Intravenous therapy
Intravenous therapy | |
---|---|
Other names | IV therapy, iv therapy |
ICD-9-CM | 38.93 |
Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous
The intravenous route is the fastest way to deliver medications and fluid replacement throughout the body as they are introduced directly into the circulatory system and thus quickly distributed. For this reason, the intravenous route of administration is also used for the consumption of some recreational drugs. Many therapies are administered as a "bolus" or one-time dose, but they may also be administered as an extended infusion or drip. The act of administering a therapy intravenously, or placing an intravenous line ("IV line") for later use, is a procedure which should only be performed by a skilled professional. The most basic intravenous access consists of a needle piercing the skin and entering a vein which is connected to a syringe or to external tubing. This is used to administer the desired therapy. In cases where a patient is likely to receive many such interventions in a short period (with consequent risk of trauma to the vein), normal practice is to insert a cannula which leaves one end in the vein, and subsequent therapies can be administered easily through tubing at the other end. In some cases, multiple medications or therapies are administered through the same IV line.
IV lines are classified as "central lines" if they end in a large vein close to the heart, or as "peripheral lines" if their output is to a small vein in the periphery, such as the arm. An IV line can be threaded through a peripheral vein to end near the heart, which is termed a "peripherally inserted central catheter" or PICC line. If a person is likely to need long-term intravenous therapy, a medical port may be implanted to enable easier repeated access to the vein without having to pierce the vein repeatedly. A catheter can also be inserted into a central vein through the chest, which is known as a tunneled line. The specific type of catheter used and site of insertion are affected by the desired substance to be administered and the health of the veins in the desired site of insertion.
Placement of an IV line may cause pain, as it necessarily involves piercing the skin. Infections and inflammation (termed phlebitis) are also both common side effects of an IV line. Phlebitis may be more likely if the same vein is used repeatedly for intravenous access, and can eventually develop into a hard cord which is unsuitable for IV access. The unintentional administration of a therapy outside a vein, termed extravasation or infiltration, may cause other side effects.
Uses
Medical uses
Intravenous (IV) 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
Fluid solutions
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:
The most commonly used crystalloid fluid is
Medication and treatment
The
Some medications, such as aprepitant, are chemically modified to be better suited for IV administration, forming a prodrug such as fosaprepitant. This can be for pharmacokinetic reasons or to delay the effect of the drug until it can be metabolized into the active form.[13]
Blood products
A
Nutrition
Imaging
Medical imaging relies on being able to clearly distinguish internal parts of the body from each other. One way this is accomplished is through the administration of a contrast agent into a vein.[17] The specific imaging technique being employed will determine the characteristics of an appropriate contrast agent to increase visibility of blood vessels or other features. Common contrast agents are administered into a peripheral vein from which they are distributed throughout the circulation to the imaging site.[18]
Other uses
Use in sports
IV rehydration was formerly a common technique for athletes.[19] The World Anti-Doping Agency prohibits intravenous injection of more than 100 mL per 12 hours, except under a medical exemption.[19] 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".[19] Players suspended after attending "boutique IV clinics" which offer this sort of treatment include footballer Samir Nasri in 2017[20] and swimmer Ryan Lochte in 2018.[21]
Use for hangover treatment
In the 1960s, John Myers developed the "
Others
In some countries, non-prescription intravenous glucose is used to improve a person's energy, but is not a part of routine medical care in countries such as the United States where glucose solutions are prescription drugs.[24] Improperly administered intravenous glucose (called "ringer" [citation needed]), such as that which is administered clandestinely in store-front clinics, poses increased risks due to improper technique and oversight.[24] Intravenous access is also sometimes used outside of a medical setting for the self-administration of recreational drugs, such as heroin and fentanyl, cocaine, methamphetamine, DMT, and others.[25]
Intravenous therapy is also used for veterinary patient management.[26]
Types
Bolus
Some medications can be administered as a bolus dose, which is called an "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.[27] A bolus may be administered rapidly (with a fast depression of the syringe plunger) or may be administered slowly, over the course of a few minutes.[27] The exact administration technique depends on the medication and other factors.[27] In some cases, a bolus of plain IV solution (i.e. without medication added) is administered immediately after the bolus to further force the medicine into the bloodstream. This procedure is termed an "IV flush". 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.[27]
Infusion
An infusion of medication may be used when it is desirable to have a constant blood concentration of a medication over time, such as with some antibiotics including beta-lactams.[28] Continuous infusions, where the next infusion is begun immediately following the completion of the prior, may also be used to limit variation in drug concentration in the blood (i.e. between the peak drug levels and the trough drug levels).[28] They may also be used instead of intermittent bolus injections for the same reason, such as with furosemide.[29] 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, for example vancomycin.[30]
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
Secondary
Any additional medication to be administered intravenously at the same time as an infusion may be connected to the primary tubing; this is termed a secondary IV, or IV piggyback.[27] This prevents the need for 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.[27] If a bolus or secondary infusion is intended for administration in the same line as a primary infusion, the molecular compatibility of the solutions must be considered.[27] Secondary compatibility is generally referred to as "y-site compatibility", named after the shape of the tubing which has a port for bolus administration.[27] Incompatibility of two fluids or medications can arise due to issues of molecular stability, changes in solubility, or degradation of one of the medications.[27]
Methods and equipment
Access
The simplest form of intravenous access is by passing a hollow needle through the skin directly into a vein. A syringe can be connected directly to this needle, which allows for a "bolus" dose to be administered. Alternatively, the needle may be placed and then connected to a length of tubing, allowing for an infusion to be administered.[32]: 344–348 The type and location of venous access (i.e. a central line versus peripheral line, and in which vein the line is placed) can be affected by the potential for some medications to cause peripheral vasoconstriction, which limits circulation to peripheral veins.[33]
A peripheral
The thickness and size 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".[32]: 188–191, 349
Peripheral lines
A peripheral intravenous line is inserted in
Central lines
A central line is an access method in which a catheter empties 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.[36]: 17–22
Peripherally inserted central catheter
A peripherally inserted central catheter (also called a PICC line) is a type of central IV access which consists of a cannula inserted through a sheath into a peripheral vein and then carefully fed towards the heart, terminating at the superior vena cava or the right atrium. These lines are usually placed in peripheral veins in the arm, and may be placed using the Seldinger technique under ultrasound guidance. An X-ray is used to verify that the end of the cannula is in the right place if fluoroscopy was not used during the insertion. An EKG can also be used in some cases to determine if the end of the cannula is in the correct location.[37]: Ch.1, 5, 6
Tunneled lines
A tunneled line is a type of central access which is inserted under the skin, and then travels a significant distance through surrounding tissue before reaching and penetrating the central vein. Using a tunneled line reduces the risk of infection as compared to other forms of access, as bacteria from the skin surface are not able to travel directly into the vein.[38] These catheters are often made of materials that resist infection and clotting. Types of tunneled central lines include the Hickman line or Broviac catheter. A tunnelled line is an option for long term venous access necessary for hemodialysis in people with poor kidney function. [39]
Implantable ports
An implanted port is a central line that does not have an external connector protruding from the skin for administration of medication. Instead, a port consists of a small reservoir covered with silicone rubber which is implanted under the skin, which then covers the reservoir. Medication is administered by injecting medication through the skin and the silicone port cover into the reservoir. When the needle is withdrawn, the reservoir cover reseals itself. A port cover is designed to function for hundreds of needle sticks during its lifetime. Ports may be placed in an arm or in the chest area.[40]
Infusions
Equipment used to place and administer an IV line for infusion consists of a bag, usually hanging above the height of the person, and sterile tubing through which the medicine is administered. In a basic "gravity" IV, a bag is simply hung above the height of the person and the solution is pulled via gravity through a tube attached to a needle inserted into a vein. Without extra equipment, it is not possible to precisely control the rate of administration. For this reason, a setup may also incorporate a clamp to regulate flow. Some IV lines may be placed with "Y-sites", devices which enable a secondary solution to be administered through the same line (known as piggybacking). Some systems employ a drip chamber, which prevents air from entering the bloodstream (causing an air embolism), and allows visual estimation of flow rate of the solution.[32]: 316–321, 344–348
Alternatively, an infusion pump allows precise control over the flow rate and total amount delivered. A pump is 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.[32]: 316–321, 344–348
Techniques
To reduce pain associated with the procedure, medical staff may apply a topical local anaesthetic (such as
: 344–348If 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.[32]: 355–359
Adverse effects
Pain
Placement of an intravenous line inherently causes pain when the skin is broken and is considered
Certain medications also have specific sensations of pain associated with their administration IV. This includes potassium, which when administered IV can cause a burning or painful sensation.[44] The incidence of side effects specific to a medication can be affected by the type of access (peripheral versus central), the rate of administration, or the quantity of drug administered. When medications are administered too rapidly through an IV line, a set of vague symptoms such as redness or rash, fever, and others may occur; this is termed an "infusion reaction" and is prevented by decreasing the rate of administration of the medication. When vancomycin is involved, this is commonly termed "Red Man syndrome" after the rapid flushing which occurs after rapid administration.[45]
Infection and inflammation
As placement of an intravenous line requires breaking the skin, there is a risk of infection. Skin-dwelling organisms such as
Inflammation of the vein may also occur, called thrombophlebitis or simply phlebitis. This may be caused by infection, the catheter itself, or the specific fluids or medication being given. Repeated instances of phlebitis can cause scar tissue to build up along a vein. A peripheral IV line 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 those whose IVs were replaced only when clinically indicated versus those whose IVs were replaced routinely.[46] If placed with proper aseptic technique, it is not recommended to change a peripheral IV line more frequently than every 72–96 hours.[47]
Phlebitis is particularly common in intravenous drug users,[48] and those undergoing chemotherapy,[49] whose veins can become sclerotic and difficult to access over time, sometimes forming a hard, painful "venous cord". The presence of a cord is a cause of discomfort and pain associated with IV therapy, and makes it more difficult for an IV line to be placed as a line cannot be placed in an area with a cord.[50]
Infiltration and extravasation
Infiltration occurs when a
Others
If the solutions administered are colder than the temperature of the body, induced hypothermia can occur. If the temperature change to the heart is rapid,
History
Discovery and development
The first recorded attempt at administering a therapeutic substance via IV injection was in 1492, when Pope Innocent VIII fell ill and was administered blood from healthy individuals.[56] If this occurred, the treatment did not work and resulted in the death of the donors while not healing the pope.[56] This story is disputed by some, who claim that the idea of blood transfusions could not have been considered by the medical professionals at the time, or that a complete description of blood circulation was not published until over 100 years later. The story is attributed to potential errors in translation of documents from the time, as well as potentially an intentional fabrication, whereas others still consider it to be accurate.[57] One of the leading medical history textbooks for medical and nursing students has claimed that the entire story was an anti-semitic fabrication.[58]
In 1656 Sir Christopher Wren and Robert Boyle worked on the subject. As stated by Wren, "I Have Injected Wine and Ale in a liveing Dog into the Mass of Blood by a Veine, in good Quantities, till I have made him extremely drunk, but soon after he Pisseth it out." The dog survived, grew fat, and was later stolen from his owner. Boyle attributed authorship to Wren.[59]
There was virtually no recorded success with any attempts at injection therapy until the 1800s, when in 1831 Thomas Latta studied the use of IV fluid replacements for cholera treatment.[56][61] The first solutions which saw widespread use for IV injections were simple "saline-like solutions", which were followed by experiments with various other liquids, including milk, sugar, honey, and egg yolk.[56] In the 1830s, James Blundell, an English obstetrician, used intravenous administration of blood to treat women bleeding profusely during or after delivery.[56] This predated the understanding of blood type, leading to unpredictable results.
Modern usage
Intravenous therapy was expanded by Italian physician
See also
References
- PMID 32832150.
- ^ a b Martin GS. "An Update on Intravenous Fluids". Medscape. WebMD. Retrieved 25 August 2020.
- S2CID 73725286.
- ^ ISBN 978-0-08-055232-3.
- ^ "What is an IV Vitamin Therapy? A Complete Guide by Nepenthe". Retrieved 2022-09-02.
- PMID 21908132.
- PMID 14739732.
- S2CID 9560849.
- ^ Doyle GR, McCutcheon JA (13 November 2015). "7.5". Clinical Procedures for Safer Patient Care. Victoria, BC: BCcampus.
- ^ "IV Fluids". Cleveland Clinic. Retrieved 2023-09-30.
- S2CID 32352501.
- PMID 10783821.
- PMID 28470980.
- ^ "Blood Transfusion | National Heart, Lung, and Blood Institute (NHLBI)". www.nhlbi.nih.gov. Retrieved 2019-06-16.
- S2CID 218532376.
- ISBN 978-0-07-183345-5.
- S2CID 8425664.
- PMID 24010394.
- ^ a b c "IV Infusion: Explanatory Note". U.S. Anti-Doping Agency (USADA). 5 January 2018. Retrieved 24 July 2018.
- ^ Press Association (1 August 2018). "Samir Nasri's doping ban extended from six to 18 months after appeal by Uefa". The Guardian. Retrieved 2 August 2018.
- ^ Caron E (23 July 2018). "Ryan Lochte suspended 14 months for anti-doping violation". Sports Illustrated. Retrieved 24 July 2018.
- ^ a b c Hess A (23 April 2014). "The Party Girl Drip". Elle. Retrieved 24 July 2018.
- S2CID 22431890.
- ^ a b Jiha Ham (March 20, 2015). "A Life Upended After an IV Glucose Treatment Popular Among Asian Immigrants". The New York Times. Retrieved March 21, 2015.
Although many doctors warn Asian immigrants in New York that the effects of injecting glucose differ little from drinking sugary water, many Asians, especially of older generations, still use the intravenous solution. In their homelands, it is commonly prescribed by doctors as a method to cure colds, fevers and sometimes an upset stomach.
- PMID 31712552.
- ISBN 978-1-78924-340-6.
- ^ S2CID 205539703.
- ^ S2CID 220732187.
- S2CID 208063606.
- ^ S2CID 13071392.
- PMID 31376243.
- ^ ISBN 978-0781786898.
- PMID 3527527.
- ISBN 9781455748594.
- PMID 16265830.
- ISBN 978-1451121186.
- ISBN 978-88-470-5665-7.
- S2CID 207955194.
- S2CID 44524962.
- S2CID 196610436.
- ^ ABIM Foundation, American College of Emergency Physicians, archived from the originalon March 7, 2014, retrieved January 24, 2014
- PMID 16856044.
- PMID 27113639.
- S2CID 204545798.
- PMID 25753888.
- PMID 30671926.
- PMID 21460264.
- PMID 6137064.
- S2CID 202745746.
- S2CID 49613143.
- S2CID 25278254.
- PMID 23032244.
- PMID 17667395.
- PMID 25866139.
- PMID 26027488.
- ^ PMID 8708844.
- PMID 13212030.
- ISBN 9780802098252.
- ^ Jorge Dagnino; Wren, Boyle, and the Origins of Intravenous Injections and the Royal Society of London. Anesthesiology 2009; 111:923–924 https://doi.org/10.1097/ALN.0b013e3181b56163
- ^ Felts, J. H. (2000). Richard Lower: anatomist and physiologist. Annals of internal medicine, 133(6), 485.
- .
- ^ See, for example, the Nobel Prize Nomination Database: https://www.nobelprize.org/nomination/redirector/?redir=archive/
- ISBN 978-0-8135-2197-8. Retrieved 2011-06-05.
Wanger and colleagues had in effect invented the modern I.V.-drip method of drug delivery [...]
- ^ Hirschfeld S, Hyman HT, .
- ^ Geggel L (3 December 2012). "A Royal Spotlight on a Rare Condition". The New York Times.
Further reading
- Royal College of Nursing, Standards for Infusion Therapy (Archive of the 4th edition (December 2016) via the Internet Wayback Machine)
External links
- Media related to Intravenous therapy at Wikimedia Commons