IV Fluids and Vascular Access
Choosing fluids, spotting complications, and central-line care
IV fluid types
| Type | Examples | Use | Caution |
|---|---|---|---|
| Isotonic (stays in the vessels) | 0.9% NaCl, lactated Ringer's, Plasma-Lyte | Volume replacement, shock, blood transfusion (NS only), resuscitation | Fluid overload in HF and kidney failure |
| Hypotonic (moves into cells) | 0.45% NaCl; D5W once the sugar is used | Cellular dehydration, hypernatremia | Avoid in ↑ICP, burns, trauma (worsens swelling and third-spacing) |
| Hypertonic (pulls fluid out of cells) | 3% NaCl, D10W, D5NS, D5½NS, D5LR | Severe hyponatremia, cerebral edema (3% saline) | Fluid overload; 3% saline via pump with frequent Na⁺ checks |
D5W is not used for resuscitation or in brain injury. Hypertonic saline correction must be slow (generally ≤8–10 mEq/L in 24 h).
IV complications
| Problem | Signs | Action |
|---|---|---|
| Infiltration | Cool, pale, swollen, tight skin; slow flow | Stop, remove, elevate; warm or cold compress per fluid; restart elsewhere |
| Extravasation (vesicant) | As above + pain, blistering, tissue damage | Stop and disconnect; aspirate through the catheter; antidote per protocol (e.g., phentolamine for norepinephrine); then remove; elevate; notify |
| Phlebitis | Red, warm, tender, cord-like vein | Stop, remove, warm compress, restart in the other arm |
| Fluid overload | Crackles, dyspnea, JVD, ↑ BP, edema | Slow the IV, high Fowler's, oxygen, notify (diuretic) |
| Air embolism | Sudden dyspnea, chest pain, hypotension | Clamp the line; left side, head down (Trendelenburg); oxygen; call for help |
| Local infection | Redness, drainage at site, fever | Remove; culture per order |
Central lines (CLABSI prevention)
- Insertion: hand hygiene, maximal sterile barriers, chlorhexidine-alcohol skin prep; avoid the femoral site when possible.
- Scrub the hub 5–15 sec before every access; needleless connectors.
- Transparent dressing changed every 7 days (gauze every 2 days) or sooner if damp, loose or soiled.
- Flush with a 10 mL (or larger) syringe, push-pause technique.
- Review every day whether the line is still needed.
- Removal: patient flat or slightly head-down; Valsalva (or breath-hold) during removal; occlusive dressing.
- PICC: no BP or blood draws on that arm.
Parenteral nutrition (TPN)
- Central line (high dextrose); dedicated lumen; never add drugs.
- Filter per policy; change tubing every 24 h.
- Monitor glucose often (hyperglycemia); weigh daily; electrolytes.
- Don't stop suddenly: if the bag is late or runs out, hang D10W at the same rate (prevents rebound hypoglycemia).
- Refeeding syndrome in malnourished patients: low phosphate, K⁺ and Mg²⁺: start slowly.