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Over my 23 years of practicing home healthcare and home infusion therapy, I have witnessed the evolution and growth in vascular access devices. Improved catheter materials and placement techniques have made it easier and safer for patients to receive infusion therapy at home.


Beginning in the 1980s, the use of peripherally inserted central catheters (PICC) emerged, and clinicians increasingly favored its use. Currently, the PICC is the most commonly used venous access device in home healthcare as well as a common access route for hospitalized patients. Advantages include a lower risk of insertion-related complications than for devices placed in the chest, a low infection rate, longevity, and ease of removal at completion of therapy. However, I have noticed a trend among home health and acute care nurses. Nurses view PICCs as the first choice, and often do not consider placement of a simple peripheral intravenous (IV) catheter. Valid reasons certainly exist for this, including longer-term therapies, poor venous access, and irritating infusion drugs. Nevertheless, due to the prevalence of PICCs and other central vascular access devices, many nurses have become uncomfortable with the placement of a peripheral IV catheter and want to avoid its use even when it may be the most appropriate choice for the patient. In home care, nurses also want to reduce the risk of "as-needed" visits, required if the peripheral IV catheter infiltrates or dislodges. But consider the following examples.


Case 1

Mrs. Johnson's physician has ordered a 7-day course of twice-daily cefapime to treat a urinary tract infection resistant to oral antibiotics. Mrs. Johnson is largely bed bound due to neurologic illness and can transfer only with the use of a lift. The home health nurse tells the physician that the patient's veins are poor and that a PICC is required, which the physician readily orders based on the nurse's assessment.

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Ambulance transportation is required to get Mrs. Johnson to the radiologist for PICC placement. The agency's certified infusion nurse learns of this case and offers to make the home visit to assess his veins. After placing a warm compress over her hands, the nurse palpates several potential veins. The end result is that the plan is revised, and a peripheral IV catheter is ordered and placed. Two peripheral IV catheters are required during the 7-day course of antibiotics, and no IV-related problems occur.


Case 2

In a similar case, Mrs. Winchester's physician has ordered of a 7-day infusion drug regimen. The patient wants a PICC because during her previous hospitalizations, no one but the anesthesiologist could place her IVs. Without assessing her veins, this patient's nurse wants to meet the Mrs. Winchester's wishes.

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The same agency infusion nurse evaluates Mrs. Winchester, finds excellent veins, and discusses the benefits of a peripheral IV catheter, including less risk than with a central line, less "hassle" because the IV therapy can be completely managed at home, and lower cost.


Mrs. Winchester, after agreeing to try again, is surprised and pleased because the insertion is almost pain free. The nurse chooses the IV site carefully so as not to decrease the patient's ability to perform daily activities, making sure that the distal catheter tip is above the wrist and stabilizing the catheter well. The goal is to reduce in-and-out movement at the site that might contribute to phlebitis or infiltration.


During the course of Mrs. Winchester's antibiotic therapy, the IV site is rotated after 7 doses, each catheter lasting 3.5 days, with no phlebitis or infiltration.



Both of the described cases are real home care examples. Why should a peripheral IV catheter be considered for short courses of infusion therapy? First, a peripheral IV catheter is a less invasive venous access option associated with a very low risk of catheter-related bloodstream infection (Maki, Kluger, & Crnich, 2006). Any central venous catheter, including PICCs, is associated with a risk of insertion- and placement-related complications including infection, venous thrombosis, and occlusion. The cost of a PICC placement varies based on who places it (interventional radiologist or nurse) and where it is placed. Charges often are in the range of $1,000. Additional costs include the x-ray to confirm tip location and possibly transportation costs for the patient. Although a few home infusion nurses still are placing PICCs in the home, that practice is less common than some years ago. The technology for PICC placement, such as bedside ultrasound and radiologic verification of the centrally placed catheter tip, is less often available in the home.


Many years ago, most peripherally inserted catheters placed in the home were not centrally placed (catheter tip located in the superior vena cava). Rather, they were advanced to the midclavicular area. This is no longer an accepted or appropriate site due to increased thrombotic risk (Cook, 2007).


In general, peripheral access is indicated for infusion therapies that have an expected duration of less than 1 week (O'Grady et al., 2002) or for therapy administered infrequently (e.g., a monthly infusion of methylprednisone). Because of the risk for vein irritation and damage, the Infusion Nurses Society (2006) Standards provide guidance for therapies that are not appropriate for peripheral administration including


* Continuous vesicant drug infusions


* Parenteral nutrition


* Infusates with a pH lower than 5 or higher than 9 or an osmolality greater than 600 mOsm/L.



The home care pharmacist is an excellent resource for consultation about properties of the intended infusion drug, including pH and osmolality. The drug cefepime, as prescribed to the patients in the described cases, has a pH range of 4 to 6 (Gahart & Nazareno, 2004), with a mild risk toward causing phlebitis. It therefore is an appropriate drug for peripheral administration. Therefore, when you get your next referral for short-term infusion therapy administration, consider whether a peripheral IV catheter is appropriate. The things to assess include


* Expected therapy duration of 7 to 10 days.


* Prescribed drug or fluid appropriate in terms of pH and osmolality.


* Intermittent therapy. However, a peripheral catheter is usually contraindicated for antimicrobial therapies that must be delivered with a programmable infusion pump because of multiple doses per day or continuous infusion due to the greater risk for catheter dislodgement or infiltration when a 24-hour pump is worn and frequent site monitoring is needed.


* Adequacy of venous access. A tourniquet must be applied, and veins must be assessed. Warm, moist compresses are very helpful in dilating veins. In case 1, the patient stated that her veins were poor due to previous experience. This may or may not be true now. Perhaps previous clinicians were less skilled, and if time has passed, perhaps venous access is now good.


* Ability of the patient to protect the site and call promptly if problems occur.



Finally, look at the skills of the clinicians in your agency. For agencies that do not have a large population of infusion patients, it is difficult for clinicians to gain the skills needed for peripheral IV insertion due to lack of opportunity. Most patients still require a central vascular access device due to the longer-term therapies administered in home health. However, it is helpful to develop a small team of nurses who have the skill and the desire to place peripheral IVs. Use these nurses to assess the patient for the most appropriate venous access device. Keep in mind that the peripheral IV is a low-risk, simple, low-cost option.




Cook, L. S. (2007). Continuing controversy of midclavicular catheters. Journal of Infusion Nursing, 30(5), 267-273. [Context Link]


Gahart, B., & Nazareno, A. (2004). Intravenous medications: A handbook for nurses and allied health professionals. St. Louis, MO: Mosby. [Context Link]


Infusion Nurses Society. (2006). Infusion nursing standards of practice. Journal of Infusion Nursing, 29(1S), S1-S92. [Context Link]


Maki, D. G., Kluger, D. M., & Crnich, C. J. (2006). The risk of bloodstream infection in adults with different intravascular devices: A systematic review of 200 published prospective studies. Mayo Clinic Proceedings, 81(9), 1159-1171. [Context Link]


O'Grady, N. P., Alexander, M., Dellinger, E. P., Gerberding, J. L., Heard, S. O., Maki, D. G., et al. (2002). Guidelines for the prevention of intravascular catheter-related infections, Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report Recommendations and Reports, 51(RR-10):1-29. [Context Link]