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INTRAVENOUS CANNULATION Introduction

Intravenous cannulation is a technique in which a cannula is placed inside a vein to provide venous access. Venous access allows sampling of blood as well as administration of fluids, medications, parenteral nutrition, chemotherapy, and blood products. Veins have a three-layered wall composed of an internal endothelium surrounded by a thin layer of muscle fibers that is surrounded by a layer of connective tissue. Venous valves encourage unidirectional flow of blood and prevent pooling of blood in the dependent portions of the extremities; they also can impede the passage of a catheter through and into a vein. Venous valves are more numerous just distal to the points were tributaries join larger veins and in the lower extremities. This topic describes the use of an “over-the-needle” intravenous catheter, where the catheter is mounted on the needle, as shown in the image below.

An "over-the-needle" intravenous catheter. This device is available in various gauges (16-24 G), lengths (25-44 mm), compositions, and designs. The image below shows different gauges of intravenous catheters.

Various sizes of "over-the-needle" intravenous catheters. In general, the smallest gauge of catheter should be selected for the prescribed therapy to prevent damage to the vessel intima and ensure adequate blood flow around the catheter, which reduces the risk of phlebitis. In an emergency situation or when patients are expected to require large volumes infused over a short period of time, the largest gauge and shortest catheter that is likely to fit the chosen vein should be used.

Veins with high internal pressure become engorged and are easier to access. The use of venous tourniquets, dependent positioning, “pumping” via muscle contraction, and the local application of heat or nitroglycerin ointment can contribute to venous engorgement. The superficial veins of the upper extremities are preferred to those of the lower extremities for peripheral venous access as they interfere less with patient mobility and pose a lower risk for phlebitis. It is easier to insert a venous catheter where two tributaries merge into a Y-shaped form. It is recommended to choose a straight portion of a vein to minimize the chance of hitting valves. This chapter describes the placement of an intravenous catheter in an upper extremity. A similar technique can be used for placement of intravenous catheters in different anatomical sites.

Indications  Indications for intravenous cannulation include the following:  Repeated blood sampling  Intravenous fluid administration  Intravenous medications administration  Intravenous chemotherapy administration  Intravenous nutritional support  Intravenous blood or blood products administration  Intravenous administration of radiological contrast agents for computed tomography, magnetic resonance imaging, or nuclear imaging

or burned extremity should be avoided if possible. pH >9. Peripheral venous access in an injured. They should only be given through a peripheral vein in emergency situations or when a central venous access is not readily available.Contraindications No absolute contraindications to intravenous cannulation exist. or osmolarity >600m Osm/L) can cause blistering and tissue necrosis if they leak into the tissue. including sclerosing solutions. and vasopressors. infected. These solutions are more safely infused into a central vein. Some vesicant and irritant solutions (pH < 5. some chemotherapeutic agents. Periprocedural Care Equipment Equipment for intravenous cannulation includes the following:  Nonsterile gloves  Tourniquet  Antiseptic solution (2% chlorhexidine in 70% isopropyl alcohol)  Local anesthetic solution  1-ml syringe with a 30-G needle  2 × 2 gauze  Venous access device  Vacuum collection tubes and adaptor (see image below)  Saline or heparin lock  Saline or heparin solution .

Some of the equipment required for intravenous cannulation . Transparent dressing  Paper tape Equipment for intravenous cannulation is shown in the images below.

Some of the equipment required for intravenous cannulation. . Positioning Make sure there is adequate light and that the room is warm enough to encourage vasodilation. Both should be used unless in emergent situation. Adjust the height or position of the bed or chair to make sure you are comfortable and to prevent unnecessary bending. Patient Preparation Anesthesia Both intradermal injection of a topical anesthetic agent just prior to intravenous insertion and topical application of a local anesthetic cream about 30 minutes prior to intravenous insertion have shown significant reduction of pain associated with the procedure. Vacuum collection tubes and adaptor for intravenous cannulation.

if you believe that the selected vein should be accessible. The patient’s skin should be washed with soap and water if visibly dirty. inadequate skin traction. Periprocedural and Postprocedural Complications Complications may include the following:  Pain  Failure to access the vein  Blood stops flowing into the flashback chamber  Difficulty advancing the catheter over the needle and into the vein  Difficulty flushing after the catheter was placed in a vein  Arterial puncture  Thrombophlebitis  Peripheral nerve palsy  Compartment syndrome  Skin and soft tissue necrosis For pain. withdraw the venous access device to just beneath the skin and reattempt to insert. use of an anesthetic cream 30 minutes prior to insertion attempt and/or subcutaneous infiltration of an anesthetic solution should be used prior to peripheral intravenous insertion whenever possible. In this case. Collapse of the vein. either attempt insertion at a different site or.Make sure the patient is in a comfortable position and place a pillow or a rolled towel under the patient’s extended arm. incorrect positioning. . and incorrect angle of penetration can all lead to a failed attempt at accessing the vein.

release the tourniquet and then reapply it to help engorge the vein. In this case. encountering a venous valve. . then attempt to “float” the device in place by flushing the catheter and advancing it at the same time. In the case of arterial puncture. or penetration of the posterior wall of the vein might be the cause. release and then reapply the venous tourniquet and attempt to gently stroke the vein to engorge it with blood and release venospasm. Observation of a developing hematoma will necessitate removal of the catheter. Failure to release the catheter from the needle before insertion. withdraw the catheter slightly to release it from a wall/valve and attempt to flush it back in. Observation of a hematoma will necessitate removal of the catheter. attempt to withdraw the needle a few millimeters to move it away from a valve. In this case.If blood stops flowing into the flashback chamber. needle hub position against a venous valve. as evidenced by arterial pulsation of blood out of the catheter. venospasm. removing the needle too far with the catheter being too soft to advance into the vein. Connect a syringe with normal saline (0. remove the catheter and apply direct pressure using gauze for at least 10 minutes. blood clot. poor skin traction. Difficulty flushing after the catheter was placed in a vein can be caused by the catheter tip position against a venous wall or a valve. palpate the vein carefully before attempting to insert a venous access device to ensure that there is no palpable pulse in the vessel. Finally. or venous collapse can all be the cause of difficulty advancing the catheter over the needle and into the vein. or piercing of the venous wall. vein collapse. If an accidental arterial puncture occurred. In this case.9%) solution to the hub.

Make sure to monitor the site while the transfusion is taking place and use extra caution in patients who are unable to communicate pain or discomfort. causing pain and (rarely) paralysis when other veins are selected.Thrombophlebitis can be caused by either thrombus formation with subsequent inflammation and/or infection. swelling. Some vesicant and irritant solutions may cause severe soft tissue damage if they extravasate outside of the vein and into the surrounding tissue. Pain in the intravenous site of along the path of the catheter. while others suggest that proper antiseptic technique and at least daily monitoring of the insertion sites may allow for safe less frequent replacement as long as no signs of phlebitis are present. or presence of a palpable venous cord are the signs of thrombophlebitis.[8] Accidental puncture of the median nerve is rare but possible as it is located just posterior to the basilic vein in the antecubital fossa. Regularly and at least daily inspect the site of insertion for signs of infections. Remove the catheter and treat with appropriate antibiotics if you suspect an infectious etiology. Some infusion pumps are preset to stop the infusion and sound an audible alert with any increase in resistance to flow. Other peripheral nerves might be accidently punctured. Continuous infusion of solutions into a venous access device that extravasated into the surrounding tissue might result in a compartment syndrome. Some sources recommend the routine replacement of peripherally inserted intravenous catheters every 3-4 days. drainage from the skin puncture site. . skin erythema and/or induration.

followed by the dorsal hand venous network (see images below). I ntravenous sites for intravenous cannulation . Intravenous Catheter Insertion Place a venous tourniquet over the patient’s nondominant arm and select a site for intravenous catheter insertion. The veins of choice for catheterization include the cephalic or basilic veins.Technique Approach Considerations Use properly fitted nonsterile gloves and eye protection device to prevent exposure via accidental blood splashes.

For prolonged courses of therapy. it is recommended. one of the following techniques may be used:  Inspection of the opposite extremity  Opening and closing the fist  Using gravity (holding the arm down)  Gentle tapping or stroking of the site  Applying heat (warm towel/pack) or a nitroglycerin ointment Application of a tourniquet to the proximal arm with infusion of 60 ml of normal saline solution via a small intravenous catheter that is inserted distally may cause enough venous engorgement to allow placement of a more proximal large bore intravenous catheter.. Intravenous site for intravenous cannulation. to start distally and move proximally as distal catheters are replaced. . although not always practical. If difficulty is encountered in finding an appropriate vein.

While the skin is allowed to dry. Application of antiseptic solution for intravenous cannulation. . flush the saline or heparin lock with the appropriate solution. Transillumination is another technique that can be used in patients with difficult intravenous access.Ultrasound guidance has been shown to facilitate peripheral venous placement in emergency department patients with difficult intravenous access and should be used when appropriate veins are not readily visualized or palpable. as shown in the image below. as shown in the image below. Allow to air dry for up to 1 minute to ensure disinfection of the site and to prevent stinging as the needle pierces the skin. do not touch or repalpate the skin. Apply an antiseptic solution such as 2% chlorhexidine solution or 70% alcohol with friction for 30-60 seconds. The syringe may be left attached to the tubing. Once cleaned.

Stabilization should be maintained throughout the procedure.Flushing of intravenous tubing with normal saline for intravenous cannulation. Stabilize the vein using your nondominant hand (thumb) to apply traction to the skin distal to the chosen site of insertion.5-1 ml of a local anesthetic using a 25. infiltrate 0. Subcutaneous injection of a local anesthetic for intravenous cannulation. This will prevent superficial veins from rolling away from the needle.or 30-G needle to raise a wheal at the site of catheter insertion. as shown in the image below. Unless in an emergent situation. if the patient is interested in local anesthesia. . as shown in the image below.

Applying traction with the nondominant thumb to stabilize the vein for intravenous cannulation. The angle of the needle entry into the skin will vary according to the device used and the depth of the vein. Release the needle from the catheter and replace it. Deeper veins should be accessed with a larger catheter at a 30. as shown in the image below. Small superficial veins are best accessed using a small catheter (22-24 G) placed at a 10. This will ensure smooth advancement once the venous access device is inside the vein. ensuring the catheter was not damaged or fragmented.to 25degree angle.to 45degree angle. Hold the venous access device in your dominant hand bevel up to ensure smoother catheterization because the sharpest part of the needle will penetrate the skin first. .

the practitioner might feel a “giving way” sensation.Angle of insertion with bevel up for intravenous cannulation. The angle of the venous access device should be reduced to prevent puncturing the posterior wall of the vein. Upon entry into the vein. as shown in the image below. flashback). It should be advanced gently and smoothly an additional 2-3 mm into the vein. the device should be withdrawn to just beneath the skin level and another attempt to recatheterize the . Blood should appears in the chamber of the venous access device (ie. If no blood is observed in the flashback chamber. Flashback of blood into the venous access device for intravenous cannulation.

Hold the needle grip of the venous access device in place between your dominant thumb and middle finger. This could result in catheter fragmentation and embolism. Sliding the hub of the catheter over the needle and into the vein for intravenous cannulation. release the tourniquet. If swelling develops. as shown in the image below. . After the venous access device’s hub is dropped to the skin. If venous catheterization is unsuccessful. as shown in the image below. maintain skin traction with your nondominant hand. the needle should never be reintroduced into the catheter. Then use your dominant hand to withdraw the needle. Flashback may stop if the device punctured the posterior wall of the vein or in extremely hypotensive patients. Use your nondominant middle finger to apply pressure over the catheter to prevent blood spill and hold the hub in place using your nondominant index and thumb fingers. and apply direct pressure for 5 minutes for a hematoma. withdraw the device. while using your dominant index finger to slide the hub of the catheter over the needle and into the vein.vein should take place.

Release the tourniquet.Using the nondominant hand to secure the venous access device in the vein while using the dominant hand to remove and secure the needle for intravenous cannulation. as shown in the image below. . If blood sampling is needed. Using the blood sampling adaptor for intravenous cannulation. Secure the needle in either its safety cover and/or a dedicated biohazard sharps container. attach an adaptor or a syringe to the hub and obtain the required samples.

withdraw a small amount of blood to verify that the catheter is still inside the vein. disconnect the blood sampling adaptor or syringe and securely attach the preflushed saline or heparin lock to the hub of the venous access device. Immediately flush the tubing with the remainder solution. Secure the venous access device to the skin using the transparent dressing and tape. . Slide the plastic tubing lock and continue to lock the tubing (if such a lock is available). Using the saline or heparin flush syringe. Securing a saline lock with a transparent dressing for intravenous cannulation.While applying pressure to the catheter to prevent blood spillage and while continuously stabilizing the hub and wings to the skin as described before. as shown in the image below. as shown in the images below.

and other facility-specific required information over the transparent dressing. Video of intravenous cannulation. as shown in the image below. An intravenous cannulation is shown in the video below. Finish securing the tubing to the skin using tape. . time. Removal of peripheral intravenous catheters can be performed as clinically indicated and they should not be routinely replaced on a fixed schedule.Flushing and locking the venous access device for intravenous cannulation. Labeling for intravenous cannulation. Place a label indicating date.[13] Intravenous Catheter Removal Stop infusion solution and disconnect tubing leaving just the saline/heparin lock tubing connected to the venous access device. MD. Release the adhesive tape and transparent dressing from the skin. Video courtesy of Gil Z Shlamovitz.

and apply direct pressure with gauze for at least 5 minutes. Instruct the patient to continue manual pressure for 10 more minutes in order to minimize hematoma formation. Inspect the catheter for fragmentation. time. Document in the patient’s chart the date. as shown in the image below. . Intravenous catheter removal. Place a 2 × 2 gauze pad or a cotton ball with a paper tape over the intravenous insertion site.Withdraw the catheter outside of the vein. and reason for catheter removal and the integrity of the catheter as inspected.

nutrition.Intravenous therapy Intravenous therapy or IV therapyis the infusion of liquid substances directly into a vein. on the other hand. there is still controversy with regard to the actual . and allows an estimation of flow rate.[1] However. The wordintravenous simply means "within avein". for example. Therapies administered intravenously are often calledspecialty pharmaceuticals. crystalloids and colloids. this parameter is decreased by crystalloids due to hemodilution. dehydration. the intravenous route is the fastest way to deliver fluids and medications throughout the body Infused substances Substances that may be infused intravenously include volume expanders. to deliver medications. while. blood based products. Volume expanders There are two main types of volume expander. It is commonly referred to as a dripbecause many systems of administration employ a drip chamber. medications. which prevents air from entering the blood stream (air embolism). Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. blood substitutes.) Compared with other routes of administration. for blood transfusion or as fluid replacement to correct. such as gelatin.Blood is a colloid. Intravenous therapy may be used to correct electrolyte imbalances. Intravenous therapy can also be used for chemotherapy (The treatment for any kind of cancer.  Colloids preserve a high colloid osmotic pressure in the blood. Colloids contain larger insoluble molecules.

are mildly hypotonic solutions often used for large-volume fluid replacement. People with hemophilia usually need a replacement of clotting factor. Blood transfusions may also be used to treat a severe anaemia or thrombocytopenia caused by a blood disease.[1]  The most commonly used crystalloid fluid is normal saline. such as fresh frozen plasma or cryoprecipitate. such as massive blood loss due to trauma. People with sickle-cell disease may require frequent blood transfusions.difference in efficacy between colloids and crystalloids.9% concentration. Early blood transfusions consisted of whole blood. . Blood substitutes Blood substitutes (also called artificial blood or blood surrogates) are artificial substances aiming to provide an alternative to blood-based products acquired from donors. or can be used to replace blood lost during surgery.[1] Crystalloids generally are much cheaper than colloids. Blood transfusions can be life-saving in some situations. which is a small part of whole blood. Blood-based products A blood product (or blood-based product) is any component of blood which is collected from a donor for use in a blood transfusion. a solution ofsodium chloride at 0. but modern medical practice commonly uses only components of the blood. which is close to the concentration in the blood (isotonic). Lactated Ringer's (also known as Ringer's lactate) and the closely related Ringer's acetate.

Other Parenteral nutrition is feeding a person intravenously. Intravenous access devices . such as when there is insufficient uptake by other routes of administration such as enterally. lipids and added vitamins. Examples includeintravenous immunoglobulin and propofol. amino acids. Lactated Ringer's solution also has some buffering effect. Other medications Medications may be mixed into the fluids mentioned above. bypassing the usual process of eating and digestion. Also. Certain types of medications can only be given intravenously. A solution more specifically used for buffering purpose is intravenous sodium bicarbonate. The person receives nutritional formulas containing salts. oxygen-carrying substitutes are emerging. Buffer solutions Buffer solutions are used to correct acidosis or alkalosis. glucose.The main blood substitutes used today are volume expanders such as crystalloids and colloids mentioned above. Drug injection used for recreational substances usually enters by the intravenous route.

for testing). thus verifying that the needle is really in a vein. but any identifiable vein can be used.These can all be used to obtain blood (e. especially the veins on the back of the hand. The most convenient site is often the arm. also known asphlebotomy as well as for the administration of medication/fluids. Hypodermic needle The simplest form of intravenous access is by passing a hollow needle through the skin directly into the vein. or the median cubital vein at the elbow. The tourniquet should be removed before injecting to prevent extravasation of the medication.g. it is common to draw back slightly on the syringe to aspirate blood. This needle can be connected directly to a syringe (used either to withdraw blood or deliver its contents into the bloodstream) or may be connected to a length of tubing and thence whichever collection or infusion system is desired. Peripheral cannula . Often it is necessary to use a tourniquet which restricts the venous drainage of the limb and makes the vein bulge. Once the needle is in place.

This is the most common intravenous access IV line method (PVC in or both hospitals andpre-hospital services. This is usually in . A peripheral PIV) consists of a short catheter (a few centimeters long) inserted through the skin into aperipheral vein (any vein not inside the chest or abdomen).20 gauge peripheral IV in hand A nurse inserting a 18-gauge IV needle with cannula.

In infants the scalp veins are sometimes used. with 14 being a very large cannula (used in resuscitation settings) and 24-26 the smallest. in which a flexible plastic cannula comes mounted on a metal trocar. . The most common sizes are 16-gauge (midsize line used for blood donation and transfusion). Any accessible vein can be used although arm and hand veins are used most commonly. a venous cutdown may be necessary. 18. Blood may be drawn at the time of insertion. between treatments. it can be connected to a syringe or an intravenous infusion line.and 20-gauge (all-purpose line for infusions and blood draws). To make the procedure more tolerable for children medical staff may apply a topical local anaesthetic (such as EMLA or Ametop) for about 45 minutes beforehand. In cases of shock. The caliber of cannula is commonly indicated in gauge. Once the tip of the needle and cannula are located in the vein the trocar is withdrawn and discarded and the cannula advanced inside the vein to the appropriate position and secured. Ported cannulae have an injection port on the top that is often used to administer medicine. a needleless connection filled with a small amount of heparin solution to prevent clotting. and 22-gauge (all-purpose pediatric line). The part of the catheter that remains outside the skin is called the connecting hub. 12. or capped with a heplock. with leg andfoot veins used to a much lesser extent. These lines are frequently called "large bores" or "trauma lines".the form of a cannula-over-needle device.and 14-gauge peripheral lines are capable of delivering large volumes of fluid extremely fast accounting for their popularity in emergency medicine.

A peripheral IV cannot be left in the vein indefinitely. The US Centers for Disease Control and Prevention updated their guidelines and now advise the cannula need to be replaced every 96 hours. If a patient needs frequent venous access. this situation is known as a "tissuing" or a "blown vein". blood may leak into the surrounding tissues. or the vein is particularly fragile and ruptures. Using this cannula to administer medications causes extravasation of the drug which can lead to edema. and even necrosis depending on the medication. because of the risk of insertion-site infection leading to phlebitis. or within the right atrium of the heart. cellulitis and sepsis. Central IV lines Central IV lines flow through a catheter with its tip within a large vein. causing pain and tissue damage. the UK Department of health published their finding about risk factors associated with increased MRSA infection.Complications If the cannula is not sited correctly. making any future access extremely difficult or impossible.[2] This was based on studies organised to identify causes of Methicillin-resistant Staphylococcus aureus(MRSA) infection in hospitals. now include intravenous cannula. central venous catheters andurinary catheters as the main factors increasing the risk of spreading antibiotic resistant strain bacteria. The person attempting to obtain the access must find a new access site proximal to the "blown" area to prevent extravasation of medications through the damaged vein. In the United Kingdom. This has several advantages over a peripheral IV: . usually thesuperior vena cava or inferior vena cava. the veins may scar and narrow. For this reason it is advisable to site the first cannula at the most distal appropriate vein.

thromboembolism and gas embolism (see Risks below).  There is room for multiple parallel compartments (lumen) within the catheter. It can deliver fluids and medications that would be overly irritating to peripheral veins because of their concentration or chemical composition. These include some chemotherapy drugs and total parenteral nutrition. so that multiple medications can be delivered at once even if they would not be chemically compatible within a single tube. and are quickly distributed to the rest of the body. They are often more difficult to insert correctly as the veins are not usually palpable and rely on an experienced clinician knowing the appropriate landmarks and/or using an ultrasound probe to safely locate and enter the vein. Surrounding structures. depending on the route that the catheter takes from the outside of the body to the vein. There are several types of central IVs. such as the pleura andcarotid artery are also at risk of damage with the potential for pneumothorax or even cannulation of the artery. gangrene.  Caregivers can measure central venous pressure and other physiological variables through the line. infection.  Medications reach the heart immediately. Peripherally inserted central catheter PICC lines are used when intravenous access is required over a prolonged period of time or when the material to be infused would cause quick damage and early failure of a peripheral IV and when a conventional central line may be too . Central IV lines carry risks of bleeding.

It is also externally unobtrusive. each with its own external connector. to estimate the optimal length. An X-ray must be used to verify that the tip is in the right place when fluoroscopy was not used during the insertion. This is usually done by measuring the distance to an external landmark. can be . a singlelumen PICC resembles a peripheral IV. extended antibiotic therapy. such as the suprasternal notch. two(doublelumen) or three (triple-lumen) compartments. a PICC does not require the skill level of a physician or surgeon. and with proper hygiene. Although special training is required. However. A PICC may have a single (single-lumen) tube and connector. due to the higher risk of serious infection if bacteria travel up the catheter. Power-injectable PICCs are now available as well. and some good luck. The insertion site requires better protection than that of a peripheral IV. The PICC line is inserted through a sheath into a peripheral vein sometimes using the Seldinger technique or modified Seldinger technique. The chief advantage of a PICC over other types of central lines is that it is safer to insert with a relatively low risk of uncontrollable bleeding and essentially no risks of damage to the lungs or major blood vessels. usually in the arm. From the outside.Typical uses for a PICC include: long chemotherapy regimens. This helps to slow the growth of bacteria which could reach the bloodstream by traveling under the skin along the outside of the catheter. except that the tubing is slightly wider. and then carefully advanced upward until the catheter is in the superior vena cava or the right atrium. a PICC poses less of a systemic infection risk than other central IVs. under ultrasound guidance.dangerous to attempt. care. because the insertion site is usually cooler and dryer than the sites typically used for other central lines. or total parenteral nutrition.

requires higher pressure to achieve the same flow. which as reflected in Poiseuille's law. it can become kinked causing poor function. They are also longer. It is commonly believed that fluid can be pushed faster through a central venous catheter but as they are often divided into multiple lumens then the internal diameter is less than that of a large -bore peripheral cannula. all other variables being equal.left in place for months to years if needed for patients who require extended treatment. In the simplest type of central venous access. Tunnelled Lines . Central venous lines There are several types of catheters that take a more direct route into central veins. The chief disadvantage is that it must be inserted and then travel through a relatively small peripheral vein which can take a less predictable course on the way to the superior vena cava and is therefore somewhat more time consuming and more technically difficult to place in some patients. a catheter is inserted into asubclavian. These are collectively called central venous lines. or (less commonly) a femoral vein and advanced toward the heart until it reaches the superior vena cava or right atrium. as a PICC travels through the axilla. Also. internal jugular. Because all of these veins are larger than peripheral veins there is greater blood flow past the tip of the catheter meaning irritant drugs are more rapidly diluted with less chance of extravasation.

piercing the silicone. The cover can accept hundreds of needle sticks during its lifetime. called a Hickman line or Broviac catheter. however. If it is plugged it becomes a hazard as a thrombus will eventually form with an accompanying risk of embolisation.Another type of central line. It is possible to leave the ports in the patient's body for years. and are therefore commonly used for patients on long -term intermittent treatment. since bacteria from the skin surface are not able to travel directly into the vein. the port must be accessed monthly and flushed with an anti coagulant. When the needle is withdrawn the reservoir cover reseals itself. into the reservoir. Other equipment . instead. Ports cause less inconvenience and have a lower risk of infection than PICCs. installation is more complex and a good implant is fairly dependent on the skill of the radiologist. This reduces the risk of infection. Implantable ports A port (often referred to by brand names such as Port-a-Cath or MediPort) is a central venous line that does not have an external connector. Removal of a port is usually a simple outpatient procedure. or the patient risks it getting plugged up. if this is done however. Medication is administered intermittently by placing a small needle through the skin. these catheters are also made of materials that resist infection and clotting. is inserted into the target vein and then "tunneled" under the skin to emerge a short distance away. it has a small reservoir that is covered with silicone rubber and is implanted under the skin.

plastic bottle or plastic bag) of fluids with an attachment that allows the fluid to flow one drop at a time. This is either an . but in cases where a change in the flow rate would not have serious consequences. a long sterile tube with a clamp to regulate or stop the flow. sterile container (glass bottle.. A rapid infuser can be used if the patient requires a high flow rate and the IV access device is of a large enough diameter to accommodate it. adding a dose of antibioticsto a continuous fluid drip. An infusion pump allows precise control over the flow rate and total amount delivered. a connector to attach to the access device.g. this is agravity drip. or if pumps are not available. making it easy to see the flow rate (and also reducing air bubbles).An infusion pump suitable for a single IV line A standard IV infusion set consists of a pre-filled. e. the drip is often left to flow simply by placing the bag above the level of the patient and using the clamp to regulate the rate. andY-sets to allow "piggybacking" of another infusion set onto the same line.

but after the complete dose of medication has been given.inflatable cuff placed around the fluid bag to force the fluid into the patient or a similar electrical device that may also heat the fluid being infused. skin-dwelling organisms such as Coagulase-negative staphylococcus or Candida albicans may enter through the insertion site around the catheter. It can use the same techniques as an intravenous drip (pump or gravity drip). meaning that a syringe is connected to the IV access device and the medication is injected directly (slowly. a second fluid injection is sometimes used. if it might irritate the vein or cause a too-rapid effect). Usually this is accomplished by allowing the fluid stream to flow normally and thereby carry the medicine into the bloodstream. following the injection to push the medicine into the bloodstream more quickly. a "flush". Intermittent infusion Intermittent infusion is used when a patient requires medications only at certain times. the tubing is disconnected from the IV access device. or bacteria may be accidentally introduced inside the catheter from . Some medications are also given by IV push or bolus. Although IV insertion is an aseptic procedure. Adverse effects Infection Any break in the skin carries a risk of infection. Once a medicine has been injected into the fluid stream of the IV tubing there must be some means of ensuring that it gets from the tubing to the patient. and does not require additional fluid. however.

scar tissue can build up along the vein. The IV device must be removed and if necessary re-inserted into another extremity. causing easily visible swelling. and redness around the vein. as it can deliver bacteria directly into the central circulation. Phlebitis Phlebitis is inflammation of a vein that may be caused by infection. An infected central IV poses a higher risk of septicemia. Due to frequent injections and recurring phlebitis. It may occur when the vein itself ruptures (the elderly are particularly prone to fragile veins due to a . Moisture introduced to unprotected IV sites through washing or bathing substantially increases the infection risks. the mere presence of a foreign body (the IV catheter) or the fluids or medication being given. pain.contaminated equipment. sometimes forming a hard. redness. Infection of IV sites is usually local. swelling. The peripheral veins of intravenous drug addicts. Symptoms are warmth. This occurs more frequently withchemotherapeutic agents and people who have tuberculosis It is also known as extravasation (which refers to something escaping the vein). the infection is called septicemia and can be rapid and life-threatening. and fever. and of cancer patients undergoing chemotherapy. If bacteria do not remain in one area but spread through the bloodstream. Infiltration / Extravasation Infiltration occurs when an IV fluid or medication accidentally enters the surrounding tissue rather than the vein. become sclerotic and difficult to access over time. painful “venous cord”.

Possible consequences include hypertension.paucity of supporting tissues). It is treated by removing the intravenous access device and elevating the affected limb so that the collected fluids can drain away. the vein may scar and close and the only way for fluid to leave is along the outside of the cannula where it enters the vein). It is usually not painful. Sometimes injections of hyaluronidase can be used to speed the dispersal of the fluid/drug. Fluid overload This occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete. and pulmonary edema. where the vein is damaged during insertion of the intravascular access device or the device is not sited correctly or where the entry point of the device into the vein becomes the path of least resistance (e.g.heart failure. Infiltration is one of the most common adverse effects of IV therapy[and is usually not serious unless the infiltrated fluid is a medication damaging to the surrounding tissue. It is characterized by coolness and pallor to the skin as well as localized swelling or edema. Hypothermia The human body is at risk of accidentally induced hypothermia when large amounts of cold fluids are infused. Electrolyte imbalance . if a cannula is in a vein for some time. in which case extensive necrosis can occur. Rapid temperature changes in the heart may precipitate ventricular fibrillation.

can stop the heart. this is calledembolism.Administering a too-dilute or too-concentrated solution can disrupt the patient's balance of (sodium) (potassium) (magnesium). Fatality by air embolism is vanishingly rare. and other electrolytes. and it is nearly impossible to inject air through a peripheral IV at a dangerous rate. as well as an air bubble. Hospital patients usually receive blood tests to monitor these levels. History . The risk is greater with a central IV. can be delivered into the circulation through an IV and end up blocking a vessel. Embolism A blood clot or other solid mass. Air bubbles can leave the blood through the lungs. One reason veins are preferred over arteries for intravascular administration is because the flow will pass through the lungs before passing through the body. Air bubbles of less than 30 microliters are thought to dissolve into the circulation harmlessly. can cause life threatening damage to pulmonary circulation. if extremely large (3-8 milliliters per kilogram of body weight). but ongoing studies hypothesize that these "micro -bubbles" may have some adverse effects. if delivered all at once. or. since large solid masses cannot travel through a narrow catheter. although this is in part because it is so difficult to diagnose. Small volumes do not result in readily detectable symptoms. A patient with a heart defect causing a right-to-left shunt is vulnerable to embolism from smaller amounts of air. A larger amount of air. Peripheral IVs have a low risk of embolism.

Hyman and Wanger but was not widely available until the 1950s. . Intravenous therapy was further developed in the 1930s by Hirschfeld.Intravenous technology stems from studies on cholera treatment in 1831 by Dr Thomas Latta of Leith.