IVs: The Risks, Rewards, and Improving Outcomes

Advanced health care workers in hospitals are often tasked with placing a peripheral IV catheter, Barbara McElroy, MSN, CRNI, VA-BC, clinical educator at New England Life Care said at the 2022 National Infusion Center Association (NICA) Annual Conference, but many nurses are not given adequate training before performing this procedure.^1,2

This lack of training can be dangerous for the patient’s health because placing IVs creates new access for environmental risks to enter the blood.³ McElroy explained why it is so important that the procedure thoroughly understood.

The vein is composed of 3 layers: the tuncia adventitia, tuncia media, and tuncia intima. When inserting solutions into the vein, there is a chance of creating inflammation, McElroy explained. Knowing this can give health care workers the tools to prevent adverse events [AEs].

Another aspect to be aware of is the difference between peripheral vascular access devices (VADs) and central VADs. Knowing that peripheral VADs have limits on what treatments can be administered because of size—flow rates of 45 to 150 mL/min—while central VADs can handle larger flow rates—2000 mL/min—can change the decision of where to place the VAD.

McElroy listed the standard of care in 3 areas:

Evaluate the solution for irritant and/or vesicant properties4

There are no defined limits for osmolarity and pH established by any regulators. That does not mean solutions do not have their risks and knowning them is important. There are also higher risks for solutions that are greater than 600 mOsm/L, pH of less than 4 or greater than 9, or those having blistering properties.⁵

McElroy said a solution that needs to be administered on a continuous basis will require a central VAD. She also advised keeping dextrose use to 10% or less and restricting protein concentration to 5% or less to avoid AEs.

Assess vascular status and history⁴

A patient’s history should be taken before the procedure to help avoid damaged veins, areas of flexion, compromised skin, impaired, or at-risk extremities. For a patient withchronic kidney disease (CKD), McElroy said she tries to preserve the veins in or relating to the head, forearm, inner forearm, and upper arm. She cautioned against using lower extremities unless the patient is a neonate or the need to do so is related to an emergent situation. She advised that if a patient has veins that are difficult to access, it is best to escalate the procedure as early as possible and limit the attempts to place an IV to 2 per clinician.^4,6

Use the smallest gauge that will accommodate therapy and preserve vessel⁶

McElroy further explained that unless it is clinically necessary, health care workers should avoid catheters greater than 20 g and that there are no clinically significant differences between the flow rate of a 20-g catheter vs a 24-g catheter.⁷

In addition to standard of care, health care workers have other options to optimize outcomes. Improving education and encouraging continuing education are key opportunities according to McElroy as is using the aseptic non-touch technique for all IV procedures. Other factors to consider are promoting venous distention, using tools to improve way of seeing the vein, needs a verb for parallel construction anesthetic agents, better documentation, and creating an evidence-based improvement protocol.

References

1. McElroy B. Vascular Access for Outpatient Infusion. June 17-18, 2022. New Orleans, Louisiana.
2. Keleekai NL, Schuster CA, Murray CL, et al. Improving nurses’ peripheral intravenous catheter insertion knowledge, confidence, and skills using a simulation-based blended learning program: a randomized trial. Simul Healthc. 2016;11(6):376-384. doi:10.1097/SIH.0000000000000186
3. Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E. Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs. 2015;38(3):189-203. doi:10.1097/NAN.0000000000000100
4. 2021 infusion therapy standards of practice updates. J Infus Nurs. 2021;44(4):189-190. doi:10.1097/NAN.0000000000000436
5. Manrique-Rodríguez S, Heras-Hidalgo I, Pernia-López MS, et al. Standardization and chemical characterization of intravenous therapy in adult patients: a step further in medication safety. Drugs R D. 2021;21(1):39-64. doi:10.1007/s40268-020-00329-w
6. Plohal A. A qualitative study of adult hospitalized patients with difficult venous access experiencing short peripheral catheter insertion in a hospital setting. J Infus Nurs. 2021;44(1):26-33. doi:10.1097/NAN.0000000000000408
7. Uptodate. Accessed June 17, 2022. https://www.uptodate.com/contents/peripheral-venous-access-in-adults