Clinical Skills Archives - Student Nurse Life

Total Parenteral Nutrition – Indications & Complications & Nursing Care

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Total parenteral nutrition can provide an individual with the necessary nutritional support and provision of therapeutic nutrients to maintain or restore optimal nutrition status and health. Total Parenteral Nutrition bypasses the digestive system by dripping a nutritionally adequate hypertonic solution containing glucose, protein, hydrolysates, minerals and vitramins directly into the venous system through an indwelling catheter into the superior vena cava or another main vein.

Total Parenteral Nutrition Contents

MACRO-NUTRIENTS:

Carbohydrates (glucose)
Proteins (amino acids)
Lipids (fatty acids)

OTHERS:

Electrolytes

total parenteral nutrition — TPN Bag consisting of Macro-Nutrients + Electrolytes – Retrieved from https://www.mims.com/hongkong/drug/info/olimel%20n9e-periolimel%20n4e?type=full on 2nd June 2021

MICRO-NUTRIENTS:

Multi-Vitamins (eg. Vitamin B)
Trace Elements/Minerals (eg. Selenium & Manganese)

Multivitamins (Cernevit) and Trace Elements/Minerals for TPN – Retrieved from https://www.mims.com/thailand/drug/info/cernevit & https://www.fda.gov/media/86363/download on 2nd June 2021

A bag of TPN provides the patient with about 2270kcal nutritional intake. This high calorie intake is not considered to be too much since patients on TPN are usually fighting inflammation, requiring wound healing etc.

Indications for Total Parenteral Nutrition

Total Parenteral Nutrition is indicated for patients who:

are lacking nutritional requirements (commonly related to health-related conditions)
have documented inadequate oral intake (common indication in the elderly)
experience an unpredictable return of their GI function (eg. malabsorption leading to lack of good nutritional outcome)
are on a prolonged nil-by-mouth period (eg. patients undergoing GI surgery)

DIGESTIVE DISORDERS:

GI fistulae
major GI surgery
uncontrolled malabsorption (eg. in Chron’s Disease)
short bowel syndrome (gastroschisis, volvulus & necrotising enterocolitis)
severe enteropathy (genetic-related issues such as microvillus atrophy, tufting enteropathy, congenital, auto-immune)
dysmotility or pseudo-obstruction
severe acute pancreatitis

NON-DIGESTIVE DISORDERS:

post-chemotherapy
radiotherapy
severe mucositis
bone marrow transplant
multi-organ failure in extensive trauma and burns
immature gut

Contraindications for Total Parenteral Nutrition

functioning GI tract (if the problem is with the upper GI tract and the lower GI tract is fully functioning, enteral feeding directly into the jenunum would be recommended)
need for <5 days of TPN with no severe malnutrition
difficulty in obtaining venous access
poor prognosis that doesn’t warrant aggressive nutritional support
if risks outweigh the benefits

TPN and CVCs Complications

catheter and systemic infections
catheter obstruction eg. blocked lumens
pneumothorax (may happen during catheter insertion)
thrombosis (may happen during catheter insertion)
bone disease
hepatobiliary disease (eg. TPN-induced liver failure due to the nutritional infusion being administered directly into the venous system)
renal disease

Patient Monitoring

vital signs (temperature to monitor for sepsis; blood glucose monitoring due to TPN containing 40% glucose)
intake & output
weight (especially malnourished patients)
fluid requirements
patient complaints
CVC exit site (monitor for signs of inflammation)
overall clinical status
blood (renal: U&E, Mg, Ca, Phos, Cr; heamat: CBC, INR; liver function: Alk Phos, Bil.; Glucose and Lipid, Iron and Ferritin; Albumin)
MRSA nasal swabbing (if patient is colonised with MRSA, treatment is required prior to developing into an infection)

TPN Bag Changing Technique

use an aseptic non-touch technique
hand hygiene
don apron
clean work surface with 70% alcohol and let dry
cover with sterile drape
place all sterile items on it: sterile IVI tubing, syringe and needle
other needed items should be placed in a cleaned tray
apply alcohol handrub
don gloves
switch off volumetric pump
disconnect previous TPN line from the needleless valve attached to the central venous catheter
mix the 3 compartments of the new TPN bag and hang on drip stand – DO NOT TOUCH CONNECTION PARTS
disinfect the needleless valve with 2% chlorhexidine in 70% alcohol and leave to dry
spike TPN bag with infusion line and prime whilst still capped
remove cap and connect to patient through the needleless valve
add additives Additrace and Cernevit to the TPN bag from the injectable port using an aseptic non-touch technique
dispose of materials appropriately

Below you can find a video that can help provide a more visual approach to total parenteral nutrition.

Total Parenteral Nutrition OSCE

Special thanks to the creators of the featured video on this post, specifically Youtube Channel University of Manitoba Nursing Skills. Featured image credit: https://badgut.org/information-centre/a-z-digestive-topics/parenteral-nutrition/

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Peripheral Vascular Access – Sites, Indications & Contraindications

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Peripheral vascular access is commonly sought through the non-dominant upper extremity due to a reduced risk of dislodgement, thrombosis and thrombophlebitis. However, peripheral venous line cannulation can be done successfully through various sites in the body.

Peripheral Vascular Access Sites

Upper Extremity: The metacarpal veins on the dorsum of the hand drain proximally through the dorsal venous arch into the cephalic and basilic veins in the forearm. These connect by the median cubital and median antebrachial veins in the antecubital fossa region, prior to continuing up the arm.

Lower Extremity: lines may be placed from the dorsal venous plexus of the foot which become the great and small saphenous veins in the leg.

Retrieved from https://www.jaypeedigital.com/book/9789351524229/chapter/ch18 on 1st June 2021

Scalp: may be appropriate in neonates or infants. Sites include the frontal, occipital, superficial temporal or posterior auricular veins.

Preferred veins for cannulation are straight, distal and non-branched (since venous valves are usually located close to branching points). When accessing a vein, a tourniquet is to be placed proximally to the site to create engorgement in the vein. Vein should feel spongy and should not pulsate on palpation (indication of an artery rather than a vein). Avoid veins that are hard to the touch due to possible thrombosis.

Indications for Peripheral Vascular Access

administration of IV medications
administration of IV fluids
phlebotomy (prior to medication and/or fluids to avoid dilution or contamination of blood samples)

Contraindications for Peripheral Vascular Access

While there are no absolute contraindications for cannulation, there are relative contraindications for which clinical judgement on benefits and risks of procedure is warranted. These include:

coagulopathy
local infection
burns
compromised skin at planned insertion site
previous lymphatic nodal clearance
arteriovenous fistula formation
deep vein thrombosis

In the case of extended treatment, it is best to opt for a central venous catheter rather than peripheral vascular access, as this offers lower failure rates in relation to long-term use.

Optimum PVA Outcome

prompt placement of peripheral vascular access when required
regular monitoring of line function
consideration regarding need for venous access
removal of lines when no longer indicated
early intervention in the case of complications

Below you can find a collection of videos that can help provide a more visual approach to peripheral vascular access.

IV Cannulation OSCE

BD Venflon I IV Cannula

IV Insertion Common Mistakes

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Geeky Medics, BD and Practical Anesthesia Techniques.

Reference:

Beecham, G.B. & Tackling, G. (2020). Peripheral Line Placement. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK539795/ on 2nd June 2021

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Chemotherapy Administration

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Cancer is a disease in which some body cells start to divide rapidly, leading to a spread to other parts of the body. Tumour cells tend to grow in a much more rapid way than normal cells. Chemotherapy administration stops this cell division process by killing them.

Chemotherapy administration routes include oral, subcutaneous, intramuscular, intravenous, intrathecal (into the spinal fluid) , intravesical (into the bladder to treat bladder cancer) and topical (eg. in melanoma).

A Chemotherapy Treatment Chart includes:

chemotherapy name
dosage
route
date and time for each chemotherapy administration (be it on the same day or on different days)
patient details
medications to be administered along with chemotherapy eg. antiemetics to counteract nausea caused by chemotherapy
signature, name or initials of medical officer prescription in chemotherapy administration chart

Excerpt from a Chemotherapy Protocol – Retrieved from http://nssg.oxford-haematology.org.uk/lymphoma/documents/lymphoma-chemo-protocols/L-80-r-chop-21.pdf on 31st May 2021

In reference to the above protocol excerpt:

R-CHOP-21 is the name of the protocol
The letters RCHOP refer to the chemotherapies being administered
P is referring to Prednisolone
21 refers to the number of days per chemotherapy cycle
The protocol outlines all details related to the chemotherapies being administered and how all medications should be administered to one specific patient

Prior To Chemotherapy Administration

Medical assessment needs to be carried out and documented on file (patient has to be deemed fit for chemotherapy prior to treatment start)
Parameters as well as height and weight need to be taken as baseline (patient shouldn’t be given when or if patient is severely unwell, as chemotherapy worsens patient condition)
Informed consent should be acquired from the patient and placed in file
Routine tests such as blood tests, allergies and pregnancy result should be acquired and checked by the medical officer
Re-discuss side effects with patient
Get chemotherapy from designated locations

First Check – Prior to Chemotherapy Administration

Patient identity details
Name of Chemotherapy
Dose of Chemotherapy
Route of administration
Date and Time of administration
Chemotherapy drugs sequence
Duration of infusion
Rate of administration
Pharmacist signature
Expiry date and time
Uncompromised integrity of chemotherapy bag
Known drug allergies
Protect from light if required

With reference to the above, the information on the chemotherapy treatment chart and the chemotherapy plastic bag must be compared and matched. Check should be carried out independently by two different nurses at the patient’s side immediately prior to administration.

Second Check – Prior to Chemotherapy Administration

Patient identity details
Name of chemotherapy
Chemotherapy dose and volume
Route of administration
Date and Time of administration
Expiry date and time
Pharmacist signature
Check for precipitation in chemotherapy container

With reference to the above, the information on the chemotherapy plastic bag and the chemotherapy container inside must be compared and matched. Check should be carried out independently by two different nurses at the patient’s side immediately prior to administration.

Third Check – Prior to Chemotherapy Administration

Patient identity details
Known drug allergies

With reference to the above, the information on the chemotherapy container must be checked with patient. Check is usually carried out by the nurse administering the chemotherapy.

Once all checks are performed, the two nurses sign on the treatment chart, indicating that the chemotherapy administration can be started.

Preparation – Prior to Chemotherapy Administration

Anaphylactic reaction/shock tray (Hydrocortisone, Chlorphenamine – antihistamine, Ventolin for bronchospasms, flushes, oxygen masks etc.)
CPR trolley
Emergency call bell
Hypersensitivity tray
Extravasation kit
Hot and Cold pack
Chemotherapy spillage kit
Emergency shower

Oral Chemotherapy

compliance with prescribed drug schedule
check dietary requirements in relation to oral drug administration
handle with gloves
do NOT crush chemotherapy tablets/capsules

Drug Administration

Administer chemotherapy preferably via a central line
If a cannula is being used (eg. if chemotherapy needs to be administered urgently), insert cannula immediately before chemotherapy administration in large veins in the upper limbs (use either the pink or the blue cannulas for chemotherapy administration); chemotherapy should NOT be administered via cannulas in the lower limbs or over bony prominences or in small veins
Avoid repeated punctures to the same vein during the same venepuncture session as this increases the risk of extravasation
Use clear dressing over insertion site to see any leakages immediately (do not use bandages or occlusive dressings)
Tell patient to report immediately any signs or symptoms such as stinging, burning sensation, tenderness, pain or any other sensation at the infusion site
Check for venous return (back-flow) prior to chemotherapy administration

Personal Protective Equipment

gloves (one set of gloves is enough)
use double gloving only in the case of chemotherapy spillage or topical application of chemotherapy
cover cuts and scratches with waterproof dressing to avoid infiltration of the skin by chemotherapy
gloves should be worn at all times when in contact with bodily fluids from patient receiving chemotherapy
plastic apron or if available, gown during chemotherapy administration
gown should be used in the case of chemotherapy spillage
goggles or full face visor should be used when dealing with spillages (if chemotherapy is splashed into eyes, rinse continuously with cold running water for 10-20 minutes and seek medical advice)
masks should be worn in chemotherapy spillage event
shoe covers should be worn for spillage management
handle chemotherapy below waist level to avoid spillages on face
pregnant nurses should avoid administering chemotherapy
items that come into contact with chemotherapy should be discarded into the appropriate chemotherapy waste bins

Chemotherapy cannot be cleaned by alcohol handrub…use soap and water instead.

In the case of Extravasation…

STOP infusion and DISCONNECT tubing
WITHDRAW as much drug from cannula or central line as possible
DO NOT FLUSH!
Inform medical officer
Open extravasation kit

Extravasation – Retrieved from https://www.pinterest.com/pin/504966176945168896/ on 1st June 2021

In the case of Hypersensitivity Reaction…

Hypersensitivity reaction manifests as uticaria, bronchospasm, rash, abdomen cramping and hypotension, usually with treatments such as Rituximab. If the patient has a high risk of hypersensitivity reaction, premedication is given as steroids and antihistamines.

Further information about different chemotherapy drugs can be found at https://www.macmillan.org.uk/

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Central Venous Access Devices – CVCs & PICC Line Insertion & Care

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Central Venous Access Devices (CVAD) are catheters inserted into a vein through the venous system, which are then advanced to the lower third of the superior vena cava, which has a higher blood flow than any other peripheral vein. This allows irritant drugs and fluids to get diluted quickly, thus avoiding damage to the vein.

A Central Venous Access Device is a central venous catheter which is inserted either through a peripheral vein (PICC Line) or through a proximal central vein, usuall through the internal jugular vein, subclavian vein or femoral vein (CVC).

A CVAD is inserted using a sterile technique in a theatre setting.

Indications for Central Venous Access Devices

ACCESS FOR DRUGS:

irritant drug infusion (eg. Chemotherapy & Total Parenteral Nutrition)
poor peripheral access (eg. patient is experiencing a hypovolaemic shock)
long term drug administration (eg. IV antibiotic treatment for weeks)

ACCESS FOR EXTRACORPOREAL BLOOD CIRCUITS:

renal placement therapy (dialysis)
plasma exchange

Both of the above are high-flow procedures for which peripheral venous access cannot be chosen.

ACCESS FOR INTERVENTION MONITORING:

central venous pressure
central venous O2 saturation
pulmonary artery pressure
temporary transvenous pacing
targeted temperature management
frequent blood sampling

Central Venous Access Devices Contraindications

site trauma
site infection
vein thrombosis or stenosis (narrowing)
coagulopathy (impaired ability to clot blood, leading to increased risk of bleeding) and thrombocytopaenia (decreased number of platelets in blood, leading to increased risk of bleeding)
vessel haemorrhage
proximal vascular injury eg. blunt or penetrating injury on site

CVAD Classification

Site (jugular or subclavian or femoral or brachial)
Lumens (single or double or triple or quad)
Time (short term or mid term or long term)
Type (central or peripheral)
Tunnelling (tunnelled or non-tunnelled <6 weeks or totally implantable port-a-cath for years)

Complete table can be retrieved from Smith and Nolan, 2013. Central venous catheters. *BMJ : British Medical Journal,* 22(7933), E44277-32.

Retrieved from https://edu.cdhb.health.nz/Hospitals-Services/Health-Professionals/pdu/Documents/CENTRAL%20VENOUS%20ACCESS%20DEVICE%20%20Resource%20Book%202011.pdf on 30th May 2021

Central Venous Catheter Insertion

May be inserted under ultrasound directed technique
Inserted by an anaesthetist in a theatre setting
Anatomical landmarks can be used in emergency situations
Trendelburg position (supine with head declined) is used during procedure to avoid air embolus

CVC (central venous catheter) is inserted through the internal jugular vein, subclavian vein or femoral vein.

PICC (peripherally inserted central catheter) is inserted through a peripheral vein eg. basilic vein or cephalic vein.

Protective Measures and Protective Equipment for Insertion

Sterility and an aseptic technique with PPEs including sterile gown, sterile gloves and sterile drape. In case of increased risk of contact with blood or body fluids, eye and/or full protection should be used.

2% Chlorhexidine Gluconate in 70% Isopropyl alcohol should be used and allowed to dry (in case of patient sensitivity use Povidone-Iodine instead).

Dressing used should be sterile, semi-permeable and transparent to allow insertion site observation.

Blood is aspirated from all lumens to confirm lumen patency.

Chest x-ray is to be performed prior to use so as to rule out pneumothorax and confirm correct placement.

Central Venous Access Devices Tip Placement

CVAD position must be verified through an x-ray prior to use
CVC distal tip inserted into the upper body must be placed in the cavoatrial junction (the point in which the superior vena cava meets the right atrium)
CVC distal tip inserted through the femoral vein must be placed in the inferior vena cava right above the diaphragm level
PICC line distal tip inserted into a peripheral vein must be placed resting in the superior vena cava

Incorrect catheter tip placement increases the risk of mechanical and thrombotic complications. Tip positioning depends on the indications for catheterisation and the chosen site of insertion in the patient.

CVC Care

Use an aseptic technique for CVC care
Needleless injection ports must be changed once a week
Catheter site must be cleaned at least once a week using 2% chlorhexidine in 70% alcohol unless visibly soiled
Ports should be cleaned with 2% chlorhexidine in 70% alcohol prior to use
Use a gauze dressing if entry site is bleeding or oozing until resolved; otherwise use a transparent semi-permeable dressing for easy observation of entry site
Push-pause technique with 0.9% saline in a 10ml syringe is recommended for flushing of lumens, as this technique creates turbulence and allows the flushing of any debris in the lumens
Apply positive pressure (hold plunger down) when disconnecting syringe to avoid air entering the catheter
Apply central line dressing using aseptic technique; Use a sterile dressing pack and sterile gloves (since you’re accessing entry site); Disinfect skin with 2% Chlorhexidine in 70% Alcohol foam; Write date of dressing change on dressing
Replace administration set immediately after blood products administration; after 24 hours after total parenteral nutrition containing lipids; otherwise within 72 hours
Remove catheter if no longer required

CVC Blood Sampling

CVC blood sampling must be performed using a Vacutainer via a needleless injection cap to maintain a closed system and prevent being contaminated with patient blood. Following blood sampling from a CVC, flush using at least 20ml 0.9% sodium chloride using a 10ml and another 10ml syringe.

CVAD Care in the Community

Patient family members may be required to care for a CVAD within the community setting. Teaching correct procedures is crucial in avoiding unnecessary infections.

Change dressing weekly unless soiled or not intact, cleaning insertion site with 2% chlorhexidine in 70% alcohol prior to dressing change
Aspirate and flush lumens weekly if not regularly used
Take a shower, not a bath, to reduce infection risk
Swimming (submerging of CVC) is not recommended
Avoid vigorous physical activity so as not to dislodge CVC
Implanted ports require no such restrictions

CVC Complications

DELAYED: central line dysfunction and/or infection

IMMEDIATE: vascular, cardiac and/or pulmonary

INFECTIOUS : sepsis (widespread infection) and/or site infection

EMBOLIC: thrombosis (eg. air embolus)

MECHANICAL: dislodgement, incorrect plaement, catheter damage and/or catheter migration

If occlusion within the catheter is noted, ask patient to cough and take deep breaths and raise arm over head, as occlusion can be a positional issue.

Central Venous Catheter Blood Stream Infection (CVCBSI)

A CLABSI (central line associated bloodstream infection) is an infection that develops within 48 hours of a central line insertion, which is unrelated to any other infection site.

EXTRALUMINAL COLONISATION – originating from skin insertion site, commonly occurring in non-tunnelled CVCs

INTRALUMINAL COLONISATION – originating from catheter hub, commonly occurring in long-term lines eg. tunnelled CVCs

HEMATOGENOUSLY COLONISED – originating from a distant infection site

Retrieved from https://slideplayer.com/slide/10175240/ on 31st May 2021

Below you can find a collection of videos that can help provide a more visual approach to Central Venous Access Devices.

Ultrasound Guided Subclavian Central Lines

Applying a Central Line Dressing

Blood Culture from Central Venous Access Devices

Drug Administration via Central Venous Access Devices

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels American Thoracic Society, SmithandNephewUKI and Infection Prevention and Control – Malta.

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Phlebotomy – Withdrawing Venous Blood for Blood Testing Purposes

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Phlebotomy is the introduction of a needle into a vein to withdraw a sample of blood for haematology (to assess blood cell composition eg. Complete Blood Count CBC), biochemistry (to assess electrolytes) or bacteriology (blood cultures) reasons.

Venepuncture is a highly invasive common diagnostic advanced skill regulated by institutional or ward protocols.

Blood investigations are required for:

evaluating treatment progress
screening for specific diseases
ensuring that a drug is within its therapeutic level (eg. checking digoxin levels to prevent digoxin toxicity)
checking for the patient’s wellbeing

Venepuncture Preferred Sites:

Basilic Vein
Cephalic Vein
Medial-Cubital Vein

The basilic vein on the dorsum of the hand can also be accessed, whilst foot veins should be accessed only as a last resort.

AVOID:

amputation, mastectomy or lymphoedema sides
fractured limb
paralysis sides
AV graft or fistula
IV infusion sites
frequently used areas for venepuncture

DO NOT USE:

pulsating vessels (they are probably arteries)
haematoma
oedema
inflammation or infection
fibrous veins (rigid, cordlike veins that roll)

phlebotomy — Veins and cutaneous nerves in the antecubital fossa. Median cubital vein near the cephalic vein is the first choice for a routine venipuncture to cause nerve damage least likely. Retrieved from https://www.researchgate.net/figure/Veins-and-cutaneous-nerves-in-the-antecubital-fossa-Median-cubital-vein-near-the_fig1_316596433 on 29th May 2021

Factors Influencing Venous Circulation

VASOCONSTRICTION – anxiety, stress, shock, cold
VASODILATION – warm, mechanical irritation, chemical irritation
BLOOD PRESSURE DROP
THROMBOSIS
LOW IV COMPONENT – dehydration, haemorrhage

Phlebotomy Procedure

Equipment Needed for Venepuncture

tourniquet
alcohol swabs
non-sterile gloves
vacutainer OR syringe & needle
blood sample bottles
sharps container
gauze swab
adhesive dressing

Nurse Safety Procedures:

hand hygiene
gloves
dispose of used items correctly
handle needles safely
dispose of needles in the sharps box

Patient Safety Procedures:

confirm patient identity
perform skill only if needed
cross-contamination prevention
disinfect skin

In the case of difficult venous access:

tap gently onto the vein
put arm in warm water to encourage vasodilation
lower arm below the level of the heart
ask for assistance
use advanced imaging techniques

NOTES:

When taking blood, mix sample bottle between 8-10 times after withdrawal.

Bleeding following venepuncture can take up to 10 minutes to stop, thus, tell patient to apply pressure to avoid haematoma formation.

Phlebotomy Problems:

ARTERIAL STAB:

immediately remove needle
apply firm pressure and elevate for more than 5 minutes until bleeding stops
assess movement, sensation and circulation of affected limb
consult physician

NERVE DAMAGE:

immediately remove needle
examine movement, sensation and circulation of affected limb
consult physician

HAEMATOMA PREVENTION:

insert needle at correct angle to avoid opposite vein wall perforation
hold vacutainer and needle steadily whilst taking blood
remove tourniquet prior to removing needle
apply pressure on puncture site immediately following needle removal

Below you can find a collection of videos that can help provide a more visual approach to Phlebotomy.

Phlebotomy

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels OSHVideo08 and RegisteredNurseRN.

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Administration of Blood and Blood Components

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Administration of blood and blood components can be indicated to restore blood volume where there is inadequate tissue perfusion, to replace platelets, coagulation factors and other plasma proteins, as well as to increase the haemoglobin concentration and the blood oxygen carrying capacity.

Red Cell Concentrates – indicated for anaemia and acute blood loss: help increase oxygen carrying capacity through raising haemoglobin concentration in the patient. Can be stored in a temperature of 4 +/-2°C for 42 days (or for 28 days if irradiated). If unused or left for more than 30 minutes in the transport box, Red Cell Concentrates should be returned to the Blood Bank to minimise the risk of bacterial growth.

Fresh Frozen Plasma – indicated for warfarin reversal in a bleeding patient, in DIC (Disseminated Intravascular Coagulation) in a bleeding patient, or in Thrombotic Thrombocytopenia Purpura during plasma exchange. Can be stored in a temperature of less than -25°C for 3 years; must be used by 6 hours following thawing if stored in the blood transport box.

Platelets – indicated for massive haemorrhage / DIC, acute leukaemia, lumbar puncture, gastroscopy, biopsy, liver biopsy, laparatomy and eye operations: help prevent and/or treat haemorrhage in patients with Thrombocytopenia or Platelet Function Defect. Can be stored in a temperature of 22 +/-2°C for 5 days in an agitator. Platelets should be transfused immediately…they should NOT be stored outside the Blood Bank.

Special Requirements:

CMV (CytoMegaloVirus) Negative Blood: indicated for intrauterine transfusions, neonate transfusion (28 days post EDD) and pregnant women transfusion.

Irradiated Blood: indicated for intrauterine transfusion, BM/ stem cell transplantation, Hodgkin’s disease, etc.

Collection of Blood Units from HBB

Prior to blood units being collected from the Hospital Blood Bank, patient must be ready to be transfused: WEARING ID band; HAVING patent IV access; RECORDING of patient baseline observations.

Blood should be collected in the appropriate transport boxes with the necessary ice pack and separator. Platelets should NOT be packed with ice packs.

Collection should be done only when providing a legibly filled out Blood Issue Form.

Once collected, blood component should be delivered without delay to the responsible healthcare professional.

Haemolysis in RCC – Retrieved from https://profedu.blood.ca/sites/msi/files/VAG_en.pdf on 3rd May 2021

Clot Formation in RCC – Retrieved from https://profedu.blood.ca/sites/msi/files/VAG_en.pdf on 3rd May 2021

Procedure for Administration of Blood Products & Blood Components

Decision – potential risks and benefits as well as alternatives to blood transfusion should be considered during discussion between the doctor and patient. Information should be given so the patient can make an informed decision (leaflet should also be given to the patient or relatives prior to transfusion).
Prescription – blood components can only be prescribed by a medical practitioner.
Collection – prescribed blood components should be picked up from the HBB (Hospital Blood Bank) ONLY when the patient is ready to be transfused (See Collection of Blood Units from HBB)
Inspection – check expiry date, integrity of pack, discolouration or haemolysis, and that platelet pack does not show clumps or looks cloudy. Transfusion should be started immediately after being collected from HBB. DO NOT STORE in medicine fridges!
Transfusion – only qualified healthcare professionals with transfusion training can transfuse blood components. Procedure must be performed by 2 healthcare professionals, both of who need to sign the Nurses Record – Blood Product Transfusion Form. Overnight transfusions should be avoided unless absolutely necessary. Blood components should be gently mixed prior to administration. The blood administration set used for transfusion should contain an integral clot filter for all blood components (170-200 µm -micrometer). Blood administration set should be primed with the blood component or 0.9% normal saline. Platelets should NOT be transfused through an administration set which has already been used for blood transfusion. DO NOT flush out the blood in the administration line once transfusion is finished.
Administration Rate – RCC should be transfused over 90-120 minutes (less tolerant patients should be transfused at a slower rate with extra monitoring, not exceeding 4 hours of transfusion); Platelets should be administered over 30-60 minutes immediately following availability; Plasma should be infused at a rate of 10-20ml/kg/hr, not exceeding 4 hours of transfusion.
Note – administration set should be changed at least every 12 hours in RCC and FFP transfusion. Transfusion completion should happen within 4 hours following removal from temperature controlled storage. RCC and FFP exposed to temperatures of over 40° may cause a severe transfusion reaction.
End of Transfusion – wear gloves and remove empty blood bag and administration set (change set if infusion is to be continued); flush the cannula, document observations; fill in Traceability Form and send to HBB; dispose of blood administration set and bag in a yellow bag (clinical waste).

Patient Observation During Transfusion

Patient should be monitored by regular visual observations which should also be documented, throughout the transfusion phase of each transfused unit.
Record baseline observations of temperature, pulse, respiration and blood pressure prior to transfusion, 15 minutes into the transfusion and at the end of the transfusion plus more if needed.
Transfusion reaction signs include: fever, nausea, respiratory distress, back/flank or IV site pain, skin changes, uticaria, diarrhoea, shaking, headache, hypo/hypertension, chest pain, urine colour changes, tachycardia, oliguria, jaundice, unusual feelings.
Acute transfusion reactions include Acute Haemolytic Transfusion Reactions, Febrile Non-Haemolytic Transfusion Reactions FNHTR (mild or moderate fever, chills or rigors without any other known cause – if patient is otherwise stable administer paracetamol and restart transfusion at a slower rate), Acute Allergic & Anaphylactic Transfusion Reaction, Transfusion Associated Circulatory Overload (TACO), Transfusion Related Acute Lune Injury (TRALI) and Hypotensive Transfusion Reaction.
Delayed transfusion reactions include Delayed Haemolytic Transfusion Reaction, Transfusion-Associated Graft-Versus-Host Disease, Post Transfusion Purpura and Transfusion Transmitted Infection.
If transfusion reaction is suspected STOP/PAUSE immediately; report reaction to nursing officer, medical officer and the Blood Bank; assess airway, breathing and circulation and if need be call for resuscitation team; maintain venous access through slow normal saline administration; record observations (temperature, pulse, RR, BP, SPO2 and Urinary Output); if patient experiences temperature rise of <1.5°C, transfusion can be paused so patient can be administered necessary medication, and later on if symptoms subside can be restarted on transfusion.
Document reaction time, signs and symptoms, name of consulted physician, treatment and patient response, and plan.

The law stipulates that “Member States shall ensure that blood establishments, hospital blood banks, or facilities retain the data for at least 30 years in an appropriate and readable storage medium in order to ensure traceability” – Directive 2005/61/EC

Below you can find a collection of videos that can help provide a more visual approach to Administration of Blood and Blood Components.

Blood Types, Blood Group Systems and Transfusion Rule – Animation

Blood Types Explained

Administration of blood and blood components

Administration of blood and blood components – Method

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Alila Medical Media, RegisteredNurseRN and The Rotherham NHS Foundation Trust.

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IV Complications – Signs & Symptoms, Prevention and Management

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More than 90% of hospitalised patients receive some form of IV therapy. Unfortunately, about 1/5 of these patients experience IV complications due to lack of administration care and adequate monitoring.

Phlebitis

Phlebitis is the inflammation of the vein which is caused whenever the used cannula is too large for the chosen vein, or when the cannula is not secured in place. Using the smallest cannula possible depending on the patient and the fluid being administered will reduce the chance of phlebitis to occur during IV therapy administration.

Signs & Symptoms:

warm to the touch around the insertion site
redness and/or tenderness at insertion site or along the vein
bulge over the vein

Management:

at first sign or symptom of phlebitis stop IV infusion immediately
apply warm compresses onto the area
if further IV infusion is required, insert a new catheter into a different vein and into a different site, preferably choosing a bigger vein and opposite arm
document patient condition and management

Air Embolism

Air Embolism a.k.a. gas embolism occur when one or multiple air bubbles enter the blood stream through a vein or artery and blocks it. Air embolism is one of the most dangerous IV complications as it can cause death.

Signs & Symptoms:

blue skin hue
anxiety
dizziness
nausea
headache
muscle pain
joint pain
hypotension
dyspnoea
gasp reflex
persistent cough
tachypnoea
respiratory failure
shock
confusion
syncope / loss of consciousness
seizures
stroke
syncope

Management:

if air embolism is noted, flush or infusion administration should be stopped immediately and the rotating haemostatic valve (RHV) should be fully opened
if patient is unresponsive administer first aid, prioritising airway (A), breathing (B) and circulation (C) and if necessary resuscitate. Once resuscitated and stabilised, patient should be administered 100% oxygen treatment through a non-rebreather mask to ensure full body oxygen perfusion.
document patient condition and management

IV Site Infection

A localised infection around the IV cannula site can be prevented by use of veins that are not small or fragile, not in extremities, not in areas that may need to be flexed and not in veins situated in sites with oedema or neurological impairment. Adherence to IV therapy safety procedures, maintaining a clear, dry dressing and frequent monitoring can help lessen the chance of infection.

Signs & Symptoms:

redness
swelling
burning sensation
discomfort
discharge
increase in temperature

Management:

when noted, infusion should be stopped immediately
remove cannula
clean site of infection
administer antibiotics as prescribed
monitor patient’s vital signs
document patient condition and management

Flare Reaction

Venous flare reaction is usually a localised allergic response to the administration of an irritant via IV. To minimise risk for a flare reaction, patient’s allergy history should be taken prior to therapy administration, and administration should ideally happen slowly through an infusion pump. Additionally, monitor patient during infusion administration for any pain or discomfort.

Signs & Symptoms:

redness along the vein or at cannula site
tenderness
itchiness
warm to the touch
swelling
hypotension
anaphylaxis

Management:

stop irritant administration immediately
administer antidote if available
monitor for worsening of patient condition
document condition and management

Extravasation

Extravasation is the unintentional leakage of vesicant fluids or medications into the vein’s surrounding tissue. It can be prevented by ensuring proper drug dilution as per recommended guidelines prior to IV administration.

Signs & Symptoms:

discomfort, blanching and/or burning sensation at IV site
cool sensation at IV site
swelling at or right above IV site
blistering
skin sloughing

Management:

stop IV therapy administration immediately by disconnecting IV tube from cannula
aspirate any residual drug
administer antidote if available
document patient condition and management

Infiltration

Infiltration is the accumulation of fluid in the IV surrounding tissue caused by the needle puncturing the vein wall or by eventual needle misplacement. Stabilising chosen vein extremity and taping cannula firmly to the skin can help prevent infiltration.

Signs & Symptoms:

little or no flow of IV infusion or bolus
cool to the touch
hard to the touch
swollen and pale infusion site
fluid leakage from infusion site
pain, tenderness, irritation and/or burning sensation at infusion site

Management:

stop infusion immediately and remove cannula
elevate effected extremity
apply warm compresses to encourage absorption (apply ice to the swelling if noticed within 30 minutes of infiltration onset)

Thrombophlebitis

Thrombophlebitis is an inflammation that causes the formation of a blood clot, which blocks one or more veins, usually in the legs. Superficial Thrombophlebitis occurs when the affected vein is closer to the surface of the skin, whilst Deep Vein Thrombosis (DVT) occurs when the affected vein is at a deeper level.

To prevent thrombophlebitis, one needs to avoid prolonged periods of standing and elevate legs when sitting down. Improving blood circulation helps. This can be done by regular exercise.

Signs & Symptoms:

sudden or gradual swelling in the affected area
tenderness and/or pain in the affected area
redness or discolouration in the affected area
warm to the touch

Management:

apply heat to affected area
elevate
use of NSAIDs
wear compression stockings

Haematoma

A haematoma is leakage of blood from the blood vessel into the surrounding soft tissue. As one of the possible IV complications, a haematoma occurs when an IV catheter passes through multiple walls of a vessel, or when not enough pressure is applied to an IV site after catheter removal.

Signs & Symptoms:

redness
swelling
pain
disfiguring bruises

Management:

during the first 24hrs from the formation of a haematoma apply ice packs wrapped in cloth for 20 minutes (you can repeat this multiple times)
after the first 24hrs from the formation of a haematoma apply warm, moist compresses to the affected site for 20 minutes (you can repeat this multiple times in the second 24hrs post haematoma formation)
do not massage affected area
compress and elevate if affected area is a limb

Electrolyte Imbalance

Electrolytes are minerals that carry an electrical charge in the blood, tissues, organs and everywhere within the body. An electrolyte imbalance is the result of too much or too little water.

Signs & Symptoms:

fatigue
lethargy
nausea and vomiting
diarrhoea or constipation
dysrhythmias
tachycardia
convulsions or seizures

Management:

monitor for dehydration
monitor ECG for prolonged QT interval
IV fluids
diet changes (eating more foods containing lacking electrolyte)
check current drug prescriptions for any possible replacement need (eg. loop diuretics may be changed to potassium-sparing diuretics in the case of loss of potassium)

Acute Hypervolaemia

Retrieved from https://en.wikipedia.org/wiki/Edema on 5th April 2021

Hypervolaemia is a condition in which there is excess fluid in the blood. Whilst an adequate amount of water is necessary for the body to function well, excessive fluid leads to an imbalance, resulting in complications.

Signs & Symptoms:

oedema in the ankles, feet, face and wrists
body discomfort
cramping
headaches
bloating
hypertension
dyspnoea
tachycardia
cardiomegaly
cardiovascular problems

Management:

watch fluid intake
minimise sodium intake
monitor weight and report any changes and swelling immediately
diuretics
if present manage other existing comorbidities such as heart failure and chronic kidney disease to minimise hypervolaemia

Anaphylaxis

Anaphylaxis is a severe immediate hypersensitive reaction which is usually triggered by an allergen. Identifying the signs and symptoms of an anaphylactic shock is crucial as this is a life-threatening situation requiring immediate treatment.

Signs & Symptoms:

hives / itching
flushed or pale skin
dizziness or fainting
hypotension
bronchoconstriction / swollen tongue and/or throat leading to wheezing and dyspnoea
weak rapid pulse

Management:

epinephrine shot administered immediately
maintain a patent airway
if required, antihistamines and / or steroids may also be administered
oxygen administration
bronchodilators
monitor blood pressure, heart rate and oxygen saturation

Speed Shock

Retrieved from http://www.cwladis.com/math104/lecture6.php on 5th April 2021

Speed Shock is a systemic reaction to a drug being administered rapidly, leading to toxicity onset. An infusion device ensures that a drug is administered at the recommended rate.

Signs & Symptoms:

headache
flushed face
chest tightness
irregular pulse
syncope
loss of consciousness
shock
cardiac arrest

Management:

Stop IV immediately
Monitor ABC’s (Airway, Breathing, Circulation)
Report reaction
Do not leave patient unattended

Retrieved from https://www.pedagogyeducation.com/Class-Catalog/Infection-Control/Goal-Zero-Catheter-Related-Blood-Stream-Infections.aspx on 5th April 2021

Catheter Related Bloodstream Infection (CRBSI) is a complication resulting from the use of IV catheters. Septicaemia can also result from a CRBSI, causing a prolonged hospital stay. CRBSI can be prevented using an aseptic non-touch technique (ANTT) during insertion, use of PPEs, disinfecting external surfaces of the catheter hub and connecting ports, and removing and/or replacing at the appropriate time.

Signs & Symptoms:

fever
chills
hypotension
signs of infection proximal to the insertion site of the PVC (peripheral venous cannula)

Management:

removing catheter immediately when a CRBSI is noted
administrating antibiotics
maintaining infection control

Adverse Drug Reactions

An adverse drug reaction (ADR) is a harmful or unpleasant reaction resulting from an IV infusion which can be caused by a single or a combination of drugs. An ADR can be prevented by avoiding consumption with alcohol, reading instructions and consuming medication only as prescribed, and taking note of any previous reactions to the same ingredients. Avoid taking over-the-counter medications with vitamins.

Signs & Symptoms:

phlebitis
infiltration
extravasation
speed shock
shock
cardiac arrest
venous spasms (presenting as cramping and pain above IV site)

Management:

stop drug administration immediately
do not discard syringe…keep for further investigation
monitor vital signs
provide reassurance
perform CPR or administer Oxygen if required

Below you can find a collection of videos that can help provide a more visual approach to IV Complications.

IV Complications

IV Complications: Phlebitis Animation

IV Complications: Air Embolism

IV Flare Reaction