Standard 37.1: Site selection for vascular access shall include assessment of the patient's condition, age, and diagnosis, vascular condition, history of previous access devices, and type and duration of therapy.
Standard 37.2: The vasculature shall accommodate the size and length of the catheter required by the prescribed therapy.1
In this column, the Site Selection Standard and Practice Criteria related to peripheral intravenous (PIV) catheter placement are addressed. For those of us who have practiced infusion therapy over many years, we have witnessed the evolution of, and changes in preference for, vascular access devices (VADs). The peripherally inserted central catheter (PICC) emerged almost 30 years ago and is a commonly selected VAD, if not the most common, for patients across all healthcare settings. Advantages such as a relatively low risk of insertion-related complications, a low infection rate (especially in outpatient and home settings), longevity, and ease of removal make PICCs a desirable and appropriate choice for many patients. However, I have increasingly noticed that nurses often look at PICCs as a first choice and often do not consider the simple peripheral catheter. I had a patient who required a regular, intermittent, nonirritating drug infusion for a chronic illness; previous nurses had encouraged her to have an implanted port. Although her veins "rolled," placing her PIV was not particularly difficult. I managed her for a long time without any IV-related complications and believed the PIV to be the best choice for her situation.
I do think that many nurses have become uncomfortable with or have never developed the skill or confidence in PIV placement. There are valid reasons for the use of a central VAD, including long-term infusion therapies, poor vascular access, and irritating infusion drugs. But in many cases, a simple PIV is the best, cost-effective, and low-risk answer. Among all VADs, PIVs have the lowest rate of infection, as found in a systematic literature review of studies that prospectively examined risk of bloodstream infection in patients with all types of vascular access catheters.2 Although PIVs are not without risk, such as infiltration and phlebitis (addressed in previous "Speaking of Standards" columns), risks are reduced when the infusion nurse places the PIV on the basis of a thorough assessment as stated in Standard 37.1 above and follows the Practice Criteria in terms of selecting the best veins for infusion therapy.
Practice criteria in this standard give guidelines as to peripheral vein selection.1 Veins that should be considered include those found on the dorsal and ventral surfaces of the upper extremities including the metacarpal, cephalic, and basilic veins. Additional sites for pediatric patients may include the veins of the head, neck, and lower extremities. In the adult patient, lower extremity placement is not recommended because of the risk of thrombophlebitis and embolism.1,3,4 Site selection should begin in the distal areas of the upper extremities and subsequent PIV catheters should be made proximal to the previously cannulated site. This is critical because fluids and medications are potentially infused in the damaged IV site if placed below the old site.
INS and others state that areas of flexion should be avoided.1,4,5 For example, when a PIV is placed in the area of the antecubital fossa, range of motion is limited, there is increased risk for infiltration and phlebitis, there is interference with blood sampling, and it may prevent use of these veins for a PICC, if needed at a later time.5 However, if the catheter must be placed in an area of flexion, splinting is necessary to reduce the risk of thrombus, infiltration, and catheter dislodgment.4 In fact, INS Standard 30 (Arm Boards) states that an arm board shall be used when a catheter is placed in or adjacent to an area of flexion for the purpose of stabilization.1
More specific guidelines can be found in additional sources of literature by infusion nursing experts. Veins in the fingers and thumb should be avoided because of their small diameter and motion of the finger that contribute to increased risk of phlebitis, infiltration, and extravasation.5 There is risk of nerve damage when a PIV is placed in the wrist area. Based on this, recommendations in the literature vary. One guideline recommends avoidance of the inner aspect of the wrist within a 5-cm radius due to risk of damage to the radial, median, and ulnar nerves.4 Other nursing experts state that best clinical practices to avoid nerve injury include avoiding placement of a PIV from 3 to 5 inches above the crease of the wrist, above the thumb, and on the inner aspect of the wrist due to close proximity of nerves.6
Risks associated with PIV catheters are minimized when the infusion nurse understands and follows basic principles in choosing appropriate sites of placement, monitors the site for any signs of complications, and educates the patient to immediately report any pain or discomfort at the site. A PIV is a cost-effective option for short-term or intermittent nonirritating infusion therapies.
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