|Other names: IV therapy, iv therapy|
|Infusion therapy: A person receiving medication via intravenous therapy.|
Intravenous therapy (IV) is the delivery of fluids directly into a vein. The intravenous route of administration can be used both for injections, using a syringe at higher pressures; as well as for infusions, typically using only the pressure supplied by gravity. Intravenous infusions are commonly referred to as drips.
The intravenous route is the fastest way to deliver medications and fluid replacement throughout the body, because they are introduced directly into the circulation. Intravenous therapy may be used for fluid volume replacement, to correct electrolyte imbalances, to deliver medications, and for blood transfusions.
Intravenous access is used to administer medications and fluid replacement which must be distributed throughout the body, especially when rapid distribution is desired. Another use of IV administration is the avoidance of first-pass metabolism in the liver. Substances that may be infused intravenously include volume expanders, blood-based products, blood substitutes, medications and nutrition.
Fluids may be administered as part of "volume expansion", or fluid replacement, through the intravenous route. Volume expansion consists of the administration of fluid-based solutions or suspensions designed to target specific areas of the body which need more water. There are two main types of volume expander: crystalloids and colloids. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. Colloids contain larger insoluble molecules, such as gelatin. Blood itself is considered a colloid.
The most commonly used crystalloid fluid is normal saline, a solution of sodium chloride at 0.9% concentration, which is isotonic with blood. Lactated Ringer's (also known as Ringer's lactate) and the closely related Ringer's acetate, are mildly hypotonic solutions often used in those who have significant burns. Colloids preserve a high colloid osmotic pressure in the blood, while, on the other hand, this parameter is decreased by crystalloids due to hemodilution. Crystalloids generally are much cheaper than colloids.
Buffer solutions which are used to correct acidosis or alkalosis are also administered through intravenous access. Lactated Ringer's solution used as a fluid expander or base solution to which medications are added also has some buffering effect. Another solution administered intravenously as a buffering solution is sodium bicarbonate.
Use in sports
IV rehydration was formerly a common technique for athletes. The World Anti-Doping Agency (WADA) prohibits intravenous injection of more than 100mL per 12 hours, except under a medical exemption. The United States Anti-Doping Agency notes that, as well as the dangers inherent in IV therapy, "IVs can be used to change blood test results (such as hematocrit where EPO or blood doping is being used), mask urine test results (by dilution) or by administering prohibited substances in a way that will more quickly be cleared from the body in order to beat an anti-doping test". Sportspeople suspended after attending boutique IV clinics include footballer Samir Nasri in 2017 and swimmer Ryan Lochte in 2018.
Medication and treatment
Medications may be mixed into the fluids mentioned above, commonly normal saline, or dextrose solutions. Compared with other routes of administration, such as oral medications, the intravenous route is the fastest way to deliver fluids and medications throughout the body. The bioavailability of an IV medication is by definition 100%, unlike oral administration where medication may not be fully absorbed, or may be metabolized prior to entering the bloodstream. Certain types of medications can only be given intravenously, such as when there is insufficient uptake by other routes of administration.
A blood product (or blood-based product) is any component of blood which is collected from a donor for use in a blood transfusion. Blood transfusions can be used in massive blood loss due to trauma, or can be used to replace blood lost during surgery. Blood transfusions may also be used to treat a severe anaemia or thrombocytopenia caused by a blood disease. Early blood transfusions consisted of whole blood, but modern medical practice commonly uses only components of the blood, such as packed red blood cells, fresh frozen plasma or cryoprecipitate.
Parenteral nutrition is the act of providing required nutrients to a person through an intravenous line. This is used in people who are unable to get nutrients normally, by eating and digesting food. A person receiving parenteral nutrition will be given an intravenous solution which may contain salts, dextrose, amino acids, lipids and vitamins. The exact formulation of a parenteral nutrition used will depend on the specific nutritional needs of the person it is being given to. If a person is only receiving nutrition intravenously, it is called total parenteral nutrition, whereas if a person is only receiving some of their nutrition intravenously it is called partial parenteral nutrition (or supplemental parenteral nutrition).
Illicit drug use
A continuous infusion may be used to correct fluid and electrolyte imbalances, or when it is desirable to have a constant blood concentration of a medication over time. Continuous infusions are used where the variation in concentration that arises from gaps in administration would be undesirable, such as antibiotic therapy. They may also be used instead of intermittent bolus injections for the same reason, such as with furosemide. Infusions can also be intermittent, in which case the medication is administered over a period of time, then stopped, and this is later repeated. Intermittent infusion may be used when there are concerns about the stability of medicine in solution for long periods of time (as is common with continuous infusions), or to enable the administration of medicines which would be incompatible if administered at the same time in the same IV line.
Failure to properly calculate and administer an infusion can result in adverse effects, termed infusion reactions. For this reason, many medications have a maximum recommended infusion rate, such as vancomycin and many monoclonal antibodies. These infusion reactions can be severe, such as in the case of vancomycin, where the reaction is termed "red man syndrome".
Any additional medication to be administered IV at the same time as an infusion may be connected to the primary tubing; this is termed a secondary IV, or IV piggyback. This prevents the need to use multiple IV access lines on the same person. When administering a secondary IV medication, the primary bag is held lower than the secondary bag so that the secondary medication can flow into the primary tubing, rather than fluid from the primary bag flowing into the secondary tubing. The fluid from the primary bag is needed to help flush any remaining medication from the secondary IV from the tubing into the patient. Some medications or solutions may not be able to be administered in this way together; this is termed "incompatibility". This can be due to issues of molecular stability, solubility, or degradation of one of the medications.
Some medications are administered as a bolus dose, called IV "push". A syringe containing the medication is connected to an access port in the primary tubing and the medication is administered through the port. A bolus dose may be administered rapidly or may also be administered over the course of a few minutes, depending on the medication. Certain medications, such as potassium, are not able to be administered by IV push due to the extremely rapid onset of action and high level of effects. In some cases, a bolus of non-medicated solution is administered after the medication to push the medicine into the bloodstream, termed a "flush". Compatibility with other medications being administered in the same line is an issue with bolus injections as well - termed "y-site compatibility" named after the shape of the tubing which has a port for bolus administration.
Methods and equipment
A standard IV infusion set consists of a pre-filled, sterile container (glass bottle, plastic bottle or plastic bag) of fluids with an attachment that allows the fluid to flow one drop at a time, making it easy to see the flow rate and reducing the risk of air bubbles. These kits may also contain a sterile tube, a clamp to regulate flow; a connector to attach the access device, and "Y-sets", devices to enable piggybacking. Many systems of administration employ a drip chamber, which prevents air from entering the bloodstream (air embolism), and allows an estimation of flow rate.
An IV administration may consist only of a bag of fluid hanging on a pole above the height of the person to whom medication is being administered - in this way, gravity will cause the fluid to flow into the IV line and the person's vein. In such "gravity" IVs, it is not possible to precisely control the rate of administration. Alternatively, an infusion pump may be used to allow precise control over the flow rate and total amount delivered. A pump will be programmed based on the number and size of infusions being administered to ensure all medicine is fully administered without allowing the access line to run dry. Pumps are primarily utilized when a constant flow rate is important, or where changes in rate of administration would have consequences.
The simplest form of intravenous access is by passing a hollow needle through the skin directly into the vein. This needle can be connected directly to a syringe (used either to withdraw blood or deliver its contents into the bloodstream) or may be connected to a length of tubing and thence whichever collection or infusion system is desired.
A peripheral cannula is the most common intravenous access method utilized in both hospitals and pre-hospital services. The most convenient site is often the arm, especially the veins on the back of the hand, or the median cubital vein at the elbow, but any identifiable vein can be used. Often it is necessary to use a tourniquet which restricts the venous drainage of the limb and makes the vein bulge. Once the needle is in place, it is common to draw back slightly on the syringe to aspirate blood, thus verifying that the needle is really in a vein. The tourniquet should be removed before injecting to prevent extravasation of the medication. The part of the catheter that remains outside the skin is called the connecting hub; it can be connected to a syringe or an intravenous infusion line, or capped with a heplock or saline lock, a needleless connection filled with a small amount of heparin or saline solution to prevent clotting, between uses of the catheter. Ported cannulae have an injection port on the top that is often used to administer medicine.
The caliber of needles and catheters can be given in Birmingham gauge or French gauge. A Birmingham gauge of 14 is a very large cannula (used in resuscitation settings) and 24-26 is the smallest. The most common sizes are 16-gauge (midsize line used for blood donation and transfusion), 18- and 20-gauge (all-purpose line for infusions and blood draws), and 22-gauge (all-purpose pediatric line). 12- and 14-gauge peripheral lines are capable of delivering large volumes of fluid very fast, accounting for their popularity in emergency medicine. These lines are frequently called "large bores" or "trauma lines".
Intravenous access methods can be categorized by the vein into which the access is obtained.
A peripheral intravenous (PIV) line is inserted in peripheral veins, such as the veins in the arms, hands, legs and feet.
A central line is an intravenous access method in which a catheter is fed through a vein to empty into a larger, more central vein (a vein within the torso), usually the superior vena cava, inferior vena cava or the right atrium of the heart. There are several types of central IV access, categorized based on the route the catheter takes from the outside of the body to the central vein output.
Indications for a central line over the more common peripheral IV line commonly includes poor ability to access and maintain a peripheral IV line. Another common indication is when patients would require infusions over a prolonged period of time, such as antibiotic therapy over a few weeks for osteomyelitis, or when the substances administered could irritate peripheral blood vessel lining such as total parenteral nutrition, whose high glucose content can damage blood vessels, and some chemotherapy regimens. Central lines are associated with less damage to blood vessels because central veins have a larger diameter than peripheral veins, have faster blood flow, and damaging substances are diluted quicker as medicine is distributed to the rest of the body.
Other advantages of a central line include the ability to administer multiple medications at once, even if they would not be able to be administered within a single peripheral line. This is possible as a central line has room for multiple parallel compartments (lumina) within the catheter. Caregivers can also measure central venous pressure and other physiological variables through the central line.
Central IV lines carry risks of bleeding, infection, gangrene, thromboembolism and gas embolism (see Risks below). They are often more difficult to insert correctly as the veins are not usually palpable and rely on an experienced clinician knowing the appropriate landmarks and/or using an ultrasound probe to safely locate and enter the vein. Surrounding structures such as the pleura and carotid artery are also at risk of damage with the potential for pneumothorax or even cannulation of the artery.
Peripherally inserted central catheter (PICC)
A PICC line is a specific type of central IV access which is inserted through a sheath into a peripheral vein and then carefully fed towards the heart until the catheter is in the superior vena cava or the right atrium. The line may be placed using the Seldinger technique, under ultrasound guidance, usually in the arm. The length of the PICC line can be calculated by measuring the distance to an external landmark, such as the suprasternal notch, to estimate the optimal length. An X-ray must be used to verify that the tip is in the right place when fluoroscopy was not used during the insertion. More modern technology utilizes EKG technology to determine when the tip is in the correct location.
The insertion site requires better protection than that of a peripheral IV line, due to the higher risk of serious infection if bacteria travel up the catheter. However, a PICC poses less of a systemic infection risk than other central IV lines, because the insertion site is usually cooler and drier than the sites typically used for other central lines. This helps to slow the growth of bacteria which could reach the bloodstream by traveling under the skin along the outside of the catheter.
While some central lines have their catheter pass through the skin and then directly into the vein, other central lines called tunneled catheters are inserted through the skin and then "tunnel" through tissues a significant distance before inserting into a vein. This reduces the risk of infection, since bacteria from the skin surface are not able to travel directly into the vein. These catheters are often made of materials that resist infection and clotting. Types of tunneled central lines include the Hickman line or Broviac catheter.
An implanted port (brand names include: Port-a-Cath or MediPort) is a central line that does not have an external connector for administration of medication. Instead, a port has a small reservoir that is covered with silicone rubber and is implanted under the skin. Medication is administered by placing a small needle through the skin to pierce the silicone and medication is then injected into the reservoir. When the needle is withdrawn, the reservoir cover reseals itself. The cover can accept hundreds of needle sticks during its lifetime. It is possible for a port to remain implanted for years; if this is done, the port must be accessed monthly and flushed with an anti-coagulant, or there is a risk for clotting blocking port access. If a port becomes clogged, a thrombus may eventually form, and carry the accompanying risk of embolisation. Removal of a port is usually a simple outpatient procedure; however, installation is more complex and a good implant is fairly dependent on the skill of the radiologist. Ports cause less inconvenience and have a lower risk of infection than PICCs, and are therefore commonly used in people on long-term intermittent treatment, such as chemotherapy.
A third type is a midline catheter which is inserted into a peripheral vein and is fed through the vein. Unlike a PICC line, however, the midline catheter falls short of emptying into a central vein.
To make the procedure more tolerable for children, medical staff may apply a topical local anaesthetic (such as EMLA or Ametop) to the skin of the chosen venipuncture area about 45 minutes beforehand.
A peripheral IV line (PVC or PIV) consists of a short catheter (a few centimeters long) inserted through the skin into a peripheral vein (any vein not situated in the chest or abdomen). This is usually in the form of a cannula-over-needle device, in which a flexible plastic cannula comes mounted over a metal trocar. Once the tip of the needle and cannula are introduced into the vein via venipuncture, the cannula is advanced inside the vein over the trocar to the appropriate position and secured, the trocar is then withdrawn and discarded. Blood samples may be drawn directly after the initial IV cannula insertion.
If the cannula is not inserted correctly, or the vein is particularly fragile and ruptures, blood may extravasate into the surrounding tissues, this situation is known as a blown vein or "tissuing". Using this cannula to administer medications causes extravasation of the drug which can lead to edema, causing pain and tissue damage, and even necrosis depending on the medication. The person attempting to obtain the access must find a new access site proximal to the "blown" area to prevent extravasation of medications through the damaged vein. For this reason it is advisable to site the first cannula at the most distal appropriate vein.
An injection inherently causes pain when the skin is broken and is medically invasive. In cases in which a choice between intravenous therapy and oral treatment may be made to achieve the same outcome, such as in the case of mild or moderate dehydration treatment (assuming oral rehydration therapy is an option), then one should avoid using intravenous therapy in place of the less invasive oral option. Children in emergency departments being treated for dehydration, in particular, have better outcomes with oral treatment because it does not cause the pain or risk the complications of an injection.
Any break in the skin carries a risk of infection. Although IV insertion is an aseptic procedure, skin-dwelling organisms such as Coagulase-negative staphylococcus or Candida albicans may enter through the insertion site around the catheter, or bacteria may be accidentally introduced inside the catheter from contaminated equipment. Moisture introduced to unprotected IV sites through washing or bathing substantially increases the infection risks. Infection of IV sites is usually local, causing easily visible swelling, redness, and fever. If bacteria do not remain in one area but spread through the bloodstream, the infection is called sepsis and can be rapid and life-threatening. An infected central IV poses a higher risk of sepsis, as it can deliver bacteria directly into the central circulation.
Phlebitis is inflammation of a vein that may be caused by infection, the mere presence of a foreign body (the IV catheter) or the fluids or medication being given. Symptoms are warmth, swelling, pain, and redness around the vein. The IV device must be removed and if necessary re-inserted into another extremity. Due to frequent injections and recurring phlebitis, scar tissue can build up along the vein. The peripheral veins of intravenous drug addicts, and of cancer patients undergoing chemotherapy, become sclerotic and difficult to access over time, sometimes forming a hard, painful “venous cord”.
A peripheral IV cannot be left in the vein indefinitely out of concern for the risk of infection and phlebitis, among other potential complications. However, recent studies have found that there is no increased risk of complications in patients whose IVs were replaced only when clinically indicated versus patients whose IVs were replaced routinely. Thus, it is becoming more common to replace IVs only when clinically indicated. There is no need to replace peripheral IVs more frequently than 72–96 hours as long as the IV was placed aseptically.
Infiltration / extravasation
Infiltration occurs when an IV fluid or medication accidentally enters the surrounding tissue rather than the vein. It may occur when the vein itself ruptures (the elderly are particularly prone to fragile veins due to a paucity of supporting tissues), when the vein is damaged during insertion of the intravascular access device, when the device is not sited correctly, from increased vein porosity or when the entry point of the device into the vein becomes the path of least resistance (e.g. if a cannula is in a vein for some time, the vein may scar and close and the only way for fluid to leave is along the outside of the cannula where it enters the vein). Infiltration is an inadvertent administration of a nonvesicant solution/drug into the tissue, which happens so often when the tourniquet isn't removed in a timely fashion. Infiltration is characterized by coolness and pallor to the skin as well as localized swelling or edema. It is treated by removing the intravenous access device and elevating the affected limb so that the collected fluids can drain away. Sometimes injections of hyaluronidase can be used to speed the dispersal of the fluid/drug. Infiltration is one of the most common adverse effects of IV therapy and is usually not serious unless the infiltrated fluid is a medication damaging to the surrounding tissue, most commonly a vesicant or chemotherapeutic agent, in which case it is called extravasation and extensive necrosis can occur.
Other side effects of intravenous therapy may include fluid overload, especially when fluids are given in higher rates. This may cause hypertension, heart failure, and pulmonary edema. If the fluids administered are colder than body temperature, there is a risk of induced hypothermia. Rapid temperature changes in the heart may precipitate ventricular fibrillation. Administration of a solution not balanced in concentration can disrupt a person's electrolyte balance. In hospitals, regular blood tests may be run to monitor electrolyte levels proactively. Failure to account for and correct electrolyte imbalance can lead to acidosis/alkalosis. An air embolism may occur due to the introduction of air into the IV line; this is more common with central IV lines.
Intravenous glucose is used in some Asian countries such as Korea as a pick-me-up, for "energy", but is not a part of routine medical care in the United States where a glucose solution is a prescription drug. Asian immigrants to the United States are at risk if they seek intravenous glucose treatment. It may be had at store-front clinics catering to Asian immigrants, but, despite having no more effect than drinking sugared water, poses medical risks such as the possibility of infection. It is commonly called "ringer".
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