Approach to Needles, IVs and IV fluids

Needle gauge refers to the diameter of the hole or bore of the needle
- The smaller the gauge, the larger the bore
- The larger the gauge, the smaller the bore
Common gauges include
- Large bore IVs
  - 16
  - 18 (eighteen green) – green
- 20 – pink
- 22 (twenty-two blue) – blue
- Pediatrics – small bore IVs
  - 24

*Common needle gauges used for injections and immunizations include from 22 to 25 gauge

Intramuscular (90 degree angle)
- Pediatrics
  - Infants (< 12 months) – anterolateral thigh 1″ needle
  - Toddlers (1-3 years)
    - Anterolateral thigh 1″ – 1 1/4″ needle OR deltoid 5/8″ – 1″ needle
  - Children+ (3+ years)
    - Anterolateral thigh 1″ – 1 1/4″ needle OR deltoid 5/8″ – 1″ needle
- Adult
  - Deltoid muscle 1″ needle
Subcutaneous (5/8″ for most ages!) (45 degree angle)
- Pediatrics
  - Infants (1-12 months) – anterolateral thigh 5/8″ needle
  - Toddler+ (1+ years) – triceps or anterolateral thigh muscle with 5/8″ needle
- Adult
  - 45 degree into tricep fat with 5/8″ needle
Tuberculin/intradermal (10-15 degree angle)
- 10-15 degree angle into skin with 1/4″ – 1/2″ needle

Primary IV bags
- Usually come in 2 quantity bags:
- 500 mL bag
- 1000 mL bag
Secondary IV bags
- Secondary IV is also known as a IV piggyback
- Because the secondary IV fluid bag is hung higher than the primary IV bag, the pressure from the fluid in the secondary IV bag will be greater than the pressure from the primary IV bag
  - This pressure differential ensures that the fluid from the secondary bag is delivered completely before the fluid from primary IV bag is allowed to resume
IV fluid orders – 2 methods
- 4-2-1 rule
  - 4 cc/kg for the first 10 kg
  - 2 cc/kg for the next 10 kg
  - 1 cc/kg after that
  - Example:
    - 70 kg man
      - 4 cc x 10 kg + 2 cc x 10 kg + 1 cc x 50 kg
      - 40 + 20 + 50 = 110 cc/hr
- What if there isn’t a weight readily available?
  - If the patient looks overweight or obese – 125 cc/hr
  - If the patient looks like a normal BMI – 100 cc/hr
  - If the patient looks underweight or cachetic – 75 cc/hr
- What about giving fluid through bolus for resuscitation?
  - 1-3 L IV bolus can be given over 30-60 mins

Ringers lactate (isotonic)
- Can be used as a first line fluid (more useful than normal saline for fluid resuscitation
- Contains sodium bicarbonate which makes the blood more basic
- Can be avoided in hyperkalemia as it contains potassium
- More similar to physiologic electrolytes
Normal saline (isotonic)
- Simply contains NaCl at 0.9 %, same as serum concentration of Na
- Can cause non anionic gap metabolic alkalosis due to chloride
D5W (isotonic in package, hypotonic in serum)
- Equivalent to providing an individual with free water
- Also contains glucose, so if repeated D5W is provided, it may be recommended to perform point of care glucose testing
- Used to treat hypernatremia or hypoglycemia
- Due to dilutional effect of free water, prolonged use of D5W may lead to hyponatremia and hypokalemia
2/3 D5W, 1/3 NS
- Commonly prescribed for patients who may be NPO for prolonged periods
D5-half normal saline
- Pre-procedure or NPO patient

The percent refers to the number of grams per 100 mL of water

Fluid challenge is a means to identifying individuals in whom providing fluids helps improve hemodynamic stability
Typically involves providing NS or RL at a rate of 500 mL over 30 minutes and assess whether tachypnea and hypotension improve in response

For elderly or pre-existing CKD, never run a RBC transfusion too fast
- 1 unit over 2-4 hours
- Consider adding lasix as well
- Always do a CBC and electrolytes 1 hour post-transfusion