Concept.
Infusion reaction is a variety of non-therapeutic effects that occur when infusion therapy is used clinically. The factors that cause infusion reaction are very complex, not only the quality of drugs, but also the comprehensive performance of many factors. Infusion reaction is the abbreviation of infusion adverse reaction, which is the general term of infusion-induced or infusion-related adverse reactions, sometimes also called “thermogenic reaction” in clinical practice. However, strictly speaking, “pyrogenic reaction” is only one part of infusion adverse reactions. The most common clinical infusion reactions are pyrogenic reactions and pyrogen-like reactions caused by fever, chills, vomiting, etc. Other reactions include bacterial (bacterial, bacillary, fungal) contamination reactions, allergic reactions, etc.
Specific performance.
I. Fever reactions
1, cause: fever is a common infusion reaction, often due to the input of fever-causing substances (pyrogen, dead bacteria, free bacteriophage protein or impure drug composition), imperfect cleaning and disinfection of the infusion bottle or contaminated again; input liquid sterilization, poor storage deterioration; infusion tube surface adherence sulfide, etc.
2.Symptoms: The main manifestations are chills, chills, fever (the fever is often around 38℃ in mild cases, and 40-41℃ in severe cases), accompanied by nausea, vomiting, headache, rapid pulse, peripheral discomfort and other symptoms.
3, prevention and treatment methods: (1) the light reaction can slow down the infusion rate, pay attention to warmth (appropriate to increase the cover or give hot water bags). In severe cases, the infusion must be stopped immediately; those with high fever should be given physical cooling, and if necessary, anti-allergy drugs or hormone therapy should be given as prescribed by the doctor, and acupuncture points of Hegu and Neiguan should be used. (2) The infuser must do a good job of removing the thermogenic treatment.
II. Heart failure, pulmonary edema
1. Cause: Due to rapid drip rate and excessive fluid input in a short period of time, the circulating blood volume increases sharply and the heart is overburdened.
2. Symptoms: The patient suddenly feels chest tightness, shortness of breath, coughing foamy bloody sputum; in severe cases, thin sputum can gush out from the mouth and nose, wet rales appear in the lungs, and the heart rate is fast.
3, prevention and treatment methods: (1) The infusion drip speed should not be too fast, and the amount of input fluid should not be too much. Particular attention should be paid to heart patients, the elderly and children. (2) When the symptoms of pulmonary edema appear, stop the infusion immediately and inform the doctor, let the patient take a sitting position with legs hanging down to reduce venous return and heart burden. (3) Give diastolic, wheezing and cardiotonic agents as prescribed by the doctor. (4) High-flow oxygen inhalation, and replace the water in the wetting bottle with 20%-30% alcohol wetting and then inhale to reduce the tension of the foam surface in the alveoli, so that the foam ruptures and dissipates, thus improving the lung gas exchange and reducing the symptoms of hypoxia. (5) If necessary, perform a tourniquet on the extremities in turns (must relax the extremities in turns every 5-10 minutes, which can effectively reduce the amount of blood return), and when the symptoms are relieved, the tourniquet should be gradually lifted.
Third, phlebitis
1.Cause: chemical inflammatory reaction of local vein wall caused by long-term infusion of highly concentrated and irritating drugs, or long time of placing irritating plastic tube in the vein; it can also be caused by local vein infection due to poor aseptic operation in the infusion process.
2.Symptoms: stripes of red lines along the vein, local tissue redness, swelling, burning, pain, sometimes accompanied by chills, fever and other systemic symptoms.
3, prevention and control methods: to avoid infection, reduce the stimulation of the blood vessel wall as the principle.
(1) Strictly implement the aseptic technique, drugs that are irritating to blood vessels, such as erythromycin and hydrocortisone, should be applied after sufficient dilution and prevent the drugs from spilling out of the blood vessels. At the same time, the injection site should be changed frequently to protect the vein.
(2) Elevate the affected limb and brake it, and apply hot wet compress locally with 95% alcohol or 50% magnesium sulfate.
(3) Apply topical Chinese medicine or Ruyi Jinhuang San twice a day for 30 minutes each time.
(4) Ultrashort wave physiotherapy, irradiation with TDP therapy device, 2 times a day, 30 minutes each time.
IV. Air embolism
1.Cause: There is a risk of air embolism because the air in the infusion tube is not exhausted, the catheter is not connected tightly and there is a leaky seam; pressurized infusion and blood transfusion are not guarded at the side. The air entering the vein is first taken to the right atrium and then to the right ventricle. If the amount of air is small, it will be pressed into the pulmonary artery by the right ventricle and dispersed into the small pulmonary arteries and finally to the capillaries, thus causing less damage. If the amount of air is large, the air in the right ventricle will block the entrance of the artery, so that the blood cannot enter the lungs for gas exchange, causing severe hypoxia and death to the patient.
2, symptoms: the patient feels abnormal discomfort in the chest, a sense of near death, followed by dyspnea, severe cyanosis, electrocardiogram can show myocardial ischemia and changes in acute pulmonary heart disease.
3.Prevention and control methods.
(1) The air must be exhausted during infusion, and if pressure infusion is needed, the nurse should observe closely and should not leave the patient to prevent the liquid from going empty.
(2) immediately make the patient lie on the left side and head low foot high position, this position can increase the intrathoracic pressure during inspiration to reduce the air into the veins, the left side can make the position of the pulmonary artery in the lower part of the right ventricle, the air bubbles are drifted upward to the right ventricle tip, avoiding the entrance of the pulmonary artery due to the heart beating, the air is mixed into foam, in small amounts into the pulmonary artery.
(3) Oxygen inhalation.
(4) When performing subclavian vein puncture to replace the squirt gun, it should be done when the patient exhales or when the patient is instructed to hold his breath to prevent air inhalation, and no part of the operation when retaining the silicone tube or changing the fluid should allow the silicone tube lumen to communicate with the atmosphere.
Common types.
Pyrogenic reaction: mainly occurs when the accumulated amount of bacterial endotoxin enters the body through intravenous infusion agent exceeds the body’s tolerance. The clinical symptoms are high fever, chills, pale skin, dilated pupils, increased blood pressure and reduced white blood cells; in severe cases, nausea, vomiting, headache and even coma, and even shock and death.
Pyrogen-like reaction: The reaction similar to pyrogen caused by insoluble particles in infusion solution, mainly contaminated by production, storage, infusion apparatus, infusion operation process and infusion environment.
Allergic reactions: In addition to general allergic reactions such as itchy skin and erythema-like rash, severe allergic reactions similar to pyrogenic reactions are common in clinical practice and are difficult to distinguish from pyrogenic reactions.
Cellular contamination caused by: contaminated by cells or fungi into the body of the fluid caused by an acute bacterial infection reaction than the pyrogenic reaction is serious, such as severe bacteremia or sepsis.
Mechanism of occurrence.
Pyrogens is a general term for substances that cause an increase in body temperature in animals. The broad sense of pyrogens includes bacterial pyrogens, endogenous polymer pyrogens and their chemical pyrogens, etc. Pharmacological pyrogens usually refer to the metabolites of microorganisms. It has been shown that pyrogens are mainly an endotoxin of microorganisms, which are complexes of lipopolysaccharides, phospholipids and proteins. Insoluble particles in intravenous infusion such as rubber particles, insoluble inorganic salts, activated carbon particles, fibers, particles generated in the process of drug compounding and pathogenic bacteria or dust that enter the infusion without filtering the air during the infusion can cause pyrogen-like reactions, phlebitis, vascular granuloma, pulmonary edema, embolism, allergic reactions, etc.
The thermogenic reactions can cause pyrogen-like reactions, phlebitis, vascular granuloma, pulmonary edema, embolism, allergic reaction, etc. The pyrogen is introduced into the bloodstream from a vein and stimulates the pituitary fever center, causing a febrile reaction.
Occurrence factors.
Drugs.
(1) I.V. solution: I.V. solution can cause microbial contamination of I.V. solution by air leakage if small cracks or loose caps occur in glass collisions during storage, handling and use. So be sure to check carefully before use. If the infusion bottle is found to have a loose mouth, small cracks in the bottle wall and unqualified clarity, it should not be used.
(2) Adding drugs.
(1) The quality of added drugs is not qualified, which is also easy to cause infusion reactions. Qualified drugs must be used.
②Added drug dose is too large, the concentration is too high, also easy to cause infusion reaction. The concentration of the drug should be reduced.
③Physical changes or decomposition, polymerization, etc. occur between the added drug and the infusion solution, thus leading to a decrease in efficacy and triggering infusion reactions. Contraindications to drug combination should be avoided.
④The patient’s body temperature will return to normal after the drug causes fever is stopped.
⑤ Inappropriate choice of large-capacity injection, herbal injection should be mixed with glucose injection diluted intravenous drip, should not be mixed with saline. The reason is that herbal injection and physiological saline can often produce a large number of insoluble particles due to salinization, thus increasing the incidence of infusion reactions.
(3) thermogenic accumulation: when intravenous administration, when the thermogenic bacterial endotoxin into the body reaches a certain amount, the patient will have a thermogenic reaction. When administered intravenously by drip, the variety of drugs to be dispensed should be minimized.
(4) particle accumulation: improper sequence of dispensing can also increase the particles, or even exceed the standard. Dispensing by air pollution, more dust particles, dispensing needle is too large, resulting in infusion rubber into the infusion, resulting in increased infusion particles. The dispensing order should be changed, the dispensing room should be equipped with purification facilities, and small needles should be used for dispensing, which can reduce the particles in the infusion.
Quality of infusion equipment: Unqualified disposable syringes and disposable infusion sets are also a way to cause pyrogenic contamination, and qualified disposable supplies must be used in clinical practice.
Infusion speed: When administering drugs containing K+, Ca2+, Mg2+ and other ions, if the drip speed is too fast sensitive patients can cause infusion reactions. The drip rate must be controlled for weak or sensitive patients.
Infusion environment: Generally, in summer when the temperature is hot and the air humidity is high, the drug solution is easily contaminated by microorganisms and causes infusion reactions. Cold weather seasons can also trigger infusion reactions in elderly patients or those with weakened constitutions. It is important to pay attention to the ambient temperature when infusing fluids.
Patient factors.
(1) Disease: Patients with inflammation, febrile diseases or weakness or immune disorders can increase the reaction rate. After excluding drug and operation-related factors, it is judged to be due to the developmental changes of the disease.
(2) Patient age: Elderly patients and young children with low or incompetent immune function and enhanced sensitivity to bacterial endotoxin have a high rate of infusion reactions, and attention should be paid to elderly, frail and young patients during infusion.
(3) Individual differences: Different patients have different tolerance thresholds for bacterial endotoxin, so special attention should be paid to sensitive patients during infusion.
Treatment and resuscitation procedures.
Once the infusion reaction occurs immediately stop the infusion, replace the infusion set and liquid (keep for inspection), and prepare for resuscitation treatment. However, the needle should not be withdrawn, because there may be difficulties in venipuncture again, leading to delay in resuscitation treatment.
Immediately treat fever and serum-like reactions with dexamethasone intravenous drip 0.3~0.5mg/kg, isoproterenol 0.5~1mg/kg intramuscularly, while giving warmth, oxygen, physical cooling or acetaminophen and other antipyretics. If the patient develops symptoms of anaphylaxis such as chills, high fever, blue lips, profuse sweating, cold extremities and respiratory distress, immediately inject epinephrine 0.01~0.03mg/kg intramuscularly and repeat the dose every 15~30 minutes. At the same time, hydrocortisone 5mg/kg should be given intravenously for up to 3~4 times in 24 hours. In case of hypotension, quickly replenish colloid and crystalloid fluids and apply dopamine, m-hydroxylamine or norepinephrine in 5% glucose solution, respectively, on the basis of adequate volume expansion. For those with persistent tracheal spasm and respiratory distress, aminophylline sedation, spray inhalation of budesonide, 0.5% salbutamol and with oxygenation were given. In case of laryngeal edema causing airway obstruction, emergency tracheotomy should be performed. For acute pulmonary edema, immediately stop the infusion of fluids, take a sitting or semi-sitting position to reduce venous reflux; give oxygen wetted with 20%-30% alcohol, if necessary.
If necessary, give aminophylline 5mg/kg slow sedation or tachyphylline 1mg/kg slow sedation, and even use cardiac therapy such as cetiran and mannitol for cerebral edema.