Intravenous therapy

“ See also Haas, Correspondence, 33 Anesthesia Progress 281 (1986) (" [Hydroxyzine's] restriction does not lie with the medicine itself, but in the practice and malpractice of intravenous techniques. Unfortunately, the practitioner who knows how to treat injection technique problems is usually not the practitioner with the intravenous technique problems") . ”

“ Intravenous injection is the best method of treating patients when the loss of blood has been great. It is unwise to transfuse more than three pints into the veins, or the lungs will become waterlogged and the patient will be later in great peril. When the loss is moderate in amount and the patient is not greatly enfeebled, a pint or more of saline solution may be poured into the abdomen before closing the incision, and this may be supplemented by the administration of six or more ounces of the solution by the anus at two-hourly intervals until the force of the circulation is restored. ”

“ Intravenous injections, while sometimes superior to the slower methods, are distinctly inferior when a continuous, rather than a sudden, action is desired. Drugs leave the blood system with great rapidity, and therefore their action on the circulation will cease promptly unless they are continuously supplied. It would be undesirable to inject intravenously such drugs as iodids, nitrites, iron or salicylates. ”

“ The following quotations taken from the circular are admissions that these preparations are not innocuous:
“That the economy will tolerate to a surprising degree substances directly introduced through the blood stream is now well known. By the intravenous injection of 10 c.c. of methyl-phenol serum we throw into the human body a massive dose of an alien substance. ”

“ Due to the close proximity of arteries and veins in the areas most commonly used for intravenous injection, extreme care should be exercised to avoid peri vascular extravasation or inadvertent intra-arterial injection. Reports compatible with inadvertent intra-arterial injection of Phenergan Injection, usually in conjunction with other drugs intended for intravenous use, suggest that pain, severe chemical irritation, severe spasm of distal vessels, and resultant gangrene requiring amputation are likely under such circumstances. ”

“ Injection of quinine.—— In any type of fever, if vomiting is persistent, if the brain is affected, or if the patient is insensible and cannot or will not swallow, recourse must be had to rectal, or intramuscular, or intravenous injection of quinine. In all cases in which life is in imminent danger, and in which the earliest possible action of the drug is of importance, it must be so administered. ”

“ If in the first place it is found that subcutaneous or intravenous injections of saline purgatives are effective in man, there arise in both medical and surgical practice occasions in which these methods of administration would be of the greatest advantage. ”

“ Medical attention should be sought immediately. Contaminated clothing should be destroyed." [17]
Yet when it comes to administering this highly toxic drug, the label provides that "the drug may be injected directly into any suitable vein, [but] it is injected preferably into the rubber or plastic tubing of a flowing intravenous infusion set. This reduces the possibility of severe local reactions due to extravasation or high concentration of the drug." ”

“ VIII. Method of Making the Intravenous Injection.—The injection is best made by means of a 5-c.c. glass syringe with an asbestos plunger (paragraph VII, k) , which is cleaned by means of the lysol solution and rinsed in sterile salt solution. The canula attached to the syringe is cleaned in the same manner. One immunizing unit (1 I. E.) is then drawn up into the syringe and any air-bubbles are expelled, care being taken that any drops of fluid expelled in this manner do not fall on the floor but are caught up in the basin. ”

“ Later, in 1910, Welch, and then Schloss, recommended the subcutaneous injection of serum or of blood, but these measures were clearly not so effective as the intravenous transfusion of blood, as has been testified by numerous observers (Lespinasse, Unger, Vincent, Graham, Bruce Robertson, Lapage, Hutchinson, etc.) . The patients may be actually moribund, for a new-born infant can only afford to lose a relatively small amount of blood, but even then transfusion is often successful. ”

“ Injections for the demonstration of blood-vessels, lymphatics, ducts of glands, etc., are rarely used in pathologic work. The organs to be injected must be fresh, warm from the body, if possible. The vessels should be washed out by a freshly filtered 8 per cent sodium nitrate or sodium sulphate solution, followed by physiologic salt-solution. A cannula is introduced into a main vessel, tightly secured, and then connected with a syringe or a gravity injection-apparatus giving a constant pressure. ”

“ Experience begets confidence, and confidence begets experience. In cautious hands I am satisfied of its usefulness; but there are cases that turn out failures. I have used the injection when the disease itself was a week old, and with like success; but I am ready to confess I have known cases, the cure of which were retarded by its employment. The inflammation has been temporarily aggravated, but they were cases where the treatment was not appropriate; the disease was far advanced, there was much heat and swelling, and the patient’s health was in most instances considerably affected ”

“ As a precautionary measure in all operations by injection, to prevent the medicine from extending too deeply into the tissue of the gut by gravity, or the overflow from running down on the outside of the pile and over the bowel, let the patient lie on the side opposite to the tumor to be treated, so that the preparation will gravitate to the apex rather than its base of attachment. ”

“ By the injection of a few drops of a medicated solution under the skin, at the point where the incision is to be made, we are now able to produce such complete local anæsthesia as to render the operation entirely painless without the administration of either chloroform or ether. This is an important consideration, as many are averse to taking chloroform or ether, and now that we are possessed of an agent that produces, locally, complete insensibility to pain, we are very glad to be able to dispense with their use in all such minor operations. ”

“ The technic, although not difficult, must be thoroughly mastered, or undue pain, infection, air embolism, or even death may result. Such accidents, however, are ordinarily easily avoided, and should be considered quite inexcusable. More serious is the fact that the drugs given intravenously reach the system, and especially the heart, in a different manner and concentration from that to which physicians are accustomed with ordinary methods of administration. ”

“ In the case of injection, the injections have been made either into the subcutaneous tissues, intramuscularly, or intravenously, or finally, directly into the tumors. Before passing to a further consideration of this subject in detail, it may be well to recall the fact that in the experimental tumors of animals, no matter what preparation has been used, it has been possible to accomplish therapeutic effects only by the use of relatively enormous doses of the medicament, of doses, in fact, which were scarcely lower than the lethal dose. ”

“ Direct instrumental medication requires the personal attention of the medical attendant. Medication by inhalation or insufflation may be entrusted to the patient or the nurse in most instances. In instituting a course of topical treatment several things must be taken into consideration, such as the condition of hyperæsthesia, hypersecretion, insufficient secretion, congestion, hemorrhagic infiltration, hemorrhage, hypertrophy of tissue or tissue-elements, erosion, fissure, ulceration, and excessive granulation. ”

“ Everybody knows of the progress made in other branches—in bacteriology, in pathology, in biologic chemistry, in surgery, in etiology and in application of technical methods to diagnosis. Recently, however, pharmacologic research and the application of scientific methods in the study of the physiologic action of drugs are resulting in definite, positive progress. An important lesson, incidentally learned through this scientific investigation, is the fallibility of the drug therapy described in textbooks. ”

“ If he has lost much blood, the limbs should be wrapped in cotton wool and firmly bandaged from below upwards, to conserve as much of the circulating blood as possible in the trunk and head. If the shock is moderate in degree, as soon as the patient has been put to bed, about a pint of saline solution should be introduced into the rectum, and 10 to 15 minims of adrenalin chloride (1 in 1000) may with advantage be added to the fluid. The injection should be repeated every two hours until the circulation is sufficiently restored. ”

“ Exception must be taken, moreover, to the statement that “its use is absolutely safe.” The danger of anaphylaxis from repeated injections of albuminates cannot be disregarded, and as J. F. Anderson, director of the Hygienic Laboratory, has pointed out54 we know little of the secondary or remote effects of the intravenous injection of toxic substances; some of them probably do permanent harm.
Such claims as the following require no comment:
“It builds up and increases the hemoglobin in the blood. ”

“ Where all these means prove ineffectual, the injection of sedative and astringent applications often answers the most sanguine expectations; but they should be employed only by professional persons, and even then with great care; as when the disease has been at its height, and they have been used, much inconvenience, and even mischief, has been occasioned. ”

“ The infiltration of skin or canal being complete the needle must be withdrawn and the syringe emptied and the plunger pressed down so that the empty syringe is attached to the needle through which the paraffin injection is to be made when the operator has assured himself that the needle has been passed as far as desired without traversing or puncturing a vein. ”

“ If possible, the patient must be kept in motion and applications of cold water be made to the face and spine. If the patient falls the limbs must be raised, and all methods used to keep the heart acting, for if you can bridge over ten or twelve minutes the patient is safe. To prevent being ‘struck,’ as he calls it, one patient of mine carries a cord, which he throws over the arm, and if an unfavorable symptom occurs, he uses it as a tourniquet, and in a moment the result is apparent in the extravasation of the blood and the morphia from the wounded vessel. ”

“ For intravenous injection the glass phial containing 9 gr. (0.6 grm.) is taken, the contents carefully added to 50 c.c. physiological saline solution (made with freshly distilled water) , and dissolved thoroughly by adding 18-23 drops of 15-per-cent. soda till a precipitate forms which redissolves on addition of more soda. The solution should be made up to 300 c.c. In a man the whole amount may be injected; in a woman, 200 c.c. ”

“ Preparation of the Inoculum.—Care must be taken in preparing the inoculum, as the injection of even small fragments may cause fatal embolism. To obviate this risk the fluid should, if possible, be filtered through sterile filter paper before filling into the syringe.
Air bubbles, when injected into a vein, frequently cause immediate death. To prevent this, the syringe after being filled should be held in the vertical position, needle uppermost. ”

“ Among the advantages, aside from the number of assistants required and the discomfort immediately following the administration of a general anesthesia, are the absence of remote ill effects of the invasion throughout the entire system of a noxious chemical substance and its direct deleterious effects on many large organs such as the lungs, heart, kidneys, and liver, and the assurance, when a proper drug, dosage, and technic are employed, that death cannot be ascribed to the anesthetic. ”

“ Therapeutic doses—those given for medical treatment—by contrast, are given to patients with a disease that is in need of control, that is, the physician desires to destroy selectively cells or tissues that are abnormal. In these cases, therefore, the skill and experience of the attending physician must be applied to limit the effects to the desired benefits, without damage to healthy organs. ”

“ The probability of escaping confinement is a great incentive to a patient to submit to an injection, when he would refuse operation.
Injections are not necessarily unphysiologic as the sufferer from a hernia has a physiologic deficiency which the paraffin accurately fills with normal connective tissue.
The dangers of injection can be eliminated. The technic is not difficult even when all precautions are taken. ”

“ When reaction has been established, antiphlogistic treatment must be pursued, and it generally requires to be extremely active. Bloody, serous, or purulent fluids, lodging in the cavity of the pleura, are to be evacuated, if need be, either by incision or by enlargement of the original wound. In the course of the cure hectic usually supervenes to a greater or less degree, and requires the reverse of the previous treatment. ”