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A peripheral intravenous catheter (PIVC) is a short catheter placed in a superficial vein, usually of the arm, for fluids, medications, and blood. It is the most common invasive device in hospitals, and up to half of PIVCs fail before therapy ends from infiltration, phlebitis, occlusion, or dislodgement. Current practice follows the Infusion Nurses Society (INS) Infusion Therapy Standards of Practice (9th edition, 2024) and CDC catheter-infection guidance.
| Type | Examples | Effect | Cautions |
|---|---|---|---|
| Isotonic | 0.9% sodium chloride, lactated Ringer's, D5W (isotonic in the bag, but becomes free water once dextrose is metabolized) | Expands extracellular (intravascular) volume | Fluid overload in heart or kidney failure; LR contains potassium and lactate (caution in hyperkalemia and severe liver failure); D5W is not a volume expander |
| Hypotonic | 0.45% sodium chloride | Moves water into cells | Avoid in increased intracranial pressure, burns, and trauma (cerebral edema, hypovolemia) |
| Hypertonic | 3% sodium chloride, D10W, D5 in 0.9% or 0.45% NaCl, D5LR | Pulls water out of cells into vessels | 3% saline via controlled infusion (often central line) — monitor sodium closely; risk of fluid overload and osmotic demyelination with overly rapid correction |
Vesicants (drugs that cause blistering and tissue necrosis if they escape the vein) include many chemotherapy agents, vasopressors (norepinephrine, high-dose dopamine), concentrated calcium and potassium, hypertonic dextrose (10% or more), and some contrast media. Irritants cause pain and phlebitis without necrosis.
During therapy — assess the site and flow regularly (commonly every 4 hours in adults, and every 1–2 hours in critically ill or sedated clients or during vesicant infusion — per policy; continuous observation for vesicant pushes)
| Complication | Signs |
|---|---|
| Infiltration (non-vesicant fluid in tissue) | Swelling, coolness, pallor, taut skin, discomfort, slowed or stopped flow, leaking at the site |
| Extravasation (vesicant in tissue) | As above plus burning pain, blistering, later necrosis |
| Phlebitis | Redness, warmth, pain along the vein, palpable hard cord, possibly purulence (infectious) |
| Occlusion | Pump occlusion alarms, inability to flush |
Phlebitis types: chemical (irritating drugs, low pH, high osmolarity), mechanical (large catheter, poor stabilization, flexion area), bacterial (poor asepsis). Use a validated phlebitis scale to grade and document.
Infiltration grading (standardized scale, e.g., INS 0–4): 1 = skin blanched, edema under 2.5 cm (1 in), cool, with or without pain; 2 = edema 2.5–15 cm (1–6 in); 3 = edema over 15 cm (6 in), cool, mild to moderate pain, possible numbness; 4 = tight, leaking, discolored or bruised skin, deep pitting edema, circulatory impairment, moderate to severe pain, or any infiltration of a vesicant, blood product, or irritant. Any escape of a vesicant is an extravasation.
Drops per minute = volume (mL) × drop factor (drops/mL) ÷ time (minutes)
Macrodrip sets deliver 10, 15, or 20 drops/mL; microdrip sets deliver 60 drops/mL (with a microdrip set, drops/min equals mL/h). Example: 1,000 mL over 8 hours with a 15 drops/mL set = 1,000 × 15 ÷ 480 ≈ 31 drops/min.
Pump rate: mL/h = total volume (mL) ÷ time (h); e.g., 1,000 mL over 8 hours = 125 mL/h.
| Element | Current practice |
|---|---|
| Site in adults | Forearm veins (large, straight, easy to stabilize, better dwell) — upper extremity |
| Avoid | Areas of flexion (antecubital fossa for longer use, wrist), the hand for longer infusions when forearm veins are available, the lower extremity in adults (thrombosis and phlebitis — move proximally as soon as possible), affected arm after axillary node dissection or with lymphedema, AV fistula/graft arm, veins below a previous infiltration or phlebitis, the radial wrist area (nerve injury) |
| Catheter size | Smallest gauge that will deliver the therapy — 20–24 G for most infusions; 18 G or larger for rapid fluid resuscitation or trauma |
| Attempts | Limit attempts per clinician (commonly 2) and in total, then escalate to a skilled inserter or ultrasound |
| Skin antisepsis | Alcohol-based chlorhexidine (more than 0.5%) preferred; povidone-iodine or 70% alcohol if contraindicated; allow to dry fully; do not repalpate after antisepsis (unless sterile gloves) |
| Gloves | Clean gloves with no-touch technique for PIVC insertion; sterile gloves if the site must be repalpated |
| Replacement | INS: remove when clinically indicated (complication or no longer needed), not on a routine schedule. CDC (2011) states there is no need to replace more often than every 72–96 hours in adults and treats clinically indicated replacement as unresolved — follow facility policy. Routine 48–72 hour changes are outdated. Remove catheters placed in an emergency without assured asepsis within 48 hours |
| Dressing | Sterile transparent semipermeable membrane: change at least every 7 days; gauze: every 2 days; change immediately if damp, loose, or soiled |
| Administration sets | Primary continuous sets: no more often than every 96 hours but at least every 7 days; intermittent (disconnected) sets every 24 hours; blood sets after each unit or every 4 hours per policy; parenteral nutrition and lipid sets every 24 hours (lipid alone per policy, often 12 hours); propofol every 6–12 hours per label; change all with a new catheter |
| Flushing | Preservative-free 0.9% sodium chloride, at least twice the internal volume of the catheter and add-on devices (commonly 3–10 mL in adults), before and after each medication; use 10 mL-diameter syringes; pulsatile (push-pause) technique; 5% dextrose flush for drugs incompatible with saline |
| Needleless connectors | Scrub the hub with alcohol or chlorhexidine-alcohol before every access and let dry, or use passive disinfecting caps |
Peripheral limits on infusates: vesicants should run peripherally only briefly and with close monitoring; continuous vesicant infusions (and long-term therapy) need a central vascular access device. Peripheral parenteral nutrition is commonly limited to an osmolarity of about 900 mOsm/L (ASPEN).
Extravasation treatment — follow the specific drug protocol: e.g., hyaluronidase for many non-cytotoxic and vinca alkaloid extravasations, phentolamine for vasopressor extravasation, dexrazoxane for anthracyclines; cold for most cytotoxic vesicants (e.g., anthracyclines); warm for vinca alkaloids and for vasopressor or hyperosmolar extravasations (with phentolamine or hyaluronidase). Always follow the drug-specific protocol.
Listed in priority order.
| Complication | What to watch for |
|---|---|
| Extravasation injury | Blistering, skin necrosis, compartment syndrome |
| Catheter-related bloodstream infection | Fever, chills, hypotension; purulence at the site |
| Circulatory overload | Dyspnea, crackles, cough, hypertension, jugular venous distension — slow the infusion, sit upright, notify, prepare diuretic |
| Air embolism (rare peripherally) | Sudden dyspnea, chest pain, hypotension |
| Speed shock | Flushing, headache, chest tightness, hypotension, syncope after rapid IV push |
| Nerve injury | Shooting pain or paresthesia during insertion — stop and remove |
| Hematoma | Bruising, swelling after failed attempt |
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