A&p Exam 2 Lecture 2: Vascular Access

Front 1

A&P EXAM 2 LECTURE 2: VASCULAR ACCESS

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A&P EXAM 2 LECTURE 2: VASCULAR ACCESS

Front 2

What are the purposes of IV placement?

Back 2

1. NPO
2. fluid loss
3. blood loss
4. drug adm.

Front 3

Types of IV fluids?

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1. crystalloid
2. colloid
3. blood products

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Fluid Vol Distribution

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60% TBW

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Osmolality

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Concentration of an osmotic solution per 1 Kg of solvent.

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Osmolarity

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.... per Liter of fluid.

Front 7

What is the effect of large protein molecules across capillary membranes?

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Produces colloid osmotic pressures.

Normal: 28 mmHg

Note: ions produce osmotic pressures across cell membranes, but NOT capillary membranes.

Normal: 285 mOsm/L

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Normal ranges for:
1. Na
2. K
3. Cl
4. HCO3
5. Ca

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Na: 135-145 mEq/L
K: 3.5-5.0
Cl: 100-106
HCO3: 22-26
Ca: 8.5-10

Front 9

What is the definition of an equivalent?

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The amount of electrolyte or ion that provides 1mol of electrical charge.

Can replace with 1g of hydrogen.

1 mol Na = 1 equiv
1 mol Ca = 2 equiv

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mEq/L =

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(mg/100ml/ atomic weight)*valence*10

Slide 13

Front 11

Normal Sodium and Osmolatlity values:

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Normal saline: 154 (308 mOsm/kg)

Normal pt: 140 (285-290)

Lactated Ringers: 130 (273)

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Tonicity of fluid dictates:

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Whether the soln should be delivered via peripheral or central venous route.

Front 13

What are some effects of solutions that differ greatly from normal range?

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1. tissue irritation
2. pain on injection
3. electrolyte shifts
4. inflammatory
5. enhanced clotting processes
6. phlebitis and thrombophlebitis

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Very Hypotonic IV soln, i.e. 1/4 NS, can cause RBCs to:

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Swell and burst

Front 15

What is the total fluid replacement therapy for healthy adults?

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2500 ml/day

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4-2-1 Rule (A rule for estimating fluid replacement)

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Ex. 70kg pt.:

4ml/kg/hr * 10kg = 40 ml/hr
2 * 10 = 20
1 * 50(remainder) = 50

70Kg = 110ml/hr

If NPO is 8hrs, then 8*110 = 880ml

Front 17

What are the normal ranges of sensible fluid loss perioperative?

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2-4 ml/kg/hr minor surgery
4-6 .. moderate
6-10... major

Front 18

Crystalloids

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Aqueous soln of LOW MW ions with or without glucose.

Ex: NS, LR

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Colloid

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Aqueous soln of high MW substances.

Maintain plasma colloid oncotic pressure.

Ex: Albumin, Hetastarch

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Blood products help to:

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Improve O2 carrying capacity.

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Some IV fluid generalizations that are good to know:

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1. crystalloids are as effective as colloids in restoring intravascular volume if given in sufficient amount.
2. crystalloids require 3X vol of colloids/blood when replacing lost volume.
3. pt have extra cellular deficit MORE than intravascular deficit.
4. Colloids correct faster

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Lactated Ringers

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Lowers Na level
Hypotonic (273 mOsm/L)

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NS 0.9% NaCl

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Tx hypochloremic metabolic alkalosis.

PRBC dilution

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D5W & D5NS

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Replace pure H2O deficit
Maintenance fluid pt w/Na restrictions.

Front 25

Crystalloid distribution

Back 25

Slide 27

Print out

Front 26

Colloid

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Generally admin in vol equivalent to vol of blood lost.

Ex.:
1. albumin
2. dextran
3. hetastarch

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Colloid distribution

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Draw out the distribution








.

Front 28

Hetastarch facts

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Composed of chains of glucose.

No antigenic, ABO interference

Prolong PT, aPTT, bleeding > 20ml/kg.

Front 29

What are some hetastarch contraindications?

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1. hydroxyethyl ether allergy
2. CHF
3. coagulopathy
4. renal dz (oligouria/anuria)

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Blood products

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PRBC
FFP
Cryoprecipitate
Platelets
Cell saver
Whole blood

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1 PRBC is how much Hct increase?

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By 3% or Hb to increase 1g/dl

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Recommedations for RBC:

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1. not usually indicated when Hb is greater than 10g/dl
2. almost always indicated when it's less than 6g/dl

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Transfusion recommendations

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Platelets < 50K

Target > 100K/mm3

Each unit increases 5-10K/mm3

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Transfusion Recommendations for FFP

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Fresh Frozen Plasma

NOTE: Plasma makes up 55% of blood. Contains clotting factors.

1. for urgent reversal of warfarin
2. correction of coagulation factor deficiencies
3. for elevated PT or PIT
4. correction of microvascular bleeding

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Fresh frozen plasma

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1. contains all plasma proteins and CF (clotting factors).
2. each unit increases CF by 2-3%
3. warmed to 37C
4. same infectious risk as PRBC.

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Cryoprecipitate

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1. Do not need it to be ABO type.
2. contains factors: VIII, fibrinogen, von Willebrand factor, and XIII.

NOTE: von Willebrand dz: hereditary coagulation abnormality. Lacks von Willebrand factor which is required for proper platelet adhesion.

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Recommendations for cryoprecipitate

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1. prophylaxis in nonbleeding pts with Von Willebrands dz.
2. correction of microvascular bleeding.

Front 38

Where do we put IVs in the upper extremities?

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1. dorsum of hand
2. forearm
3. antecubital fossa (cephalic, basilic)

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.... in the lower extremeties?

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1. dorsum of foot
2. femoral vein

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Other sites for IVs?

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1. external/internal jugular veins.
2. subclavian vein

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Things you need for IVs

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1. gauze
2. alcohol wipes
3. tourniquet
4. catheter
5. IV tubing
6. tape and tegaderm
7. lidocaine

Front 42

Talk to pt about IV experience

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Ask:
Have u ever had an IV done before?

Location that was most successful for you?

Explain procedure

Front 43

IV prep

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1. apply tourniquet
2. maximize venous engorgement
3. locate suitable vein
4. clean/disinfect

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IV insertion

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1. apply traction
2. insert angiocath
3. watch for flash in hub
4. advance catheter
5. release tourniquet

Front 45

What are the indications for arterial lines?

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1. BP monitoring
2. blood sampling
3. deliberate hypotension

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Sites for arterial lines?

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1. radial
2. brachial
3. femoral
4. dorsalis pedis

Front 47

Radial artery vs. Ulnar artery

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Ulnar artery provides the majority of blood flow to the had in 90% of patients.

Ulnar artery is more difficult to cannulate. However, radial is usually chosen since ulnar provides the majority of blood flow to the hand.

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What diseases would give contraindications to arterial cannulations?

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1. raynaud's syndrome
2. Buerger's dz

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Raynaud's Dz

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Pale fingers due to constriction of vessels.

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Brachial artery

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Large easily identifiable vessel in the antecubital space.

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Femoral artery

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Prone to pseudoaneurysm and atheroma formation following cardiac catherization.

Possible higher rate of infection.

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Dosalis pedis & Posterior tibial

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Reasonable alternative to radial or ulnar artery cannulation.

NOTE: should not be used in patients with diabetes or peripheral vascular disease (PVD).

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Axillary

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Nerve damage may occur

Air or thrombus may quickly gain access to cerebral circulation during flush.

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What are some risks to radial artery catherization?

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1. vascular thrombosis
2. distal embolization
3. proximal embolization
4. vascular spasm
5. skin necrosis
6. local infection

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Indications for Central venous access

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1. monitoring central venous pressure.
2. fluid administration
3. TPN
4. air emboli aspiration
5. poor peripheral access

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What is central venous access?

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It is used to:
1. administer medication or fluids
2. obtain blood tests (specifically the "mixed venous oxygen saturation"),
3. directly obtain central venous pressure.

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Contraindications to central venous catherization:

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1. R atrial tumors
2. fungating tricuspid valve vegetations.

Front 58

Routes of central venous?

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1. peripherally inserted central cather (PICC)
2. femoral vein
3. external/internal jugular
4. subclavian vein

Front 59

Complications of central venous?

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1. pneumothorax/hemothorax
2. air embolism
3. arrythmias
4. infection

Front 60

Does size of catheters really matter?

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YES