Day 4: IV Treatments

Day 4: IV Treatments

Previous Days Review 

Be able to answer the following questions. Review protocols if unable to give succinct answers.

• What is the importance of scrubbing in and out properly?

• When do you switch a puppy off SQ treatment to PO meds? SQ to IV?

• Why do SQ fluids not absorb completely in some patients? How can you tell?

• What are the drug types, routes, and dangers of the following drugs?

  • Baytril - What is the drug name? How is it administered?

  • Polyflex - How must this drug be stored?

  • Reglan - What is the drug name? How must this drug be stored?

• Why is a dog switched from SQ to IV medications?

Review the following protocols 

• Sterile Guidelines Review

• Feeding Guidelines 

• Cage Cleaning 

  • Only change blankets if they're sufficiently soiled

  • Always dispose of feces/solid materials before placing in laundry bin.

Introduction to IVs

When patients become more critical (lethargy, pale gums, increased vomiting, and/or bloody diarrhea), they are placed on IV medications and IV fluids as a constant rate infusion (CRI) continuously throughout the day. This is accomplished by placing an IV catheter. The IV catheter must be maintained properly.

See http://veterinaryteam.dvm360.com/step-step-photo-gallery-how-place-cephalic-catheter for images of IV catheter placements.

• Important checks prior to treatment include the following:

  • Swelling above or below the catheter

    • Paw swelling below the catheter indicates the tape or vet wrap is too tight

    • Arm swelling above the catheter indicates the the vein may have ruptured, or blown, and the patient needs a new catheter

      • A blown vein will leak blood and fluid in the surrounding area, causing swelling 

      • Swelling from a blown vein is generally above the catheter site due to direction of blood and IV fluid flow

      • A blown vein will clot on its own when its able to "rest" after the IV fluids and catheter have been removed.

      • A different vein/arm must be used for a new catheter.

      • The swelling is often painful depending on severity. A special bandage may be needed to prevent infection.

  • Flushing the catheter

    • Plain LRS or NaCl fluids can be injected into the catheter to check for patency, meaning there are no blood clots clogging the catheter and that the vein has not blown. A patent catheter will have minimal resistance when pushing/administering the flush. 

      • If its a blood clot: There will be moderate to high resistance. Remove the clot by pushing the flush through it, or carefully remove any visible clots with a sterile needle. 

      • If the catheter is blown: There will be low to moderate resistance and swelling above the catheter site.

    • Flush before, between and after medications. Only use however much is needed - as little as 0.2-0.5mL.

    • The drug Heparin, and anticoagulant, is often added to the flush to help prevent blood clots forming inside the catheter

      • Review the dangers of Heparin on the medical chart.

• Catheters should be changed every 72 hours. In the ICU we may leave them in longer if possible because puppies may become critical and may need extended IV treatment ie we go through all their veins including jugulars. 

• The IV Catheter port (orange/yellow parts in the picture above) is where medications are injected, and should be cleaned with an alcohol swab prior to administering medications when visibly contaminated. 

IV Medications

As a general rule, most IV medication are clear in color and nothing colorful should be injected IV.  The most common result of injecting a drug not meant for IV use is seizures and/or death. Never inject something into a dog without knowing what it is and what route is safe.

• Cefazolin OR Ampicillin - used interchangeably depending on cost, same dose. If given too fast will cause vomiting. 

• Famotidine (pepcid) - when there is a concern for ulcers or stomach acid imbalance

• Cerenia - can be given IV. When given IV prescribed BID 

• Ondansetron - IV or SQ

• IV CRI - Patients are typically on an IV CRI for several days until they start eating again

  • Lactated Ringers Solution is the most common and affordable crystalloid fluid solution given IV.

  • Additional medications are added to the fluid bag depending on need

    • 50% Dextrose - sugar

    • Reglan - anti nausea

    • KCL (Potassium Chloride) - electrolytes

**Review the following common IV medications on the medical chart page.

**Don't forget to flush before administering any medications via the catheter

Intro to Hetastarch

• • Hetastarch is a colloid fluid that contains proteins, unlike crystalloid fluids (LRS). Protein helps draw fluid from outside cells into the blood vessels, this increasing blood volume and pressure. Increased pressure helps improve circulation to all internal organs.

  • This drug is typically used on critical, and/or crashing dogs, especially when their gums are pale/grey/white. It is most commonly given as a bolus in the AM and PM shifts. It will be prescribed, for example, as "Hetastarch 50mL over 20 minutes". You must be able to calculate what fluid rate (mL/hr) to set an IV pump to.

  • Some dogs may be on a Hetastarch CRI to replenish and maintain protein levels

  • Dangers - this drug must be given slowly, and can only be given a certain amount (depending on weight) a day. Overdosing can cause severe fluid overload, fluid in the lungs, and/or internal bleeding. Use caution with this drug and triple check dosage and time.

  • The most critical patients will be on Hetastarch, especially with severe bloody diarrhea, pale to grey/white gums, and/or severe lethargy. 

Making a basic IV CRI fluid bag:

•     per 1000ml bag (new bag) add the following:

  • 3ml Reglan

  • 20 meq KCL 

  • to make a 5% bag (baseline) add 100ml 50% dextrose. Vets may request more dextrose if the patient is very small and/or not maintaining BG on 5%. 

Crashing Puppy Protocol

• Crashing Puppy Protocol - Its imperative to be familiar with this information so you'll be prepared in an emergency situation. A few minutes can be the difference between life and death for a crashing puppy!

IV Pumps

An IV Pump is used to administer a CRI (constant rate infusion) of fluids throughout the day. They are generally simple to use, but small mistakes can result in severe medical consequences. Carefully check that the IV Pump has the proper settings with every use.

See http://apexx-equipment.com/veterinary-mfg/leading-edge/Conntrol-V-935i-IV-Pump-from-Leading-Edge for an image of a common pump.

• The two setting you are responsible for setting every shift include the 'Volume To Be Infused', or VTBI, and the Rate

  • VTBI

    • The VTBI, also called 'Preset' on some pumps, is the total volume of fluid that will be administered to the patient.

    • For Hetastarch, set the VTBI/Preset to the dose prescribed by the doctor (i.e. 50mL)

    • For a CRI, set the VTBI to 9999mL, as we are unsure how many days the patient will continue to be on IV fluids and we don't want it to stop. 

  • Rate

    • The rate is always prescribed in mL/hr and NOT drops/mL

    • The doctor will prescribe the fluid rate in mL/hr (i.e. 12mL/hr) based on the patients body weight

    • The Hetastarch rate must be calculated. If the doctor prescribes 50mL over 20 minutes, set the rate to 150mL/hr and the VTBI/Preset to 50mL. The IV Pump will administer Hetastarch at a rate of 150mL/hr until it has given 50mL