IV fluids to gravity, infiltration?

UM Review RN, ASN, RN · Jan 31, 2008

I dont' consider this backup, sorry. To quote you from earlier, this is what happens when you ran a bolus on NS with KCl in it...remember, this is YOUR quote...

I really think that some of the misunderstanding on this thread is being caused by semantics. We mean different things when using the same word. So I'm going to clarify what I mean.

Take the word "bolus" for instance. Our general usage of the word "bolus" means "as fast as we can give it."

It's pretty rare that I would give a bolus of 1000 ml of anything, let alone with any KCL in it.

Even though sometimes a K+ rider is called a "bolus" in my hospital, that doesn't mean that it runs flat out. The only bolus I'd feel OK with running flat out would be NS -- and even that would ultimately be regulated by the size of the needle catheter in the patient's arm (a #16 will run a whole lot faster than the #22's that are common on our unit) and the patient's condition.

I have had IVFs with KCL in them infiltrate, with or without a pump. It just happens when that particular vein can't take any more and starts leaking. I recently had a patient who was on D5W with 40 mEq's of KCL @ 150. Of course, it was on a pump. However, if the thing infiltrated and I was only checking q1 hour on the IV, the patient's arm would look pretty bad by the time I was able to shut it off.

The trick is to be very vigilant in checking patient IVs and don't assume, as you're going past the patient's room, that eyeballing the drip chamber and seeing that it's running means anything at all about whether the fluid is getting where it's supposed to go.

(Had one extremely confused s/p stroke patient routinely pull apart the IV line from her PICC. I have no idea how she did it, but it'd happen several times a night till we figured out a configuration she couldn't reach.)

At any rate (no pun intended) this thread has strayed pretty far from the OP's question, which was "Can IVF's infiltrate if they're hung to gravity?" with the answer that everyone agrees on being, yes, they can.

nursemoons14 · Feb 1, 2008

I wrote my post after working a 12 hour night and unfortunately didn't get across what i was meaning to get across, i didn't mena we were bolusing her, she was on a pump but she didn't tell us her arm was blowing up so it kept pumping in, nevertheless we still run potassium without a pump. 20kcl with 1L. So its either put it to that or ask another nurse if i can steal her pump for her nitro drip so i can run my maintenance fluid.

UM Review RN, ASN, RN · Feb 1, 2008

I wrote my post after working a 12 hour night and unfortunately didn't get across what i was meaning to get across, i didn't mena we were bolusing her, she was on a pump but she didn't tell us her arm was blowing up so it kept pumping in, nevertheless we still run potassium without a pump. 20kcl with 1L. So its either put it to that or ask another nurse if i can steal her pump for her nitro drip so i can run my maintenance fluid.

I do understand what you were saying. I guess you now know to check that IV site for infiltration frequently. And I know that you understand that it's really not the patient's responsibility to tell us -- it's our job to check and recheck the IV site for infiltration.

northshore08 · Feb 1, 2008

I have noted in the last few years a greater tendency for the MD's order to read "1LNS WO" for any patient they want to hydrate in the ED except for peds and those with fluid restrictions. And many of those patients are not critical or even very serious. IVF WO has many downfalls, though, as stated previously. Say you started your IV and your initial few seconds of watching the fluid infuse was okay. Now at any point during the infusion the IV site can infiltrate/extravasate for any number of reasons. I definitely recommend an IV pump. Dial-a-flos only slow the flow. My biggest complaint is after the fluid is in, leaving the empty bag and tubing attached to the patient. That has been a regular occurrence, at least in the last several ER's I have worked in. I routinely was called by patients (not mine) to come check the IV--partially backed up with blood, etc. and had to check the order and fix the IV. Back to the original poster, I have heard the term "to gravity" for all of my emergency nursing career (22 years in 4 states) and it always referred to roller clamp control. And yes, the fluid will continue to infuse to somewhere.

ayla2004, ASN, RN · Mar 16, 2008

we use ivax pumps that are not locked out, and sometimes their isn't enough pumps so one kcl infusion was running on a gravity and i wasn't happy about it.

what would you do with sub/cut .9 nacl would you put it on a pump

northshore08 · Mar 19, 2008

what would you do with sub/cut .9 nacl would you put it on a pump

I have heard of subq infusions, but have never seen an intentional one in my practice in the US. Is that usual in the UK?

MedSurgLPN2005, LPN · Dec 22, 2009

I've always known to run Kcl as 10 mEq per hour and its our hospital policy that its always on a pump.. Yes, you can use the roller clamp to adjust the flow rate, but anybody could come mess with it, like the patient or family members.. I try to remember to lock the pump too..

My concern with running IVF is getting air bubbles... I know its almost impossible with a closed system but Ive seen little ones get in there somehow... Maybe moving the drip chamber the wrong way?? I dunno, it just makes me nervous....

MassED, BSN, RN · Dec 22, 2009

Well there you go, and i learned from my mistake is what I was saying but thanks for pointing that out again after I stated "and never agian will i run kcl without a pump"
It was my first week out of orientation and I got an order from who I thought was a resident. and again.... it was 1L NS w/ 20 kcl. And for the record yes you can run that without a pump, we get orders to bolus 1L w/20 kcl tim eand time again, dehydrated and healthy pt's with low K.

definitely would put that on a pump - anything, really, nowadays, should be on a pump, but absolutely anything w/ K.

Emergency RN · Dec 28, 2009

i have heard of subq infusions, but have never seen an intentional one in my practice in the us. is that usual in the uk?

hypodermoclysis is the infusion of fluids for absorption by the subcutaneous tissues when venous access is poor. you can give up to 3 liters a day using two sites. the needles are usually stuck directly into the subcutaneous tissue of upper arms, upper legs, or chest, taking special care to avoid veins or muscle. it's mostly used in nursing homes or other limited care facilities in the us.

read more here: http://www.aafp.org/afp/2001/1101/p1575.html

another thing about the kcl debate; for those that claim to have never given anything iv with kcl in it unless it was on a pump? please take a close look at your average ringers lactate solution. you would also have to say that you would never give rl by iv unless it was on a pump because ...it contains kcl, lol...

no offense, but to say that one would purposely and slavishly put ivf on a pump simply because it has 20 meq of kcl per liter is just plain ridiculous. imho, before one can run that liter in so quick that the 20 meq of kcl would actually do harm to the patient, we've already killed him with fluid volume overload instead. :bugeyes:

ayla2004, ASN, RN · Jul 4, 2010

Hypodermoclysis is the infusion of fluids for absorption by the subcutaneous tissues when venous access is poor. You can give up to 3 liters a day using two sites. The needles are usually stuck directly into the subcutaneous tissue of upper arms, upper legs, or chest, taking special care to avoid veins or muscle. It's mostly used in nursing homes or other limited care facilities in the US.

we use sub/cut fluid in elderly acute care if iv acess is poor or if the pt is likley to remove the iv(due to confusion) as removing sub cut is less harmful.