Intravenous Access

Background

Venous access is something that is often taken for granted. Establishing reliable venous access will facilitate a wide array of medical therapies and diagnostic exams. Currently, there are numerous types of intravenous (IV) access available, including peripheral IV (PIV), midline catheters, peripherally inserted central catheters (PICCs), non-tunneled and tunneled central venous catheters (CVCs), and completely implantable devices known as “ports.” Selecting the appropriate type of venous access may not always be easy. The type of access needed depends on a number of factors, mainly the type of therapy and duration.

Probably the most important initial consideration when selecting venous access is the type of therapy planned. Some medications and fluids are nontoxic and can be administered safely through any type of access. However, there are many medications that are toxic and should only be administered through specific types of access. It is critical to know the safety profile of the planned therapy.

Irritants are medications and fluids that can cause localized inflammation of the vein called phlebitis. If the vein is disrupted, the medication can leak into the surrounding tissues, termed “infiltration.” There is a spectrum of severity ranging from slight pain and erythema to severe pain, induration, and fever. Inflammation can be associated with thrombus formation, called thrombophlebitis. Mild reactions can be managed by discontinuing the IV and elevation. More severe cases may also require anti-inflammatory medication, compression, and potentially anticoagulation if there is extensive thrombus.

Vesicants are medications that can cause severe tissue damage or necrosis if infused into the tissue surrounding the vein, called “extravasation.” Complications of extravasation can be severe leading to tissue loss and potentially requiring surgical management. The safety profile of certain vesicants precludes them from ever being administered peripherally, and are thus often referred to as “non-peripherally compatible” in much of the literature. Some examples of vesicants and their mechanism of injury are listed in Table 37.1 .

How to Use It

IV access has several benefits and is frequently used in the hospital setting. Certain medications and fluids can only be given IV. Other medications have significantly improved efficacy when delivered IV. Certain diagnostic studies involving radiographic imaging also often require IV medication and contrast agent administration. Central venous access may be required for medications and fluids that cannot be given peripherally if they are damaging to the blood vessel or surrounding tissues if extravasation occurs. The frequent phlebotomy necessary in many hospitalized patients may also occasionally necessitate specialized venous access when it cannot be performed conventionally.