By Candy Finley, RN, IgCN & Michelle Greer, RN, IgCN.

Peripheral intravenous access catheters are a commonly used IV device for patients receiving infusion therapy at home. They are primarily used for administration of medications, fluids and/or blood products, and occasionally blood sampling. Long term and daily therapies have created a need for indwelling catheters, and PIV's are becoming less common. As a result, the skills required to properly access a vein with a catheter that can stay in place without complications have become somewhat "rusty."

When it comes to Intravenous administration of immune globulin (IVIG) IG, PIV's are the preferred access route. Long term, indwelling catheters are much less common. Because the therapy is typically monthly, and it requires a little more care on the patient's part to be sure the line is maintained appropriately in between courses. Additionally, with a long term indwelling catheter comes some increased risks such as thrombosis and infection. For people with primary immune deficiencies, having trouble with venous access may be a reason to switch to subcutaneous administration (SCIG), rather than placing a central line.

It is as crucial for any nurse caring for patients who receive IVIG to have impeccable PIV skills as it is for them to understand the therapy itself and all it entails. One of the most common complaints voiced by patients is, "The nurse had to stick me so many times!" Let's review the technique for successful PIV placement. Insertion technique and position of the cannula are critical to the success of a PIV lasting the desired three day dwell time.

The aim of this discussion is to provide an outline of insertion and securing of the PIV and ongoing management of the PIV device, including infection control in the home setting and management of common complications. The PIV should be inserted using the standard precautions and aseptic, no-touch technique. With no-touch technique, the intended insertion area is not palpated after skin cleansing, unless sterile gloves are worn. When you call the patient it's wise to ask them about their venous access. Questions like, "Have you had IV therapy in the past?" and "How did that go?" or even questions around blood draws will give you an idea of what you are walking into. No more than three attempts will be made by any one nurse. Further attempts at PIV insertion should be made only if venous access is felt to be adequate. In fact, you should be reasonably confident you can access a vein before you actually do. Since three is the magic number, you want each attempt to count. The goal, of course, is to be successful on the first try!

Assessment during PIV maintenance requires both local and systemic assessments be completed. Assessing the PIV insertion site and the patient should be done on a regular basis. The PIV site should be checked hourly for pressure for any signs of infection. For home infusions patients, the PIV should be assessed at each visit. You should educate the patient and/or primary care giver about the signs of pressure injuries, contacting the RN and removing the cannula in an emergency.

Considerations for PIV insertion:

• Use aseptic technique when preparing and administering fluids and medications.
• Adhere to the six rights of medication safety.
• Prepare patient and family for the procedure.

Site selection procedure for PIV:

• Explain procedure to patient.
• Assess patient's upper extremities.
• Use non-dominant arm.
• Assess appropriate veins on both dorsal and ventral surfaces including the metacarpal, cephalic and basilic veins of hand and forearm.
• Avoid areas of flexion and areas of pain upon palpation; compromised veins (e.g., bruised, phlebitis, infiltrated, sclerosed or corded areas); areas near valves, areas where there are planned procedures.
  For patients with chronic kidney disease, avoid forearm and upper arm veins.

Assess veins by applying tourniquet:

• Palpate extremity distal to tourniquet to assess vein condition and visually inspect skin integrity.
• Palpate intended venipuncture site to differentiate arteries from veins.

If unable to palpate vein:

• Instruct patient to open and close fist several times.
• Position extremity lower than the heart for several minutes.
• Lightly stroke vein downward.
• Apply heat to extremity for 10-15 minutes to promote vein relaxation and dilation. Do not leave patient unattended.
• Select most distal site for short peripheral catheter placement.
• Remove tourniquet.
• Perform hand hygiene.

Gather supplies:

• Gloves, non-sterile
• Short peripheral catheter
• Needleless connector
• Preservative-free 0.9% sodium chloride prefilled syringe
• IV start kit

8 Tips to help you improve your IV success:

1. Assess the patient veins with tourniquet in place.
2. Check your tourniquet application.
3. Warm up the arm.
4. Hydrate the patient.
5. Use palpation to find veins.
6. Use visualization device when available.
7. Use B/P cuff on low setting.
8. Prevent vein "rolling."

Good hand hygiene before PIV catheter insertion and maintenance, combined with proper aseptic technique during catheter manipulation provides protection against infection. Prevention of infections is always a priority! Prior to accessing PIV cannula, clean with an approved antiseptic wipe. Complications associated with IV therapy are common. Most are preventable by attention to IV infusion equipment and aseptic technique.

Common problems are:

Infection:

• Skin-based bacteria may enter through insertion site.
• Local cellulitis or systemic bacteraemia are possible.
• If infection is present, remove the IV cannula immediately, swab the insertion site and notify NuFACTOR.

Phlebitis or vein irritation:

• Caused by presence of the catheter/fluids or medication.
• Chronically ill patients require multiple and recurrent IV access.
• Notify NuFACTOR promptly.

Infiltration occurs when fluids or medications leak into surrounding tissue. If infiltration occurs:

• Immediately stop the infusion and disconnect the tubing as close to the catheter hub as possible.
• Remove the catheter without placing pressure on the site.
• Elevate the affected limb.
• Continue to assess and document the appearance of the site and associated signs and symptoms.

Documentation of PIVs:

• Document the presence of any atypical findings or complications and any actions taken in the progress notes.
• Fluids and medications through peripheral IVs.
• Any complications
• Record the date and time and notify NuFACTOR Nurse Coordinators or Clinical Educators.

Links:
www.nejm.org/doi/full/10.1056/NEJMvcm0706789
youtu.be/qtfpU98I-Ow