Standard catheter.

1. The catheter itself is composed of (a) a tip for insertion into the vein, (b) wings for manual handling and securing the catheter with
adhesives, (c) a valve to allow injection of drugs with a syringe, (d) an end which allows connection to an intravenous infusion line, and
capping in between uses.
2. The needle (partially retracted) which serves only as a guidewire for inserting the cannula.
3. The protection cap which normally covers the needle's tip.

A peripheral intravenous catheter in place, fixed to a patient's arm with adhesives and attached to a drip.
In medicine, a peripheral venous catheter (PVC or peripheral venous line or peripheral venous access catheter) is a catheter (small,
flexible tube) placed into a peripheral vein in order to administer medication or fluids. Once placed, the line can also be used to draw
blood.
The catheter is introduced into the vein by a needle (similar to blood drawing), which is subsequently removed while the small tube of
the cannula remains in place. The catheter is then fixed by taping it to the patient's skin (unless there is allergy to adhesives). Newer
catheters have been equipped with additional safety features to avoid needlestick injuries. Modern catheters consist of synthetic
polymers such as teflon (hence the often used term 'Venflon' for these venous catheters).
A peripheral venous catheter is the most commonly used vascular access in medicine. It is given to most emergency room and surgical
patients, and before some radiological imaging techniques using radiocontrast, for example. In the United States, more than 25 million
patients get a peripheral venous line each year.[1]
A peripheral venous catheter is usually placed in a vein on the hand or arm. It should be distinguished from a central venous catheter
which is inserted in a central vein (usually in the internal jugular vein of the neck or the subclavian vein of the chest), or an arterial
catheter which can be placed in a peripheral as well as a central artery. In children, local analgesic (painkiller) gel (such as lidocaine) is
applied to the insertion site to facilitate placement.

Complications

Infection, phlebitis, extravasation, infiltration, air embolism, hemorrhage (bleeding) and formation of a hematoma (bruise) may occur.
Because of the risk of insertion-site infection the CDC advises in their guideline that the catheter needs to be replaced every 96 hours. [2]
Although these catheters can best not be left in place longer than necessary, the need to replace these catheters routinely is debated. [3]
Expert management has been shown to reduce the complications of peripheral lines. [1][4]
Additional images

Newer catheter with additional

The catheter in between safety features.
Just before inserting. uses.
Placement of a cannula in progress. The first steps
are the same as for drawing blood.

Extravasation (intravenous)

Extravasation is the accidental administration of intravenously (IV) infused medicinal drugs into the surrounding tissue, either by
leakage (e.g. because of brittle veins in very elderly patients), or direct exposure (e.g. because the needle has punctured the vein and
the infusion goes directly into the arm tissue). Extravasation of medicinal drugs during intravenous therapy is a side-effect that can and
must be avoided.
In mild cases, extravasation can cause pain, reddening, or irritation on the arm with the infusion needle. Severe damage may include
tissue necrosis. In extreme cases, it even can lead to loss of an arm.
Medicinal drugs
Medicinal drugs that cause only slight damage on the arm with the infusion needle if extravasated are called "irritants", and medicinal
drugs that cause severe damage up to tissue necrosis if extravasated are called "vesicants".
Occurrence is possible with all IV drugs, but is a large problem with cytotoxic drugs for the treatment of cancer (i.e. during
chemotherapy). The percentage of patients affected by extravasation may be as high as 10%. However, the actual percentage is
unknown, since extravasation is often unnoticed and/or undocumented, especially if not severe.
In recent years, healthcare professionals are becoming more aware of this problem. [1] [2] [3] [4] [5]
Treatments and Techniques
The best "treatment" of extravasation is prevention. While there is no real treatment per se, there are some techniques that can be
applied in case of extravasation, though their efficacy is modest. If there is tissue necrosis, surgical reconstruction may be helpful. The
following procedure may also be helpful if extravasation occurs:
 Stop infusion immediately. Put on sterile gloves.
 Replace infusion lead with a disposable syringe. While doing this, do not exert pressure on the extravasation area.
 Slowly aspirate back blood back from the arm, preferably with as much of the infusion solution as possible.
 Remove the original cannula or other IV access carefully from the arm.
 Elevate arm and rest in elevated position. If there are blisters on the arm, aspirate content of blisters with a new thin needle.
 If, for the extravasated medicinal drug, substance-specific measures apply, carry them out (e.g. topical cooling, DMSO,
hyaluronidase or dexrazoxane may be appropriate).[6]

1
  Recent clinical trials have shown that Savene (dexrazoxane for extravasation) is effective in preventing the progression of
anthracycline extravasation into progressive tissue necrosis. In two open-label, single arm, phase II multicenter clinical trials,
necrosis was prevented in 98% of the patients. Dexrazoxane for extravasation is the only registered antidote for extravasation
of anthracyclines (daunorubicin, doxorubicin, epirubicin, idarubicin, etc.). [7]
Pain management and other measures
 Pain management is very important for the patient, as are full documentation and prevention of infection and superinfection. If
there is superinfection, get an antibiogram and consult with an infectious diseases specialist. Of course, regular controls and
aftercare are necessary.
If the extravasated medicinal drug is a vesicant
 Do not flush the IV access
 No moist compresses, no alcohol compresses, no occlusive dressings
 Consult a physician with experience in the treatment of extravasation and a reconstructive surgeon early in the course of
extravasation
 Such cases may necessitate skin grafting and intensive physiotherapy.
Prevention of extravasation in hospitals
 Venipuncture and placement of the cannula (or other IV access) should be performed by experienced personnel, where
available. Yet this is not always possible because of personnel resources. In this case, placement by experienced personnel
for patients especially prone to extravasation (e.g. patients with hardly visible veins, very obese patients, very elderly patients,
young children, etc.). In all other patients, avoid multiple venipunctures in the same area.
 Choose a large, intact vein with good blood flow for the venipuncture and placement of the cannula. Do not choose
inadvertently "dislodgeable" veins (e.g. dorsum of hand or vicinity of joints) if an alternative vein is available.
 Use thin cannulas with high gauges. Check the position of the cannula by aspirating blood, as well as the patency of the vein
by flushing with the carrier solution (e.g. 0.9% NaCl solution), before beginning the IV infusion.
 Observe infusion at least for the first 10 minutes and do the same every hour. Ask medical student/student
nurse/patient/patient's family to do this for you if you do not have the time. Instruct them how to observe an infusion and to
alert you as soon as possible if something seems to "go wrong".
 The IV infusion should be freely flowing. The arm with the infusion should not begin to swell (oedema), "get red" (erythema),
"get hot" (local temperature increase), and the patient should not notice any irritation or pain on the arm. If this occurs, stop
infusion immediately!
 The infusion should consist of a suitable carrier solution with an appropriately diluted medicinal/chemotherapy drug inside.
 After the IV infusion has finished, flush the vein "clean" with only the carrier solution.
 Finally, an excellently and very cleanly placed central line (= central venous catheter) is a huge advantage while infusing
vesicant drugs.
Examples of vesicant medicinal drugs
Cytotoxic drugs
 Amsacrine  Epirubicin  Paclitaxel
 Cisplatin (if > 0.4 mg/mL)  Idarubicin  Vinblastine
 Dactinomycin  Mechlorethamine  Vincristine
 Daunorubicin  Mitomycin C  Vindesine
 Docetaxel  Mitoxantrone  Vinorelbine
 Doxorubicin  Oxaliplatin
Non-cytotoxic drugs
 Alcohol  Digoxin  Propylene glycol
 Aminophyllines  Nafcillin  Sodium thiopental
 Chlordiazepoxide  Nitroglycerine  Tetracyclines
 Diazepam  Phenytoin  TPN

Phlebitis
Phlebitis
Classification and external
resources

The popliteal vein.

Phlebitis is an inflammation of a vein, usually in the legs.
When phlebitis is associated with the formation of blood clots (thrombosis), usually in the deep veins of the legs, the condition is called
thrombophlebitis.
Etiology
 Bacterial: Pathogenic organisms can gain access and stimulate inflammation.
 Chemical: caused by irritating or vesicant solutions.
 Mechanical: physical trauma from the skin puncture and movement of the cannula into the vein during insertion; any
subsequent manipulation and movement of the cannula; clotting; or excessively large cannula.

2
  Medications including Celebrex, Olanzepine, antidepressants, and others.
 Lupus
 Genetic as it is known to run in families.
Signs and Symptoms
 Redness (erythema) and warmth with a temperature elevation of a degree or more above the baseline
 Pain or burning along the length of the vein
 Swelling (edema)
 Vein being hard, and cordlike
 If occurring due to an intravenous infusion line, then slowed infusion rate
Notable cases
 Former United States President Richard Nixon and former Vice President Dan Quayle suffered from phlebitis.
 Truman Capote, famed author of In Cold Blood and many other works, suffered from phlebitis. Pablo Neruda, the famous poet,
also suffered from it.
 During the shooting of Sense and Sensibility (1995), actress Kate Winslet, who played the role of Marianne Dashwood,
suffered from phlebitis.
 Mario Lanza suffered from phlebitis, and his cause of death in 1959 was from a blood clot going from his leg to his lungs.
 Orson Welles also suffered from chronic phlebitis and it may have contributed to his death in 1985, as it is listed on his death
certificate.[1]

Infiltration (medical)

Infiltration is the diffusion or accumulation (in a tissue or cells) of substances not normal to it or in amounts in excess of the normal.
The material collected in those tissues or cells is also called infiltration.
Classification
As part of a disease process, infiltration is sometimes used to define the invasion of cancer cells into the underlying matrix or the blood
vessels. Similarly the term may describe the deposition of amyloid protein. During leukocyte extravasation white blood cells move in
response to cytokine chemicals (chemotaxis), from within the blood out to infiltrate into the diseased or infected tissues. The presence
of lymphocytes in tissue in greater than normal numbers is likewise called infiltration.
As part of medical intervention, local anaesthetics may be injected at more than one point so as to infiltrate are area prior to a surgical
procedure. However the term may also apply to unintended iatrogenic leakage of fluids from phlebotomy or intravenous drug delivery
proceedures, a process also known as extravasation or "tissuing".
Tissuing
Inflitration or tissuing, described leakage of fluids or blood from damaged blood vessels as a result of medical interventions.
Etiology
Infiltration may be caused by:
 Puncture of distal vein wall during venipuncture
 Puncture of any portion of the vein wall by mechanical friction from the catheter/needle cannula
 Dislodgement of the catheter/needle cannula from the intima of the vein which may be a result of a poorly secured IV device or
the selection of which venous site is used.
 Improper cannula size or excessive delivery rate of the fluid
Signs/Symptoms
The signs and symptoms of infiltration include:
 Inflammation at or near the insertion site with swollen taut skin with pain
 Blanching and coolness of skin around IV site
 Damp or wet dressing
 Slowed or stopped infusion
 No backflow of blood into IV tubing on lowering the solution container.
Clinical Criteria for Grading
Skin on
Grade Skin appearance Edema Symptoms
examination
0. No symptoms
1. Skin blanched Edema <1 inch in any direction Cool to touch With or without pain
Edema 1-6 inches in any
2. Skin blanched Cool to touch With or without pain
direction
Gross edema >6 inches in any Mild-moderate pain
3. Skin blanched, translucent Cool to touch
direction Possible numbness
Skin blanched, translucent
Gross edema >6 inches in any Moderate-severe pain
Skin tight, leaking Circulatory
4. direction Infiltration or any amount of blood product,
Skin discolored, bruised, impairment
Deep pitting tissue edema irritant, or vesicant
swollen
Nursing Treatment
The use of warm compresses to treat infiltration has become controversial. It has been found that cold compresses may be better for
some infiltrated infusates and warm compresses may be more effective for others. It has also been documented that elevation of the
infiltrated extremity may be painful for the patient. To act in the best interest of the patient, following IV infiltration, consult with the
physician for orders regarding compresses and elevation.

Bleeding

Technically known as hemorrhaging/haemorrhaging (see American and British spelling differences) is the loss of blood from the
circulatory system.[1] Bleeding can occur internally, where blood leaks from blood vessels inside the body or externally, either through a
natural opening such as the vagina, mouth or anus, or through a break in the skin. The complete loss of blood is referred to as
exsanguination,[2] and desanguination is a massive blood loss. Loss of 10-15% of total blood volume can be endured without clinical
sequelae in a healthy person, and blood donation typically takes 8-10% of the donor's blood volume.[3]
Causes, prevalence, and risk factors

3
Hemorrhage generally becomes dangerous, or even fatal, when it causes hypovolemia (low blood volume) or hypotension (low blood
pressure). In these scenarios various mechanisms come into play to maintain the body's homeostasis. These include the "retro-stress-
relaxation" mechanism of cardiac muscle, the baroreceptor reflex and renal and endocrine responses such as the renin - angiotensin -
aldosterone system (RAAS).
Certain diseases or medical conditions, such as haemophilia and low platelet count (thrombocytopenia), may increase the risk of
bleeding or may allow otherwise minor bleeds to become health or life threatening. Anticoagulant medications such as warfarin can
mimic the effects of haemophilia, preventing clotting and allowing free blood flow.
Death from hemorrhage can generally occur surprisingly quickly. This is because of 'positive feedback'. An example of this is 'cardiac
repression', when poor heart contraction depletes blood flow to the heart, causing even poorer heart contraction. This kind of effect
causes death to occur more quickly than expected.

Types of bleeding

A subconjunctival hemorrhage is a common and relatively minor post-LASIK complication.

Hemorrhaging is broken down into 4 classes by the American College of Surgeons' Advanced Trauma
Life Support (ATLS).[4]
 Class I Hemorrhage involves up to 15% of blood volume. There is typically no change in vital
signs and fluid resuscitation is not usually necessary.
 Class II Hemorrhage involves 15-30% of total blood volume. A patient is often tachycardic
(rapid heart beat) with a narrowing of the difference between the systolic and diastolic blood pressures. The body attempts to
compensate with peripheral vasoconstriction. Skin may start to look pale and be cool to the touch. The patient might start
acting differently. Volume resuscitation with crystaloids (Saline solution or Lactated Ringer's solution) is all that is typically
required. Blood transfusion is not typically required.
 Class III Hemorrhage involves loss of 30-40% of circulating blood volume. The patient's blood pressure drops, the heart rate
increases, peripheral perfusion, such as capillary refill worsens, and the mental status worsens. Fluid resuscitation with
crystaloid and blood transfusion are usually necessary.
 Class IV Hemorrhage involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached and
aggressive resuscitation is required to prevent death.
Individuals in excellent physical and cardiovascular shape may have more effective compensatory mechanisms before experiencing
cardiovascular collapse. These patients may look deceptively stable, with minimal derangements in vital signs, while having poor
peripheral perfusion (shock). Elderly patients or those with chronic medical conditions may have less tolerance to blood loss, less ability
to compensate, and may take medications such as betablockers that can potentially blunt the cardiovascular response. Care must be
taken in the assessment of these patients.

Causes
Minor traumatic bleeding from the head
Traumatic
Traumatic bleeding is caused by some type of injury. There are different types of wounds which
may cause traumatic bleeding. These include:
 Abrasion - Also called a graze, this is caused by transverse action of a foreign object
against the skin, and usually does not penetrate below the epidermis
 Excoriation - In common with Abrasion, this is caused by mechanical destruction of
the skin, although it usually has an underlying medical cause
 Hematoma - (also called a blood tumor) - caused by damage to a blood vessel that in
turn causes blood to collect under the skin.
 Laceration - Irregular wound caused by blunt impact to soft tissue overlying hard
tissue or tearing such as in childbirth. In some instances, this can also be used to describe an incision.
 Incision - A cut into a body tissue or organ, such as by a scalpel, made during surgery.
 Puncture Wound - Caused by an object that penetrated the skin and underlying layers, such as a nail, needle or knife
 Contusion - Also known as a bruise, this is a blunt trauma damaging tissue under the surface of the skin
 Crushing Injuries - caused by a great or extreme amount of force applied over a long period of time. The extent of a crushing
injury may not immediately present itself.
 Gunshot wounds - Caused by a projectile weapon, this may include two external wounds (entry and exit) and a contiguous
wound between the two
The pattern of injury, evaluation and treatment will vary with the mechanism of the injury. Blunt trauma causes injury via a shock effect;
delivering energy over an area. Wounds are often not straight and unbroken skin may hide significant injury. Penetrating trauma follows
the course of the injurious device. As the energy is applied in a more focused fashion, it requires less energy to cause significant injury.
Any body organ, including bone and brain, can be injured and bleed. Bleeding may not be readily apparent; internal organs such as the
liver, kidney and spleen may bleed into the abdominal cavity. The only apparent signs may come with blood loss. Bleeding from a
bodily orifice, such as the rectum, nose, ears may signal internal bleeding, but cannot be relied upon. Bleeding from a medical
procedure also falls into this category.

Due to underlying medical conditions

Medical bleeding is that associated with an increased risk of bleeding due to an underlying medical condition. It will increase the risk of
bleeding related to underlying anatomic deformities, such as weaknesses in blood vessels (aneurysm or dissection), arteriovenous
malformation, ulcerations. Similarly, other conditions that disrupt the integrity of the body such as tissue death, cancer, or infection may
lead to bleeding.
The underlying scientific basis for blood clotting and hemostasis is discussed in detail in the articles, Coagulation, haemostasis and
related articles. The discussion here is limited to the common practical aspects of blood clot formation which manifest as bleeding.
Certain medical conditions can also make patients susceptible to bleeding. These are conditions that affect the normal "hemostatic"
functions of the body. Hemostasis involves several components. The main components of the hemostatic system include platelets and
the coagulation system.
Platelets are small blood components that form a plug in the blood vessel wall that stops bleeding. Platelets also produce a variety of
substances that stimulate the production of a blood clot. One of the most common causes of increased bleeding risk is exposure to
non-steroidal anti-inflammatory drugs (or "NSAIDs"). The prototype for these drugs is aspirin, which inhibits the production of
thromboxane. NSAIDs inhibit the activation of platelets, and thereby increase the risk of bleeding. The effect of aspirin is irreversible;
therefore, the inhibitory effect of aspirin is present until the platelets have been replaced (about ten days). Other NSAIDs, such as
"ibuprofen" (Motrin) and related drugs, are reversible and therefore, the effect on platelets is not as long-lived.

4
There are several named coagulation factors that interact in a complex way to form blood clots, as discussed in the article on
coagulation. Deficiencies of coagulation factors are associated with clinical bleeding. For instance, deficiency of Factor VIII causes
classic Hemophilia A while deficiencies of Factor IX cause "Christmas disease"(hemophilia B). Antibodies to Factor VIII can also
inactivate the Factor VII and precipitate bleeding that is very difficult to control. This is a rare condition that is most likely to occur in
older patients and in those with autoimmune diseases. von Willebrand disease is another common bleeding disorder. It is caused by a
deficiency of or abnormal function of the "von Willebrand" factor, which is involved in platelet activation. Deficiencies in other factors,
such as factor XIII or factor VII are occasionally seen, but may not be associated with severe bleeding and are not as commonly
diagnosed.
In addition to NSAID-related bleeding, another common cause of bleeding is that related to the medication, warfarin ("Coumadin" and
others). This medication needs to be closely monitored as the bleeding risk can be markedly increased by interactions with other
medications. Warfarin acts by inhibiting the production of Vitamin K in the gut. Vitamin K is required for the production of the clotting
factors, II, VII, IX, and X in the liver. One of the most common causes of warfarin-related bleeding is taking antibiotics. The gut bacteria
make vitamin K and are killed by antibiotics. This decreases vitamin K levels and therefore the production of these clotting factors.
Deficiencies of platelet function may require platelet transfusion while deficiciencies of clotting factors may require transfusion of either
fresh frozen plasma of specific clotting factors, such as Factor VIII for patients with hemophilia.

First aid

External Bleeding

All people who have been injured should receive a thorough assessment. It should be divided into a primary and secondary survey and
performed in a stepwise fashion, following the "ABCs". Notification of EMS or other rescue agencies should be performed in a timely
manner and as the situation requires.
The primary survey examines and verifies that the patient's Airway is intact, that s/he is Breathing and that Circulation is working. A
similar scheme and mnemonic is used as in CPR. However, during the pulse check of C, attempts should also be made to control
bleeding and to assess perfusion, usually by checking capillary refill. Additionally a persons mental status should be assessed
(Disability) or either an AVPU scale or via a formal Glasgow Coma Scale. In all but the most minor cases, the patient should be
Exposed by removal of clothing and a secondary survey performed, examining the patient from head to toe for other injuries. The
survey should not delay treatment and transport, especially if a non-correctable problem is identified.

Minor bleeding

Minor bleeding is bleeding that falls under a Class I hemorrhage and the bleeding is easily stopped with pressure.
The largest danger in a minor wound is infection. Bleeding can be stopped with direct pressure and elevation, and the wound should be
washed well with soap and water. A dressing, typically made of gauze, should be applied. Peroxide or iodine solutions (such as
Betadine) can injure the cells that promote healing and may actually impair proper wound healing and delay closure. [5]

Emergency Bleeding Control

Severe bleeding poses a very real risk of death to the casualty if not treated quickly. Therefore, preventing major bleeding should take
priority over other conditions, save failure of the heart or lungs. Most protocols advise the use of direct pressure, rest and elevation of
the wound above the heart to control bleeding.
The use of a tourniquet is not advised in most cases, as it can lead to unnecessary necrosis or even loss of a limb. Tourniquets should
rarely be used as it is usually possible to stop bleeding by the application of manual pressure. [citation needed]

Bleeding from body cavities

The only minor situation is a spontaneous nosebleed, or a nosebleed caused by a slight trauma (such as a child putting his finger in his
nose).
Simultaneous externalised bleeding from the ear may indicate brain trauma if there has been a serious head injury. Loss of
consciousness, amnesia, or fall from a height increases the likelihood that there has been a severe injury. This type of injury can also
be found in motor vehicle accidents associated with death or severe injury to other passengers.
Hemoptysis, or coughing up blood, may be a sign that the person is at risk for serious bleeding. This is especially the case for patients
with cancer. Hematemesis is vomiting up blood from the stomach. Often, the source of bleeding is difficult to distinguish and usually
requires detailed assessment by an emergency physician.

Internal bleeding

Internal bleeding occurs entirely within the confines of the body and can be caused by a medical condition (such as aortic aneurysm) or
by trauma. Symptoms of internal bleeding include pale, clammy skin, an increased heart rate and a stupor or confused state.
The most recognisable form of internal bleeding is the contusion or bruise.

Risk of blood contamination

Because skin is watertight, there is no immediate risk of infection to the aide from contact with blood, provided the exposed area has
not been previously wounded or diseased. Before any further activity (especially eating, drinking, touching the eyes, the mouth or the
nose), the skin should be thoroughly cleaned in order to avoid cross contamination.
To avoid any risk, the hands can be prevented from contact with a glove (mostly latex or nitrile rubber), or an improvised method such
as a plastic bag or a cloth. This is taught as important part of protecting the rescuer in most first aid protocols.
Following contact with blood, some rescuers may choose to go to the emergency department, where post-exposure prophylaxis can be
started to prevent blood-borne infection.

As a medical treatment

Before the advent of modern medicine the technique of bloodletting, or phlebotomy, was used for a number of conditions: causing
bleeding intentionally to remove a controlled amount of excess or "bad" blood. Phlebotomy is still used as an extremely effective
treatment for Haemochromatosis.