A peripheral intravenous catheter (PVC or PIVC) is the most common intravenous access device used across the world. Intravenous Insertions, themselves, are the most common procedure performed in both hospital and pre-hospital services around the world ¹ . The insertion of a PVC is one of the most crucial skills that a nurse or other health care provider can provide. Intravenous administration of fluids and medication is the fastest method of administration and can often help save a patient’s life ¹ . Due to the fact that IV therapy is so common, it is often forgotten just how invasive and dangerous the procedure actually is. The potential for serious infections and complications exists and thus it is crucial that health care providers are familiar with the evidenced based practices of the different elements of IV therapy.

Intravenous catheters should only be administered when clinically indicated ^{1, 2}. Often times IV insertion become a “routine” process – this should consistently be challenged. The clinical indications for a Peripheral IV line include:
1. In order to administer prescribed IV fluids or specific medications ¹
2. In order to administer medications that cannot be administered by any other route
3. In order to maintain and correct electrolyte imbalance ²
4. For the administration of emergency and lifesaving medications – these are situations in which rapid effect is required ¹
5. For the administration of blood or blood products
6. In order to administer Total Parenteral Nutrition

The contraindications include:
1. Situations in which alternative routes would be just as effective (oral administration)
2. When the patency of the vascular access device is in doubt ³.
3. When administration exceeds a health care provider’s level of competence. This should not be glazed over – regular education for safe practices of infusion therapy are crucial to preventing complications. An experienced health care provider should be brought in to perform the procedure.

4. Situations in which a health care provider’s workload or work environment does not enable them to carry out the procedure safely (cluttered patient area, under staffed area, etc.) ³.
5. When the patient does not provide consent.

In regards to selecting a catheter and the site, an upper-extremity site should be used for adults ^{1, 3, 4}. In the event that there is an existing catheter in a lower extremity site, replace the catheter as soon as possible ¹. Other potential patient-specific concerns about site selection may be: anatomic deformity, bleeding diathesis, and pre-existing catheters⁴. Site pre-assessment should be a routine procedure for IV teams. Lower-extremity sites and areas of flexion should be avoided due to their potential to lead to adverse events and complications ⁵.

The insertion of an intravenous access device is an invasive procedure and certain aseptic techniques must be followed ¹. Evidence has showed that when aseptic techniques are standardized, proper hand washing is employed, and specialized “IV Teams” are employed, the risk of infection declines ⁵. Listed below are key evidence based aseptic techniques that can be standardized throughout an organization:

• Perform hand hygiene procedures before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter ^1,4.
  • Use a conventional soap/water or alcohol-based hand rub.
  • Palpitation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained ^{1, 6}.
• The site should be cleaned for a minimum of 30 seconds with a chlorhexidine-based product (unless a patient-specific contraindication to chlorhexidine exists) and be allowed to dry.
  • In practice we often see a single swipe of an alcohol pad across the skin. Cleaning the skin area is crucial to preventing bacteria from the skin to enter the open area – this step must not be overlooked ⁴.
  • Also, once the skin has been cleaned with a chlorhexidine-based product, the vein must be palpated (if palpation is necessary) using sterile gloves¹.
• Often times the skin is cleaned correctly, then the nurse uses bare hands or non-sterile gloves to palpate the vein. The aseptic procedure must not be broken ⁶.
• Difficult to find veins can be distressing to both patients and health care providers. The amount of insertion attempts should be limited in order to reduce the potential sites of infection ⁵.
  • Of interest – it is estimated that 47% of all insertion attempts are unsuccessful on the first attempt ⁵.

Many organizations choose to set a limit on the number of attempts at insertion. If this preset threshold is crossed then ultrasound/infrared/dry heat techniques should employed ^{1, 5}. These relatively new techniques are each associated with higher insertion success rates and can be extremely helpful if the patient has difficult to find veins⁷.

The practice of simply referring the patient for a central line insertion after several failed attempts should be challenged whenever possible ¹. A central line has increased costs and exposes the patient to a variety of additional, and potentially unnecessary, infection risks ^{1, 7}.

Ultrasound-Guided Peripheral I.V. Placement (USGPIV) is a technique that reduces the number of unsuccessful attempts and ensures catheter visualization in the vessel ⁷. The use of ultrasound technology is associated with a significantly higher success rate (97% per attempt when properly trained) ⁷ . Poor visualization of or the inability to palpate a vessel suggests the need for a clinician with USGPIV expertise for the first attempt ^{1, 5, 7}.

Although an Ultrasound can be used on any patient, it is especially helpful for locating and visualizing vessels in:

• Obese Patients ⁷.
• Edematous (or hypovolemic) patients whose veins are not readily visible on the surface ⁷.
• Patients with vein-debilitating conditions (Cancer, Sickle cell disease, etc.).
• Patients who have undergone repeated venipuncture.
• USGPIV can be used in pediatric and neonatal procedures, however specialized training will be necessary for those procedures ⁷.

Training is necessary for health care providers that would like to learn USGPIV competency. Training normally includes both a didactic and hands-on learning process in a classroom along with additional supervised insertions. Of course, a nurse must be competent in traditional Peripheral IV insertions prior to learning how to use the ultrasound technique. Key components of an Ultrasound-Guided Peripheral I.V. Placement course can include:

• How to prepare the device.
• Proper Infection-Control measures for the device.
• Proper Patient positioning.
• Learning to differentiate various anatomic structures on the ultrasound.
• Proper aseptic technique for the entire procedure 7 .
• Correct entry angle for insertion and confirming the tip placement 7 .
• Verification of blood return and patency to flushing.
• Potential troubleshooting techniques.
• Proper Sterile dressing application.
• Documentation techniques.
• Patient education.

• The dry heat method can also be a significant way to increase IV insertion success (recent studies showed an 81% first attempt success rate) ⁸.
  • This method involves using a towel (12”X24”) wrapped around the patient’s upper extremity insertion site prior to an IV cannulation attempt ^{1, 8}.
  • In the study the towel was warmed using a Gettinge® 5524 warming cabinet and was set for a dry heat at 160 degrees Fahrenheit ⁸. The goal is to increase the skin temperature of the site to 98.9 degrees Fahrenheit ⁸.
  • The towel was left on the site for seven minutes and the skin temperature was measured using a Mon-A-Therm monitoring system ⁸.
  • The dry heat method helps to make veins easier to located and identify for health care providers. As with any technique, strict aseptic adherence is necessary.
  • Note – under no circumstances should therapeutic heat devices or microwavable heat devices be used. These have been linked to 2nd and 3rd degree burns ⁸ . Heat tolerance will vary from patient to patient.
• Using Near-infrared light is another alternative technique in which a device emits near-infrared light into the proposed site area. The blood in a patient’s veins then absorbs the light while the surrounding tissue area reflects the light. Veins can then appear as dark lines in contrast with the lighter surrounding areas.
  • Modern devices (VeinViewer for example) create a digital image of a patient’s veins, and then project the image onto the patient’s skin. This creates a literal map on the patient’s skin that can be used to locate the veins.
  • Studies have shown mixed results ¹. In situations of non-ideal lighting (battlefield, transport, etc.) near-infrared has proven statistically effective in increasing successful insertion attempts. However, in traditional health care settings only a moderate increase in successful attempts has been noticed. Further studies are necessary in order to draw a concrete conclusion on the efficacy of this technique.

• Proper personal protective equipment (PPE) should be worn at all times to reduce potential infections to both patient and the health care provider ¹. At minimum this should include:
  • Clean gloves for the insertion of peripheral intravascular catheters (as long as the access site is not touched after the antiseptic use)⁶.
  • Sterile gloves for the insertion of arterial, central, or midline catheters ⁶.
  • Either clean or sterile gloves (per hospital policy) when changing any dressing on intravascular catheters ¹.
  • The practice of cutting a finger out of the glove (so as to expose the health care provider’s finger and “feel” the vein better) is not evidenced based ^{4, 5}. This practice negates the purpose of a sterile glove and can increase the likelihood of contamination.
• Whenever possible, implement the “Aseptic Non Touch Technique” during drug administration or cannula manipulation. This includes:
  • Effective hand hygiene.
  • Cleaning down any plastic trays (if used) with sporicidal detergent wipes. Dry down with clean paper towel and set your equipment to the side of the tray ⁶.
  • Clean hands again (while handling equipment they may have gotten contaminated). Put on an apron and clean gloves ⁶.
  • Unwrap equipment and place into the sterile tray.
  • “Key parts” should remain covered/sheathed so as to prevent contamination ⁶. Key parts include: needles, syringe tips, etc.
  • Locate the cannula (moving aside clothing or bedding).
  • Remove gloves (they will have become contaminated while moving throughout the facility and interacting with the patient’s bedding and clothing) ⁶.
  • Decontaminate hands ⁹.
  • Put on clean non-sterile gloves and decontaminate the port or injection site with a chlorhexidine based solution ⁶. Allow the appropriate amount of time for the disinfectant to dry (30 seconds).
  • Dispose of all used equipment per your facility’s waste procedure.
  • Remove gloves and clean hands once again. Be sure to disinfect the plastic tray in the manner stated earlier ⁶.
• The use of steel needles should be avoided for the administration of fluids of medication that have the potential of causing tissue necrosis should extravasation occur ^{1, 9, 10}.
• In regards to dressings and stabilization methods – a clear semi-permeable dressing should be applied. (Tegaderm or versaderm – for example) ⁴.
  • The dressing should be individually wrapped and sterile ^{1, 4}. The use of non-sterile tape and gauze is not evidenced based ^{4, 6}.
  • If the patient will be showering – protect the catheter and connecting device with an impermeable cover ^{1, 4}.

• Once inserted, an intravascular catheter should be monitored during each shift ¹ . The site should be monitored hourly for any signs of phlebitis, infiltration, or tenderness ^{1, 9}.
• All data should be documented in the patient record (date/time of insertion, the times that any filters, tubing, or intravenous solutions were replaced, the results of each hourly check, etc.) ¹.
• The CDC recommends that a Cannula be removed within 72 hours ¹. If there is a significant reason to it not being removed – this must be noted in the patient documentation.
• Needleless Intravascular Catheter Systems are becoming more and more prevalent in US hospitals. Aseptic Non Touch Techniques are applicable and there are several needless specific points worth focusing on:
  • Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine) and accessing the port only with sterile devices ¹¹.
  • Use a needleless system to access any IV tubing ¹¹.
  • Ensure that each component is compatible with one another in order to prevent leaks or breaks in any of the lines.
  • A needless system should be changed or removed within 72 hours unless otherwise indicated ¹¹ . This is the same as a traditional catheter system.

The CDC currently recognizes 4 main routes of contamination of catheters. Each of the aseptic techniques listed above are designed to help minimize the risk of site and blood infection. The 4 recognized routes of infection are:
1. Migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the catheter ¹. Colonization occurs at the catheter tip – this is the most common route of infection in all short term catheters ¹.
2. Direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices ¹.
3. Catheters becomes hematogenously seeded from another focus of infection.
4. Infusate contamination leads to Catheter Related Blood Stream Infection (very rare) ¹.

Medication errors involving IV therapy are some of the most potentially dangerous errors possible within a health care environment. Medication errors can occur in any part of the medication administration process, however it is estimated that over 75% off all medication errors are directly related to a health care provider’s lack of knowledge/experience with specific medication or equipment^1,10. The huge variety of IV pumps in use, different units of measurement for medications, and different generic and no-name brands of medications have created a dizzying array of potential medication error scenarios.

New technologies have helped introduce sophisticated checkpoints into the medication administration process. However, they require training and are by no means a “silver bullet” solution ⁹. Health care providers should be able to match the prescribed medication, with the received medication via bar code (if available). They can then match the medication to the patient using a patient’s ID bracelet ⁹.
Whenever possible, it should be necessary for the facility to follow the path of a prescribed medication from the starting point to the end point. Smart IV pumps can also be programmed to display a limited amount of information in order to help the health care provider focus on the specific medication administration and the specific patient ⁹.

IV therapy is an integral part of modern health care. Although it is often considered a basic part of nursing care, it is inherently an invasive procedure that truly has significant patient safety risks. As such, health care providers must continually strive for quality improvement and the incorporation of evidence based practices in their daily processes.

(1) O’Grady, Naomi, Alexander, Mary, Burns, Lillian. (2011). Guidelines for the Prevention of Intravascular Catheter-Related Infections. The Centers For Disease Control and Prevention. PDF Retrieved From: http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
(2) Ingram, P and Lavery, I. (2005). Peripheral Intravenous Therapy: Key Risks and Implications for Practice. Nursing Standard.19 (46). 55-64. Retrieved from: http://vincesaliba.com/yahoo_site_admin/assets/docs/IV_Therapy_Article_for_Exam.22635255.pdf

(3) Baldwin, Wayne, Murphy, Jayne, Shakespeare, David, Kelly, Chris, Fox, Louise, and Kelly, Matthew. (2013). Campaign for Best Practice in Intravenous Therapy. Nursing Times. 109 (33/34). 22-23. Retrieved from: http://www.nursingtimes.net/Journals/2013/08/16/e/l/g/210813-Campaign-for-best-practice-in-intravenous-therapy.pdf
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(8) Fink, Regina, Hjort, Ellen, Wenger, Barbara, Cook Paul, Cunningham, et al. (2009). The impact of Dry Versus Moist Heat on Peripheral IV Catheter Insertion in a Hematology-Oncology Outpatient Population. Oncology Nursing Forum. July 2009 36 (4). 198-204. Retrieved From: http://ons.metapress.com/content/f3434k6423428153/fulltext.pdf
(9) Maddox, Ray, Danello Sherry, Williams, Carolyn, and Fields, Marianne. (2008). Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes. Advances in Patient Safety: New Directions and Alternative Approaches. Aug 2008. PMID: 21249948
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