Clinical Care Topic Vascular Access Device Infusion Therapy – Neonates

Purpose of Infusion Therapy

To understand the purpose or rationale for the infusion therapy prescribed, information can be obtained from the authorized prescriber’s order, the patient health record, and patient assessment.

Indications for infusion therapy include: • Restoration and/or maintenance of fluid and electrolyte balance • Restoration, maintenance, and/or promotion of nutritional status (parenteral nutrition) • Administration of medication, blood components/products, diagnostic reagents, and general anesthesia or procedural sedation

Orders related to the initiation and management of infusion therapy may include: • Patient identification • Route • Date and time order was written • Infusion type • Volume over time for bolus infusions • Medication name, dosage, standard , and patient weight • Duration of continuous infusions • Frequency of intermittent infusions • Prescribers name, signature, and designation • Communications regarding special considerations • Total fluid intake: volume of all fluids/kg/day

The source of truth for guidance related to medication orders is the AHS Medication Orders Policy and Procedure.

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Intravenous Solutions

Intravenous (IV) infusion solutions are used to prevent or correct problems with fluid and/or electrolyte status. Many prepared IV solutions are available for use, and can be categorized by two main types: crystalloid and colloid.

Two Main Types of Volume Expanders

Colloid Crystalloid Description Contains substance particles in water Contains solutes that are completely Particles do no dissolve completely dissolved in water Particles do not pass through a semi- Solutes readily pass through a semi- permeable membrane permeable membrane Particles stay within the intravascular Solutes are comprised of dextrose, space electrolytes, or a combination of the two Can be classified into isotonic, hypertonic, and hypotonic solutions Examples Natural: human blood and blood solutions products including albumin and Dextrose solutions plasma Ringers Lactate Artificial: gelatine and dextran See Types of Crystalloid Solutions solutions, hydroxyethyl starches (HES)

Warning: Do not use HES products in neonates

Uses Plasma expanders used to replace To expand intracellular or extra circulating blood volume cellular fluid volumes and replace electrolytes Choice of solution depends on desired outcome

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Types of Crystalloid Solutions

Osmolarity Indications Precautions Examples 250–330 No net increase in Excessive amounts Dextrose 5% in Water mOsm/L cell size can lead to circulatory (D5W)* overload and Increases the NaCl 0.9% intravascular volume pulmonary edema Blood plasma is Lactated Ringers Monitor electrolytes: 280–300 mOsm/L Replaces water loss Dextrose 3.3% alterations can occur ic Treats n depending on the and fluid replacement to volume of solution o

Is administered Use with caution in patients with impaired renal or cardiac function

Less than Causes fluid to shift Contraindicated in D5W 0.45% NaCl

ic 250 mOsm/L into the cells increased intra- NaCl 0.45% n cranial pressure (ICP) to Rehydrates cells NaCl 0.33% o and hypovolemia p y

H Monitor for water intoxication Greater than Causes fluid shift Ce llular dehydration Dextrose 10% and

ic 330 mOsm/L from the cells into Fluid overload greater n intravascular space o NaCl 3-5% t r

e Restores electrolytes Mannitol 10–20% p

y and nutrients Dextrose 5%-Lactated H Ringers

*Dextrose in IV solutions is rapidly metabolized. Dextrose-only solutions become hypotonic in the body once all the dextrose is metabolized. Close monitoring for water intoxication is therefore indicated. Signs and symptoms include lethargy, vomiting, and increased work of breathing.

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Osmolarity Osmolarity, or osmotic concentration, is the concentration of osmotically active particles in solution, which may be quantitatively expressed in osmoles (Osm) of solute per liter (L) of solution (Osm/L). A solution is considered isotonic in the body if osmolarity is the same as blood plasma (range of 280 – 300 mOsm/L), and therefore expands the body’s fluid volume without causing a fluid shift from Osmolarity in milliOsmoles per Litre one compartment to another. An example of an isotonic solution is 0.9% . Figure 1 Osmolarity of NaCl 0.9% (Normal Saline) A hypertonic solution, such as 3% sodium chloride, has a higher than plasma and pulls fluid from cells through , causing them to shrink. Solutions/emulsions with a high osmolarity pose a risk of damage to local tissues with peripheral administration and are better administered through a central venous access device.

A hypotonic solution, such as 0.45% sodium chloride, has an osmotic pressure lower than plasma and pulls fluids into the cells, causing them to enlarge. This cell-enlargement can occur to cells at the catheter insertion site which may lead to them bursting, exposing the vein’s basement membrane and potentially leading to infiltration and local tissue damage.

In general, isotonic fluids are mostly commonly used for extracellular volume replacement. The use of hypertonic or hypotonic solutions depends on the specific fluid and electrolyte imbalances.

Colloids, unlike crystalloids, are solutions in which particles do not dissolve or break down into smaller pieces in water. Colloid solutions contain larger molecules that typically cannot penetrate the capillary wall, thus tend to stay within the vascular space (blood vessels).

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