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Prevention is by assessment and recording of patient allergies (drug, food and products) and application of allergy identification wristbands (NPSA 2008, Perucca 2010). In the event of an allergic reaction, the infusion should be stopped immediately, the tubing and container changed and the vein kept patent. The doctor should be notified and any interventions undertaken (Lamb and Dougherty 2008).

Circulatory overload (isotonic fluid expansion)

A critical and common complication of intravenous therapy is circulatory overload, which is isotonic fluid expansion. It is caused by infusion of fluids of the same tonicity as plasma into the vascular circulation, for example sodium chloride 0.9%. As isotonic solutions do not affect osmolarity, water does not flow from the extracellular to the intracellular compartment. The result is that the extracellular compartment expands in proportion to the fluid infused (Weinstein and Plumer 2007). Because of the electrolyte concentration, no extra water is available to enable the kidneys selectively to excrete and restore the balance. It can also occur due to:

infusing excessive amounts of soduim chloride solutions

large volume infusions running over multiple days

rapid fluid infusion into patients with compromised cardiac, liver or renal status (Lamb and Dougherty 2008, Macklin and Chernecky 2004).

Prevention includes thorough assessment of the patient before commencing IV therapy, close monitoring of patient; maintaining infusion rates as prescribed and use of infusion devices where required (Lamb and Dougherty 2008). If circulatory overload is detected early, place the patient in an upright position (Macklin and Chernecky 2004). Treatment consists of withholding all fluids until excess water and electrolytes have been eliminated by the body and/or administration of diuretics to promote rapid diuresis (Weinstein and Plumer 2007). However, careful monitoring should continue to prevent isotonic contraction occurring (where there is loss of fluid and electrolytes isotonic to the extracellular fluid such as blood and large volumes of fluid from diarrhoea and vomiting; Weinstein and Plumer 2007). If fluid administration is allowed to continue unchecked, it can result in left-sided heart failure, circulatory collapse and cardiac arrest (Dougherty 2002).

Dehydration

Dehydration may be categorized as either hypertonic or hypotonic contraction and may be caused by underinfusion. Hypertonic contraction occurs when water is lost without corresponding loss of salts (Weinstein and Plumer 2007) and occurs in patients unable to take sufficient fluids (elderly, unconscious or incontinent patients) or who have excess insensible water loss via skin and lungs or as a result of certain drugs in excess. Hypotonic contraction occurs when fluids containing more salt than water are lost and this results in a decrease in osmolarity of the extracellular compartment (Weinstein and Plumer 2007).

It is important that the nurse recognizes the symptoms of overinfusion or underinfusion and certain factors should be considered when monitoring patients (Weinstein and Plumer 2007) (see Table 13.11).

Table 13.1

Speed shock

Speed shock is a systemic reaction that occurs when a substance foreign to the body is rapidly introduced into the circulation (Perucca 2010, Weinstein and Plumer 2007). This complication can manifest following administration of intravenous bolus injections or when large volumes of fluid are given too rapidly (Perucca 2010). This should not be confused with pulmonary oedema, which relates to the volume of fluid infused into the patient. Rapid, uncontrolled administration of drugs will result in toxic concentrations reaching vital organs (Lamb and Dougherty 2008). Toxicity may be manifested by an exaggeration of the usual pharmacological actions of the drug or by signs and symptoms specific for that drug or class of drugs. The most extreme toxic response which can occur if a drug is given at a dose or rate exceeding that recommended is termed the lethal response.

Signs of speed shock may include: