Introduction

Peripheral intravenous catheters (PIVC) are the most commonly used intravenous device in hospitalised
patients. They are primarily used for therapeutic purposes such as administration of medications, fluids and/or
blood products as well as blood sampling. 

Aim
The aim of this guideline is to provide an outline of the ongoing maintenance and management of the PIVC for
patients in hospital, outpatient, and home healthcare settings. For information related to insertion of PIVC,
please refer to intravenous access guideline . Nurses who are deemed competent in IV insertion could
continue to insert PIVC in consultation with NUM/CSN’s. 

Definition of terms

 Peripheral IV devices: are cannula/catheter inserted into a small peripheral vein for therapeutic
purposes such as administration of medications, fluids and/or blood products.
 Aseptic technique: is a part of all procedures which aims to prevent pathogenic microorganisms, in
sufficient quantity to cause infection, from being introduced to susceptible key sites by key parts, hands,
surfaces and equipment. Therefore, unlike sterile techniques, standard and surgical aseptic techniques
are possible and can be achieved in typical hospital and community settings.
 Decontaminate hands: Perform hand hygiene in order to protect the patient from organisms which
may enter their key sites or devices during a procedure.
 Key Parts: part of the device/s that must remain aseptic throughout the clinical procedures. Examples
of Key parts include, catheter hub, needleless connector, syringe hub, needle etc.
 Key Sites: the area on the patient such as IV insertion site that must be protected from
microorganisms. 
 Extravasation: An extravasation occurs when there is accidental infiltration of a vesicant drug or fluid
into the tissue surrounding the venipuncture site.
 Infiltration: occurs when drugs or fluid infiltrates into the tissue surrounding the venipuncture site. This
happens when the tip of catheter slips out of the vein, catheter passes through the wall of the vein, or
as blood vessel wall stretches which allows fluid to infuse into the surrounding tissue. 
 Phlebitis: a sign of vessel damage. The cause can be chemical (due to the osmolarity of the solution),
mechanical (from trauma at insertion or movement) or infective (microorganisms contaminating the
device). Signs include swelling, redness, heat, induration, purulence, a palpable venous cord (hard
vein) and pain related to local inflammation of the vein at or near the insertion site.
 Infusion Pump: refers to infusions pumps like large volume pumps (LVPs)/volumetric pumps e.g.
Alaris Signature Edition (SE), Syringe drivers (e.g. Alaris GH+), Patient Controlled Analgesia/PCA
pumps (Alaris PCAM) etc.
 Double checking: refers to the practice of two clinicians (appropriately endorsed Enrolled nurses (EN),
Registered Nurses (RN), Doctors or Pharmacists) independently checking the medications. 

Assessment
Patient and IV site assessments should be done on a regular basis. 
PIVC assessment includes: 

 Assessment of PIVC insertion site - Catheter position, patency/occlusion, limb symmetry, any signs of
phlebitis (erythema, tenderness, swelling, pain etc.), infiltration/extravasation. PIVC are considered as
high risk for pressure injury. PIVC sites should be checked hourly for pressure sore and any signs of
infection unless documented
otherwise. http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/
Pressure_Injury_Prevention_and_Management/.
 Assessment of PIVC dressing and splints: check securement of dressing- if it’s intact, clean and dry or
if it’s loose or if visible ooze was present underneath the dressing. Check splint tapes are not too tight
or restrictive.
  Assessment of IV lines, equipment and IV fluid infusions:

 If the patient is receiving continuous IV fluid infusion- observations of the IV site, type of fluid
and volume infused, accurate rate of infusion for patient and pressure alarms of infusion pumps
are observed hourly and documented in the fluid balance flowsheet. 
 If the patient (inpatient setting) is having intermittent infusion, eight hourly assessments are a
minimum. Unstable patients who have signs and symptoms of complications are to be assessed
more frequently.
 If the patient no longer requires IV access for infusions, remove the cannula at the earliest to
avoid complications.
 For Hospital in the Home (HITH) patients, the nurse will assess the PIVC with each visit. 
 Caregiver and patient education will be provided on the signs of injuries and the process of contacting
the nurse.

Flushing of PIVC’s

 If the cannula is accessed intermittently for the administration of medications or fluids, the cannula
should be flushed prior to infusion or at least once a shift.
 Sterile 0.9% sodium chloride for injection should be used to flush a catheter. This must be prescribed
as a medication.
 The optimal volume used for intermittent injections or infusions is unclear. The literature suggests the
volume of flush should equal at least twice the volume of the catheter and add on devices and a
minimum of 2mL normal saline flush is recommended.
 Use 10ml syringe for flushing to avoid excessive pressure and catheter rupture. Syringes with an
internal diameter smaller than that of a 10mL syringe can produce higher pressure in the lumen and
rupture the catheter. If resistance is felt during flushing and force is applied this may result in
extravasation
 Use aseptic non touch techniques including cleaning the access port (scrub the hub) with a dual
disinfectant agent (e.g. chlorhexidine and alcohol) vigorously for at least 15 seconds and allowing to dry
prior to accessing the system.
 Flush in a pulsatile (push-pause) motion.
Flush catheters:

 Immediately after placement

 Prior to and after fluid infusion (as an empty fluid container lacks infusion pressure and will allow
blood reflux into the catheter lumen from normal venous pressure) or injection.
 Prior to and after blood drawing.

Common IV Cannula Complications:

https://www.ausmed.com/cpd/articles/intravenous-cannula

 Phlebitis (inflammation of the vein) is characterised by one or more of the following: pain, redness,
swelling, warmth, a red streak along the vein, hardness of the IV site, and/or purulence.
 Infiltration is the leakage of a non-vesicant solution into the surrounding tissues, causing pain and
swelling.
 Extravasation is the migration into the tissues of a vesicant medicine or fluid, such as chemotherapy.
This can be severely painful and cause major tissue trauma.
 Thrombosis or thrombophlebitis is the formation of a clot in the vessel, often caused by the cannula
moving around in the vein and aggravating the vessel wall.
 Nerve damage can occur during PIVC insertion. If the patient complains of a sharp pain shooting up
the arm, or ongoing numbness or tingling of the extremity, the cannula should be removed immediately.
 Partial or complete dislodgement of the PIVC indicates it is no longer in the vessel and must be
removed.
The cell is divided into two parts: (intracellular & extracellular). Each part is made up of a solution and
depending on the tonicity of the fluid you can having shifting of fluids from outside of the cell to the inside
via osmosis.

The cell loves to be in an isotonic state and when something happens to make it unequal (like with hypotonic
or hypertonic conditions) it will use osmosis to try to equal it out.

Osmosis allows molecules of the solvent to pass through a semipermeable membrane from a less
concentrated solution to a higher concentrated solution. The key thing to remember here is that everything
will move from a LOW concentration to a HIGH concentration.

Remember when we are talking about isotonic and hypo/hypertonic we are talking about how it looks outside
of the cell compared to inside.

The cell is divided into two parts: (intracellular & extracellular). Each part is made up of a solution and
depending on the tonicity of the fluid you can having shifting of fluids from outside of the cell to the inside
via osmosis.

The cell loves to be in an isotonic state and when something happens to make it unequal (like with hypotonic
or hypertonic conditions) it will use osmosis to try to equal it out.

Osmosis allows molecules of the solvent to pass through a semipermeable membrane from a less
concentrated solution to a higher concentrated solution. The key thing to remember here is that everything
will move from a LOW concentration to a HIGH concentration.

Remember when we are talking about isotonic and hypo/hypertonic we are talking about how it looks outside
of the cell compared to inside.

Isotonic

Iso: same/equal

Tonic: concentration of a solution

The cell has the same concentration on the inside and outside which in normal conditions the cell’s intracellular
and extracellular are both isotonic.

It is important to be familiar with what fluids are isotonic and when they are given.

Isotonic fluids

 0.9% Saline
 5% dextrose in water (D5W)**also used as a hypotonic solution after it is administered because the body
absorbs the dextrose BUT it is considered isotonic)
 5% Dextrose in 0.225% saline (D5W1/4NS)
 Lactated Ringer’s
Isotonic solutions are used: to increase the EXTRACELLULAR fluid volume due to blood loss, surgery,
dehydration, fluid loss that has been loss extracellularly.

Hypotonic
Hypo: ”under/beneath”

Tonic: concentration of a solution

The cell has a low amount of solute extracellularly and it wants to shift inside the cell to get everything back to
normal via osmosis. This will cause CELL SWELLING which can cause the cell to burst or lyses.

Hypotonic solutions

 0.45% Saline (1/2 NS)

 0.225% Saline (1/4 NS)
 0.33% saline (1/3 NS)
Hypotonic solutions are used when the cell is dehydrated and fluids need to be put back intracellularly. This
happens when patients develop diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemia.

Important: Watch out for depleting the circulatory system of fluid since you are trying to push extracellular fluid
into the cell to re-hydrate it. Never give hypotonic solutions to patient who are at risk for increased cranial
pressure (can cause fluid to shift to brain tissue), extensive burns, trauma (already hypovolemic) etc.
because you can deplete their fluid volume.

Hypertonic

Hyper: excessive

Tonic: concentration of a solution

The cell has an excessive amount of solute extracellularly and osmosis is causing water to rush out of the cell
intracellularly to the extracellular area which will cause the CELL TO SHRINK.

Hypertonic solutions

 3% Saline
 5% Saline
 10% Dextrose in Water (D10W)
 5% Dextrose in 0.9% Saline
 5% Dextrose in 0.45% saline
 5% Dextrose in Lactated Ringer’s
When hypertonic solutions are used (very cautiously….most likely to be given in the ICU due to quickly arising
side effects of pulmonary edema/fluid over load). In addition, it is prefered to give hypertonic solutions via a
central line due to the hypertonic solution being vesicant on the veins and the risk of infiltration.