

Dose 0.5 to 2gm infused over NO greater than 200mg/minute. More conservative rates are used in ambulatory settings. Levels should not exceed 11mg/dl. (8.5 to 10.5)

Contraindications Patients with ventricular fibrillation; hypercalcemia and digitalized patients.

Incompatibilities Incompatible with carbonates and phosphates. Inspect carefully when mixing with sodium bicarbonate. May inactivate folic acid depending on concentrations of each. pH 6 to 8. Check stock vials for precipitate

Adverse reactions Cardiac arrhythmias, bradycardia, syncope, decreased blood pressure, cardiac arrest and sudden death.

Availability Calcium gluconate 10% (100mg/ml)

Storage Room temperature


11. KNOW WHICH TYPE OF IV ACCESS DEVICES ARE APPROPRIATE FOR WHICH USES
--Not entirely sure what this question is asking.
-Needle gauges suitable for IV infusions are 20-27, with bigger #s being smaller needles (16 is 1/16th of an inch; 24 is 1/24th) and so being suitable for smaller and more frail people, and requiring slower infusion rates.
-Butterfly gauges are odd#s, straight needles are even. We usually use 23 and 24 gauge equipment.
-“Cannulas” (angiocaths, catheters) are intended for longer infusions so needle can be removed and pt can be more comfortable
-Butterfly needles are appropriate for infusions lasting…? Was it 30 min or less?

12. KNOW WHAT OSMOLARITY RANGES ARE SAFE TO GIVE IV
Hypotonic solutions can cause lysis of RBCs; lowest osmolarity allowed is 145mOsm/L
Hypertonic solutions >600mOsm/L may damage the tunica intima

According to notes from Dr. Shauna’s lecture: “with a push osmolarity can range 145-800; drips go 145-1200. Stronger than 800 with a push or 1200 with a drip can burn a patient’s vein”

Also, not asked, but: Normal Arterial pH is 7.35-7.45, veins are slightly more acidic. With IV solution, aim for a pH of 7.

13. KNOW THE DIFFERENCE BETWEEN HYPERTONIC, HYPOTONIC, & ISOTONIC. KNOW REPRESENTATIVE EXAMPLES OF THE PRECEEDING; e.g., 0.9 % saline is an example of an ISOTONIC solution.
Normal Blood Plasma ranges 280-295 mOsm/L
Isotonic IV Fluid approximates the osmolarity of plasma: 250-375mOsm/L; e.g. 0.9% saline, 5% Dextrose in Water (“D5W”)
Hypertonic IV Fluid is greater than 375 mOsm/L; e.g. 5% Dextrose in Normal Saline; 25% Albumin
Hypotonic IV Fluid is less than 250 mOsm/L; e.g. 2.5% Dextrose in Water


14. BE FAMILAR WITH DOCUMENTATION REQUIRED WHEN GIVING IV THERAPY.
Criteria:
1.Accurate
2.Complete written account of what was given to the patient (order)
3.Legible
4.Standard abbreviations only
5.Include in the chart: pts. medical hx., current health status, allergies, medicines patient is taking
6.Consent forms
7.No vacant lines
8.Every entry is signed and dated
9.Post IV instructions given to patient
10.Documentation of Lot Number & expiration date for each nutrient, including the carrier solution.

Physician notes:

1.Site of IV
a.Dorsal metacarpal vein, Left hand
b.Right cephalic vein at wrist
c.Left median cubital vein
2.Type and size of catheter or needle used
a.#25 gauge butterfly
b.#24 angiocath or #24 OTN catheter
3. Type and amount of carrier fluid infused
a.1000cc D5W
b.500cc LR
c.500cc Sterile H2O
d.500cc 0.45% NS (half-normal saline)
e.500cc 0.9% NS (normal saline)
4.Nutrients added to carrier solutions or “cocktail” used: (w/ mg/cc, and cc’s used)
a.Ca Gluconate 10%, 2 cc
b.HCL 2 mg/ml, 5 cc
c.Vit C 500 mg/ml, 10 cc
d.Myers’ Cocktail, 35 cc.
5.Duration of IV
a. Time started and stopped
6.Vital Signs before, during, and after IV
7.Drip rate of IV
8.Documentation of when you checked patient during course of infusion
9.Discontinuation of IV
a.Time
b.Status of pt.
c.Status of cannula / catheter (should be intact): “Catheter D/C intact.”
10.Patient status after IV and at time of leaving clinic

15. KNOW THE TYPICAL TESTS YOU NEED TO REVIEW BEFORE ADMINISTERING IV THERAPY.
OVERVIEW: Lab tests are used to help assess a patient’s suitability as a candidate for receiving IV therapy, and may also help in selection of nutrients to add to the formula. The recommended minimum tests are the CMP, CBC, and dipstick urinalysis. Typically, these tests are ordered prior to the patient’s first IV appointment. Since we are putting fluid into the vasculature, it is especially important to evaluate the adequacy of renal and hepatic function. Abnormalities don’t necessarily preclude a candidate from receiving IV therapy, but adjustments may need to be made to the formula.

GENERAL CATEGORIES OF TESTS:
Renal Function Tests: Historical focus has been on BUN and Creatinine. Remember to consider non-renal causes of azotemia (see flowsheet). New trend is to focus on eGFR (estimated Glomerular Filtration Rate). Desirable GFR is > 60 ml/min/1.73 m2 of body surface area. Renal function tests help determine allowable fluid load, nutrient / drug dose, and the rate of IV fluid infusion. Uric acid is also a useful indicator of renal function, but note that it is NOT part of the standard CMP. The dipstick UA also provides a quick check of renal function. Patients consistently producing urine with a specific gravity of 1.010 (isosthenuria) are likely to have decreased renal function (kidneys ability to “concentrate” urine has been compromised). Conversely, consistently high specific gravity readings may reflect dehydration (patient not drinking enough water during the day).

Liver Function Tests: Classically considered to be AST, ALT, Total Bilirubin, Alkaline phosphatase, and Albumin. Be aware that the AST and ALT enzymes are found in other tissues as well. GGT is a sensitive indicator of hepatobiliary disease, but it is not part of the standard CMP. Alkaline Phosphatase (Alk phos) is found in higher concentrations in the epithelial cells that line the bile ducts than in hepatocytes. In cases where the elevation in Alk phos is greater than the elevation in AST and ALT, think more of cholestasis, which can be intra-hepatic or extra-hepatic (refer to elevated liver enzymes flow sheet and jaundice flow sheet).

Hematapoietic Tests: It is advantageous to be aware of issues such as:
Leukopenia – increased risk of infection.
Anemia – patients may be more sensitive to the IV txs they receive (Hgb is one of the main pH buffers in blood, so anemic patients have somewhat less buffering capacity for protocols that can influence pH).
Thrombocytopenia – increased risk for excessive bleeding, bruising.
Thrombocytosis – increased risk for excessive bleeding, bruising (platelets may be dysfunctional, so in those cases normal blood clotting is impaired and the patient will be prone to bleeding), possible risk for increased clot formation.
Test of choice is the CBC. Focus primarily on WBC count, RBC count, Hgb, MCV, and Platelet count.
Refer to flow sheets for microcytic, normocytic, and macrocytic anemias.

CBC CONSIDERATIONS:

TEST
NORMAL
OPTIMAL
CONSIDERATIONS
WBC
5-10 x 103/mm3
5-7.5 x 103/mm3
Low: Immunosuppression, toxic metals, severe acute or chronic infection.
High: Viral infection (lymphocytosis), bacterial infxn (neutrophilia), leukemias
Rx: Vit C, Vit A, Zn, HCl
Hgb
(RBC)
Male:14-18 g/dL
Female: 12-16 g/dL
Male: 14-15
Female: 13.5-14.5
Low: Anemia – use MCV to classify. If hemoglobinopathy, watch Vitamin C; keep other nutrient doses moderate
High:1oPolycythemia- consider high dose C;
2oPolycythemia – Chronic lung Dz.
Rx: Vit. C; antioxidants
MCV
80-95 fl
82-89.9 fl
Low: Iron, B6, or Cu deficiency; Thalassemia. Fe best given IM via Z-track injection. Do NOT Give Fe to Thalassemia patients
High: B12 or folate def. Best to tx with both nutrients. If no response, consider HM toxicity (esp. Hg)
Platelets
150 – 400 x 103
Same as Norm.
If < 50 or > 700, possible bleeding or bruising at infusion site


SELECTED CHEMISTRY TEST CONSIDERATIONS:

1. Glucose: Normal Fasting 70-100 mg/dL; Optimal 80-100 mg/dL.
a.Low: NOTE that Vitamin C is structurally similar to glucose, so high dose Vitamin C can induce hypoglycemia – have patients eat snacks or consider setting up infusion in D5W (5% Dextrose in Water).
b.High: Be aware of diabetic complications, e.g., diabetic nephropathy, diabetic neuropathy, etc.

2. Albumin: Normal 4-5.5 g/dL; Optimal 4-5 g/dL.
a.Low: Consider liver or kidney disease, malnutrition, over-hydration, Hypochlorhydria, oxidative stress, low Vitamin C. Be aware of increased likelihood of edema in tissues due to decreased plasma oncotic pressure, so closely watch extremities and consider weighing patient before, during, and after the IV. Rx: Combination amino acids, e.g., “FreAmine III” (NOTE: need advanced IV Therapy class to legally infuse anything other than Vitamins and Minerals).
b.High: Dehydration (there are NO pathological causes for ’d albumin).

3. AST: Normal 5-40 IU/L
a.Low: Consider B6 deficiencyHigHh (necessary co-factor in AST reactions).
b.High: MI, Liver Dz, Kidney Dz, Skeletal muscle dz, pancreatitis, infectious mononucleosis. IM injections may elevate levels.

4. ALT: Normal 5-35 IU/L
a.Low: Consider B6 deficiencyHigHh (necessary co-factor in ALT reactions).
b.High: Liver dz, Kidney dz,, infectious mononucleosis. IM injections.

5. GGT: Normal 7-47 U/L; Female Normal 5-25 U/L.
a.Sensitive indicator of hepatobiliary dz.
b.High: Heavy, chronic alcohol consumption (alcohol induces GGT production); cholestatic liver dz, infectious mono, prostate cancer.
c.Remember that GGT is NOT part of a CMP or a Liver Panel.

6. Calcium: Normal 8.5-10.5 mg/dL.
a. Vitamin C is a weak chelating agent, so to maintain normal blood calcium levels it is useful to add 1 ml of 10% Calcium gluconate for each 10 grams of Vitamin C used.

7. Total Bilirubin: Normal – 0.1- 1.1 mg/dL.
a. Total Bili = Direct Bili (conjugated) + Indirect Bili (unconjugated).
b. High: Due to pre-hepatic, hepatic, or post-hepatic causes. If patient is jaundiced, you know that the Total Bili is at least 2 – 2.5 mg/dL. To sort out the underlying cause, consult jaundice flow sheet, and be sure to call your reference lab ASAP to request a Direct Bilirubin test (only the Total Bili is part of the CMP).
c. If elevated, watch dose of niacin, and AVOID vitamin A.

8. Electrolytes (Na, K, Cl, CO2)
a.Dehydration usually presents with varying degrees of electrolyte imbalance; 500 ml of Lactated Ringer’s is useful in such situations. Lactated Ringers can be a stand alone IV infusion, or you may choose to add other nutrients.
b.Watch the Na and K closely in patients with renal dz.
c.If any doubt exists in your mind, do not do the IV. Severe electrolyte imbalances need to be corrected in a HOSPITAL setting. Such patients will need frequent blood tests to monitor the efficacy of corrective therapies, and potentially special testing to determine the underlying cause of the imbalance.
d.Potassium: Normal 3.5-5.3 mEq/L. Optimal 4-4.5. Panic values: <2.5 or >6.5.
(1) NOTE: Insulin facilitates movement of Potassium into cells, so infusions in D5W may  hypokalemia.
(2) Glucose infusion in patients with heart disease can drop potassium levels as much as 0.4 mEq/L.

9. Uric Acid: Normal 2.3-8.2 mg/dL. Male optimal 3.5-5.9. Female optimal 3.0-5.5.
a.Low: Deficiency of molybdenum, B12, folic acid, or copper; late stage liver dz; possibly toxic metal overload.
b.High: Gout, atherosclerosis, oxidative stress, RA, renal dz, leaky gut.
c.Remember that Uric acid is NOT on a CMP

10. BUN: Normal 7-20 mg/dL. Optimal 10-16 mg/dL.
a.Low: Chronic Liver Dz, inadequate protein intake.
b.High: May be due to renal dz, but also consider that pre-renal azotemia is the most common cause of ’d BUN (refer to flow sheet; take good hx). If azotemia is due to renal causes, ability to excrete IV fluids may be impaired.
11. Creatinine: Normal 0.5-1.5 mg/dL. Optimal 0.8-1.1 mg/dL
a.Low: Low muscle mass (may be age-related), cachexia.
b.High: Think renal dz. Doubling of Creatinine suggests a 50% reduction in Glomerular Filtration Rate (GFR). Note that athletes supplementing with creatine may show values up to 1.7-1.8 mg/dL.


16. WHAT TEST DO YOU NEED TO ORDER BEFORE ADMINISTERING HIGH DOSE VITAMIN C? WHY IS THIS TEST IMPORTANT? WHAT IS CONSIDERED A HIGH DOSE OF VITAMIN C?
G6P because in patients with G6PD, AA administration can lead to hemolysis

17. WHAT MAY OCCUR IN THE SERUM OF CANCER PATIENTS IF VITIMIN C CAUSES TUMOR LYSIS SYNDROME? WHICH TEST IS THE BEST TO USE TO MONITOR VISCERAL PROTEIN STATUS? WHAT TEST DO YOU NEED TO ORDER TO CALCULATE NITROGEN BALANCE?
-“Though rare, some patients have died from tumor necrosis and hemorrhage after high dose Ascorbic Acid”
A.- High dose Vitamin C protocols: Remember to do G6PD testing first. Best to start with lower amount and work one’s way up. Be aware that tumor lysis syndrome can result from too-rapid destruction of the tumor. Blood chemistry changes = increased uric acid, potassium, and phosphorous along with decreased calcium. Hazards: Hyperkalemia may lead to cardia arrhythmia; Hyperphosphatemia may cause acute renal failure; Hypocalcemia may cause cardiac arrhythmia, tetany, or muscle cramps.

- Classically, 3 tests have been used: albumin, transferrin, and pre-albumin – the last is the best choice, basically because it has a much shorter half-life than albumin or transferrin (2-3 days versus 17-20 days for albumin and 8 days for transferrin) and is therefore a more sensitive indicator for assessing visceral protein status and for monitoring the impact of nutritional therapy. If pre-albumin serum level is 150 mg/L, monitor patient carefully. If < 110 mg/L, more intensive nutritional intervention is likely warranted (e.g. TPN).

-Nitrogen balance = Protein intake (grams) - ( 24-hr Urine Urea Nitrogen + 4)
6.25
Goal is to keep a positive nitrogen balance of 4-6 grams per day. Consider monitoring weekly to keep on top of the protocol and make adjustments as needed.

18.WHY MIGHT ONE WISH THAT A PATIENT HAD A CENTRAL LINE? WHAT SIZE SYRINGE SHOULD BE USED TO FLUSH ALL CENTRAL LINES? Be familiar with the various flushing protocols.
-???Might wish a pt had a central line because?? I know Dr. S had mentioned some common-sense reasons like pt needs frequent IVs dt cancer protocol or significant immune/nutrition support, or want to use high-osmolarity solutions, but I don’t see a good list anywhere.
-Flush ALL central lines using positive pressure with a 10cc syringe; never force if resistance is met.
-Flushing protocols are:
Hickman: heparin 10-100u/cc; 2.5cc; clamp on catheter line
Groshong/Picc: Normal Saline 5cc
Per-Q-Cath: Heparin 10-100u/cc; 2.5cc; clamp on tubing
Peripheral IV lock (aka Hep lock, buffalo cap): Normal Saline 2cc or Heparin 10u/cc, 2cc.

19. WHAT IS THE RATIONALE FOR USING IV ALPHA LIPOIC ACID AND LOW DOSE NALTREXONE IN CANCER PATIENTS? WHAT ARE THE DOSING RECOMMENDATIONS FOR THIS PROTOCOL? WHAT IF THE PATIENT IS ON PAIN MEDICATION?
??What if the pt is on pain medication??
VI. Intravenous Alpha Lipoic Acid and Oral Low Dose Naltrexone (LDN) Therapy.
A. Protocol: 300 – 600 mg of IV alpha lipoic acid twice weekly and a daily regimen of LDN 4.5 mg at hs. Oral supplements to include: alpha lipoic acid 300 mg BID, selenium 200 micrograms BID, silymarin 300 mg QID, and 3 B complex capsules QD.
1. Above is based on Dr. Burt Berkson’s work at the Integrative Medical Center in Las Cruces, N.M.
2.Refer to article in Integrative Cancer Therapies, 5(1); 2006, p 83-89.
B. Mechanisms for anti-cancer activity of Alpha lipoic Acid:
1.Induces hyperacetylation of histones  apoptosis.
2. Stabilizes NF-, the “master” transcription factor  slows rate of transcription of deleterious genes that have NF- binding sites. This inhibition occurs in T cells   inflammation.
1.Increases uptake of oxidizable substrates into mitochondria   prooxidant-driven apoptosis in human colon cancer cells.
2.Enhances Vitamin C cytotoxicity vs. cancer cells (tissue culture study).
3.’s oxidative stress: Beneficial because those with advanced cancer have a chronic inflammatory state ( levels of pro-inflammatory cytokines such as IL-1, IL-6, and TNF- and increased levels of acute phase reactants such as CRP and fibrinogen) and high oxidative stress.
4.Stimulates development and maturation of cancer-fighting lymphocytes (e.g., NK cells).
5.’s homocysteine content of cancer cells  toxic for cancer cells.
6.Discriminates between normal lymphocytes and leukemic T-cell lines, inducing apoptosis only in the latter. Also ’s IL-2 production   NK cell activity and  Lymphokine-Activated Killer (LAK) cell activity.
7.Restores functional defects in peripheral blood mononuclear cells (PBMC) isolated from patients with advanced cancers   expression of CD 25 (a high-affinity IL-2 receptor) and CD 95 on PBMC surfaces (cell culture study).

C. Mechanisms for Anti-cancer Activity of Low Dose Naltrexone (LDN):

1.First noted in mid-1990s by Dr. Bernard Bihari, who had been using LDN to enhance T-cell activity in patients with HIV and AIDS since the mid-1980s.
2.Dr. Bihari has treated > 450 cancer patients, many with advanced stage disease. Of these, 354 had regular follow-up: 84 with advanced dz died within 1st 8-12 weeks. Of the remaining 270 patients, 86 had > 75%  in tumor bulk, and >125 were moving toward remission/stabilization.
3.LDN is given at hs because most endogenous opiate production (endorphins from brain, metenkephalin from adrenal medulla) occurs between 2-4 AM.
4.LDN temporarily blocks opiate receptors  endogenous opiates cannot bind  initiates positive feedback loop   production of endogenous opiates (body’s attempt to overcome receptor blockade)  induction of Th1 immune response and cancer cell apoptosis.
5.LDN induces 2-3X  in metenkephalin production  specific activation of delta-opioid receptors (these are the main endorphin-related anti-cancer growth factors).
6.LDN induces  number of opiate receptors on tumor cell membranes  ’d sensitivity to endogenous opiate anti-tumor effects (e.g., ’d apoptosis, specifically if the cancer cell is dividing when the endogenous opiate binds).
7.LDN activity lasts but 3-4 hours, while that of the endogenous opiates persists all day.
8.’s number and activity of NK Cells.
9.’s Lymphokine-Activated CD8 Cells.
10.Per Dr. Bihari, the follo [not sure what is supposed to come next, that’s all my notes had]

Other randomly emphasized points that caught my eye:
-Fat soluble nutrients MUST be give in a class bottle (only fat sol we use is vit A)
-if given IV, vit K may cause anaphylaxis, arrhythmias or hypersensitivity reactions
-Folic Acid does not play well with the other B vitamins. Unless in a big bag, will form a precipitate


STUDY GUIDE IV THERAPY – Spring 2009

1. KNOW HOW TO CALCULATE FLOW RATE/DRIP RATE (same thing), TIME OF INFUSIONS
Flow (Infusion, Drip) Rate = Volume to be infused­­­ (ml) x Drop Factor (drops/ml)
Infusion time (min)
= 240 ml x 20 drops/ml = 80 drops/min
60 min
2. KNOW HOW TO CALCULATE OSMOLARITY
Solution osmolarity = total mOsm / total volume x 1000 ml/L

Solution osmolarity = 151.66 mOsm x 1000ml/L = 285 mOsm/L
532 ml

3. KNOW S/Sx OF IV COMPLICATIONS. BE ABLE TO RECOGNIZE POTENTIALLY EMERGENT SCENARIOS IN PTS RECEIVING IV THERAPY:
ecchymosis hematoma: discoloration and swelling at site of needle insertion, difficulty advancing needle
thrombosis: pain at the site, warm to touch, slow or no infusion rate
phlebitis: redness, swelling, pain, palpable cord along vein, increased temperature, warm to touch, slugglish infusioin rate
infiltration: cool to touch, taut skin, edema, slowing drip rate (but still working), pain, backflow absent
extravasation: taut/edema, pain, blisters/tissue necrosis, pain/burning, skin cooling
infection at insertion site: pain/tenderness, redness, swelling, mb fever and incr WBC
venous spasm: difficulty locating vein after needle/cannula insertion, pain may travel up arm
septicemia: abrupt incr in pt temperature, profuse cold sweat, n/v/d, malaise, abd pain, tachycardia, tachypnea, hypotension
circulatory overload: tachypnea/SOB, crackles in lungs if pulm edema, edema, puffy eyelids, HTN, wt gain in short amt of time, large variance between volume intake and output, distended neck veins, rise in venous pressure, tachycardia, HA, if untreated can lead to CHF, shock, or cardiac arrest
air embolism: weakness, palps, light-headed, pulm edema, dyspnea, cyanosis, cough, tachypnea, hypotension, tachycardia, chest pain, jvd, confusion, anxiety, seizure or coma
speed shock; dizziness, facial flushing, HA, tightness on chest, hypotension, irreg pulse, progressive shock
catheter emboli: sudden sharp pain at iv site, cyanosis, weak rapid pulse, hypotension, chest pain, minimal blood return, damaged catheter noted on removal
allergic rxn: rash, tachypnea, tachycardia, itching, possible anaphylaxis

4. KNOW EMERGENCY TX FOR IV COMPLICATIONS
CHF: refer to hospital
cardiac arrest: call 911, CPR, defibrillator
angina: nitroglycerin, returning fluid balance, addressing stress, homeopathics/botanicals
asthma: iv magnesium, hydro/herbs/homeo
anaphylaxis: Immediately administer 0.1 to 0.5 mL of Epinephrine 1:1000 dil. SQ or IM. Can repeat in 15-20 min., benedryl 25-50 mg, monitor for several hours, call 911
respiratory arrest: if obstruction, use Heimlich maneuver, otherwise give epinephrine for bronchodialtion: Dose of epinephrine 1:1000 dil. Administer 0.3-0.5 cc. SQ, O2 (no more than 2 L/min with copd)
pulmonary embolism; call 911, keep pt upright, O2, maintain iv site, to hospital
air embolism: 911, pt in trendelenburg (left lat decubitus) c head down, O2, transfer to hosp and tell dr what is happening
catheter embli: stop infusion, apply tourniquet above site, start new iv in other arm, arrange for xray
circulatory overload: decr iv rate, raise head/chest, vitals, O2, keep warm,
speed shock: give anedote/resusitation meds, have emergency equip avail
syncope: lie horizontal, raise legs, smelling salts, reorient

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