Peripheral Intravenous Access

---

CICM Exam Focus

Second Part Written SAQ Stems

Expect questions testing:

• Indications and contraindications for PIVC vs central access vs intraosseous access
• Cannula gauge selection and flow rate calculations (Poiseuille's Law) for trauma resuscitation
• Technique for ultrasound-guided PIVC in difficult access patients
• Complications - classification, recognition, management (phlebitis, infiltration, extravasation)
• VIP score interpretation and decision-making for cannula replacement
• Evidence-based dwell time - clinically indicated vs routine replacement
• Vesicant extravasation management (noradrenaline, chemotherapy)
• Infection prevention - ACSQHC standards, ANTT, chlorhexidine skin prep

Second Part Hot Case Scenarios

Be prepared to discuss:

• Patient with multiple failed IV attempts - escalation strategy (heat, USS, IO, CVC)
• Septic patient requiring vasopressor - PIVC vs CVC decision, extravasation risk
• Trauma patient in hemorrhagic shock - two 16G antecubital lines, flow optimization
• VIP score 3-4 at existing PIVC site - phlebitis management, investigation for CRBSI
• Chemotherapy extravasation - immediate management, antidote protocols

Second Part Viva Topics

Examiners will probe:

• Applied anatomy - superficial venous system, preferred sites, valves
• Poiseuille's Law and flow rate determinants (radius to 4th power, length)
• Ultrasound technique - probe selection, vessel identification, static vs dynamic
• DIVA Score - predictors of difficult access, when to escalate
• Cochrane evidence for clinically-indicated replacement (Webster 2019)
• Phlebitis pathophysiology - mechanical, chemical, bacterial
• Australian guidelines - ACSQHC 10 Quality Statements
• Indigenous health considerations - cultural safety, interpreter use, higher chronic disease burden

---

Key Points

1. Peripheral IV access is the most common invasive procedure - 80-90% of hospitalized patients, 330 million PIVCs inserted annually in USA alone (PMID: 22449262).

2. Cannula gauge determines flow rate - Poiseuille's Law: flow ∝ r⁴/L. A 14G (2.1mm) delivers 240-300 mL/min vs 18G (1.3mm) at 90-110 mL/min. For trauma resuscitation, two large-bore 16G catheters are superior to a single multi-lumen CVC (PMID: 28481355).

3. Ultrasound guidance increases first-attempt success in DIVA - Standard technique 35-40% vs USS 85-97% (PMID: 24156914, 23369563). Deep brachial/basilic veins accessible with long PIVCs (5-8cm).

4. Phlebitis occurs in 5-70% of PIVCs - VIP score ≥2 requires removal. Mechanical (catheter size), chemical (drug pH/osmolality), bacterial (skin flora contamination) (PMID: 21157098).

5. Cochrane 2019 meta-analysis - No difference in CRBSI or phlebitis between clinically-indicated vs routine 72-96h replacement (RR 0.97, 95% CI 0.84-1.12). Current standard: replace only when clinically indicated (PMID: 30695087).

6. Vesicant extravasation causes tissue necrosis - Vasopressors (noradrenaline, dopamine), chemotherapy (doxorubicin, vincristine), calcium, potassium >40 mmol/L, glucose >10%. Management: stop infusion, do NOT remove catheter, aspirate residual drug, administer antidote if available (PMID: 25533770).

7. ACSQHC 2021 Clinical Care Standard - 10 Quality Statements: assess need, ANTT insertion, 2% chlorhexidine/70% alcohol skin prep, transparent dressing, daily VIP score, clinically-indicated removal. Target: reduce Staphylococcus aureus bacteraemia (SAB) from PIVCs.

---

Definition and Epidemiology

Definition

Peripheral intravenous cannulation is the insertion of a short catheter (≤8 cm length) into a peripheral vein, most commonly in the upper limb, to establish vascular access for:

• Intravenous fluid therapy (resuscitation, maintenance)
• Medication administration (antibiotics, analgesia, vasopressors)
• Blood product transfusion
• Parenteral nutrition (short-term, less than 2 weeks)
• Contrast media for CT imaging

The procedure involves percutaneous puncture of a vein using a needle-catheter assembly, followed by advancement of the catheter over the needle into the vessel lumen.

Epidemiology

Global Burden

• 80-90% of hospitalized patients receive at least one PIVC during admission (PMID: 22449262)
• 330 million PIVCs inserted annually in USA alone (PMID: 28481355)
• 1.7 billion PIVCs estimated globally per year
• ICU patients: 95-98% have PIVC at some point during ICU stay

Difficult Intravenous Access (DIVA)

• Occurs in 10-40% of adult patients (PMID: 23369563)
• 50-75% of IV drug users, hemodialysis patients, obese patients (BMI >40)
• DIVA Score predictors (each scores 1 point, total 0-4):
  • No vein palpable
  • No vein visible (after tourniquet)
  • History of difficult access
  • IV drug use or dialysis history
  • "Score ≥2: 50% chance of first-attempt failure (PMID: 26475246)"

Australian/NZ Context

• ACSQHC (Australian Commission on Safety and Quality in Health Care) identifies PIVC-related Staphylococcus aureus bacteraemia (SAB) as a sentinel event
• ANZICS-CORE Statement 3.2 provides vascular access device guidelines
• Aboriginal and Torres Strait Islander patients: Higher rates of chronic kidney disease (10× general population), diabetes (3× general population) - increased DIVA risk (PMID: 30761655)

---

Applied Basic Sciences

Anatomy: Superficial Venous System of Upper Limb

Dorsal Venous Network (Hand)

• Digital veins → dorsal metacarpal veins → dorsal venous arch on dorsum of hand
• Drains laterally into cephalic vein, medially into basilic vein
• Dorsal hand veins: small caliber (1-2mm), fragile, high failure rate (35-40%)
• Contraindicated for vesicants, rapid resuscitation, repeated long-term access

Cephalic Vein (Lateral Forearm/Arm)

• Originates from lateral dorsal venous arch
• Ascends along radial (lateral) border of forearm and arm
• Passes through deltopectoral groove (between deltoid and pectoralis major)
• Terminates by piercing clavipectoral fascia to join axillary vein
• Advantages: Superficial, easily palpable, large caliber (3-5mm), lower infection risk than ACF
• Disadvantages: Valves at distal wrist (difficult passage), mobile over tendons

Basilic Vein (Medial Forearm/Arm)

• Originates from medial dorsal venous arch
• Ascends along ulnar (medial) border of forearm and arm
• Pierces deep fascia at mid-humerus to join brachial veins → axillary vein
• Advantages: Large caliber (3-6mm), straight course, excellent for USS-guided long PIVC
• Disadvantages: Deep location (requires USS), proximity to brachial artery/median nerve

Median Cubital Vein (Antecubital Fossa - ACF)

• Communication vein connecting cephalic and basilic veins across ACF
• "H-shaped pattern" (cephalic + median cubital + basilic) is commonest
• "M-shaped pattern" variant: median antebrachial vein bifurcates into median cephalic and median basilic
• Advantages: Large (4-6mm), superficial, stabilized by bicipital aponeurosis, highest first-attempt success rate (90-95%)
• Disadvantages: Proximity to brachial artery (medial), median nerve (deep), high phlebitis risk (movement at elbow joint), difficult to secure dressing
• Preferred for: Resuscitation (large-bore 16G), blood transfusion, contrast CT

Deep Brachial/Basilic Veins (Mid-Upper Arm)

• Located >1.5 cm depth from skin
• Require ultrasound guidance for access
• Advantages: Large caliber (4-8mm), last resort before CVC/IO
• Disadvantages: Require long PIVCs (5-8cm), higher dislodgement risk if standard 3cm catheter used, proximity to brachial artery (PMID: 23369563)

Venous Valves

• Bicuspid cusps prevent retrograde flow
• Most numerous in distal veins (hand, wrist) - average 1 valve per 2cm
• Proximal veins (ACF, upper arm) have fewer valves - easier catheter threading
• Clinical relevance: Resistance during catheter advancement = valve - do NOT force, withdraw and redirect

Physiology: Blood Flow and Hagen-Poiseuille's Law

Determinants of Intravenous Flow Rate

Hagen-Poiseuille's Law for laminar flow:

Q = (π × ΔP × r⁴) / (8 × η × L)

Where:

• Q = Flow rate (mL/min)
• ΔP = Pressure gradient (mmHg) - gravity (hydrostatic) or pressure bag
• r = Internal radius of catheter (mm) - most critical factor (to 4th power)
• η = Fluid viscosity (Pa·s) - blood 3-4× water, cold fluids 2× warm fluids
• L = Length of catheter (cm)

Clinical Implications

• Doubling radius increases flow 16-fold (r⁴ relationship)
• Halving length doubles flow (inverse relationship)
• Pressure bag (300 mmHg) increases ΔP from 100 mmHg (gravity alone) to 400 mmHg - 4× flow increase
• Warming fluids to 37°C reduces viscosity η by 50% - 2× flow increase

Cannula Gauge and Flow Rates (Gravity-Driven, Water)

Why Two 16G Peripherals > One Triple-Lumen CVC for Resuscitation

• 16G PIVC: 4.5 cm length, 1.8mm diameter → 180 mL/min
• CVC (16cm, 16G lumen): 16cm length → 4× resistance → 45 mL/min per lumen
• Two 16G PIVCs = 360 mL/min vs triple-lumen CVC = 135 mL/min total
• ATLS recommendation: Two large-bore peripheral lines (14-16G) for trauma resuscitation (PMID: 28481355)

Pathophysiology of Complications

Phlebitis (Inflammation of Vein Wall)

Three types (PMID: 21157098):

1. Mechanical Phlebitis (60-70% of cases)

   • Catheter too large for vein lumen (catheter:vein ratio >45%)
   • Catheter movement within vein (friction on endothelium)
   • Insertion site at joint (elbow, wrist) - repeated flexion
   • Pathophysiology: Endothelial damage → platelet aggregation → fibrin deposition → inflammatory cascade (IL-1, TNF-α)

2. Chemical Phlebitis (20-30%)

   • Drug pH less than 5 or >9 (vancomycin pH 2.5-4.5, phenytoin pH 12)
   • Osmolality >600 mOsm/L (10% dextrose 505 mOsm/L, TPN 900-1200 mOsm/L)
   • Prolonged infusion time (>24 hours continuous infusion)
   • Pathophysiology: Direct chemical endothelial injury → vascular smooth muscle spasm → thrombosis

3. Bacterial Phlebitis (5-10%)

   • Skin flora contamination during insertion (Staphylococcus epidermidis, S. aureus)
   • Hub manipulation without aseptic technique
   • Pathophysiology: Biofilm formation on catheter → bacterial colonization → suppurative thrombophlebitis → systemic sepsis
   • CRBSI rate: 0.5-2.6 per 1000 catheter-days (PMID: 22449262)

Infiltration vs Extravasation

Infiltration (Non-Vesicant Leakage)

• Catheter dislodgement → IV fluid leaks into interstitial space
• Fluids: 0.9% NaCl, 5% dextrose, Hartmann's, blood products
• Signs: Swelling, coolness, blanching, slowed infusion rate
• Management: Remove catheter, elevate limb, warm compress

Extravasation (Vesicant Leakage)

• Vesicants: Agents causing tissue blistering, ulceration, necrosis
  • "Vasopressors: Noradrenaline (α1-vasoconstriction → ischemia), dopamine (>10 mcg/kg/min), adrenaline"
  • "Chemotherapy: Anthracyclines (doxorubicin), vinca alkaloids (vincristine, vinblastine), nitrogen mustards"
  • "Electrolytes: Calcium chloride/gluconate, potassium >40 mmol/L (pH >8)"
  • "Hypertonic fluids: 10% dextrose, 3% NaCl, TPN (osmolality >600 mOsm/L)"
• Pathophysiology: Direct cytotoxic effect + vasospasm → coagulation necrosis, thrombosis → tissue death
• Tissue injury progression: Erythema (2-6h) → blistering (12-24h) → ulceration (48-72h) → full-thickness necrosis (5-10 days)
• Antidotes (PMID: 25533770):
  • "Noradrenaline/adrenaline: Phentolamine 5-10 mg in 10 mL NS (α-blocker reversal)"
  • "Calcium salts: Hyaluronidase 150 U subcutaneously (increases dispersion)"
  • "Anthracyclines: Dexrazoxane IV (iron chelator, free radical scavenger)"
  • "Vinca alkaloids: Hyaluronidase"

---

Indications and Contraindications

Indications

Therapeutic

1. Fluid resuscitation - Hemorrhagic shock, septic shock, dehydration
2. Medication administration - Antibiotics, analgesia, antiemetics, vasopressors (short-term)
3. Blood product transfusion - Packed red cells, platelets, FFP (requires ≥18G)
4. Parenteral nutrition - Short-term (less than 2 weeks) peripheral parenteral nutrition (PPN)
5. Emergency access - Cardiac arrest (if IO not available), anaphylaxis

Diagnostic

1. Contrast-enhanced CT - Requires 18-20G, flow rate >4 mL/s for CT pulmonary angiogram
2. Blood sampling - NOT recommended (false hemolysis, contamination), but pragmatic if phlebotomy difficult

PIVC vs Central Venous Catheter Decision

PIVC Preferred When:

• Short-term therapy (less than 2 weeks)
• Non-vesicant medications
• Moderate fluid requirements
• Patient mobile, cooperative
• Adequate peripheral veins visible/palpable

CVC Indicated When:

• Long-term therapy (>2 weeks) - TPN, chemotherapy
• Vesicant infusion - High-dose vasopressors (noradrenaline >0.3 mcg/kg/min), chemotherapy
• Central venous pressure monitoring required
• Hemodialysis access (large-bore dual-lumen catheter)
• DIVA - Repeated failed PIVC attempts (>3 in emergency, >2 in elective)
• High-volume resuscitation - Consider large-bore introducer sheath (Cordis 8.5F) rather than triple-lumen CVC

PIVC vs Intraosseous (IO) Access

IO Indicated When:

• Cardiac arrest - PIVC not achievable within 90 seconds (ANZCOR Guideline 9.1.3)
• Profound shock - Collapsed veins, agitated patient
• Massive trauma - In-field access by paramedics
• Pediatric emergency - Age less than 6 years with difficult access
• Sites: Proximal humerus (highest flow 5 L/h), proximal tibia, distal tibia, distal femur
• Limitations: Painful (requires lidocaine flush), compartment syndrome risk, remove within 24 hours

Contraindications

Absolute Contraindications

• Overlying skin infection - Cellulitis, abscess (bacteremia risk)
• Thrombosed vein - Palpable cord, history of thrombophlebitis
• AV fistula limb - Dialysis fistula preservation (KDIGO 2012 guideline)
• Lymphedema limb - Post-mastectomy, filariasis (infection risk, impaired drainage)
• Fracture/trauma to limb - Compartment syndrome risk, fluid extravasation

Relative Contraindications

• Coagulopathy (INR >3, platelets less than 20 × 10⁹/L) - Hematoma risk (compressible, so relative contraindication only)
• Burns or scars - Avoid insertion through burned skin (infection)
• Agitated/confused patient - Risk of self-removal, injury
• Previous failed attempts at same site - Damaged endothelium, increased phlebitis

Site-Specific Contraindications

• Lower limb veins (saphenous, dorsal foot) - Higher DVT and infection risk (PMID: 16557327). Avoid unless upper limb impossible. Exception: Massive trauma with bilateral upper limb injuries.

---

Equipment

Peripheral IV Cannula Components

Standard Over-the-Needle Catheter (Teflon or Polyurethane)

1. Catheter hub (color-coded by gauge)
2. Catheter shaft (radiopaque stripe for X-ray visibility)
3. Introducer needle (beveled tip, retracts into safety shield)
4. Flashback chamber (confirms venous entry)
5. Safety shield (activated after withdrawal, prevents needlestick)

Catheter Materials

• Polyurethane: Stiff during insertion, softens at body temperature (37°C) - preferred (less thrombophlebitis)
• Teflon (PTFE): Stiffer, higher thrombogenicity - older technology
• Vialon™ (BD brand): Proprietary polyurethane, reduced friction coefficient

Long Peripheral IV Catheters (LPIV) for Ultrasound-Guided Deep Vein Access

• Length: 5-8 cm (standard 2.5-4.5 cm)
• Gauge: 18-20G (balance between flow and vein size)
• Indications: Deep brachial/basilic veins (>1.5 cm depth), difficult access, intermediate-term therapy (5-14 days)
• Advantages: Lower dislodgement than standard PIVC in deep veins, bridges PIVC and PICC (PMID: 26475246)
• Limitations: Requires ultrasound guidance, modified Seldinger technique, higher cost

Ancillary Equipment

Preparation and Insertion

• Tourniquet (disposable single-use preferred - infection control)
• Skin antiseptic: 2% chlorhexidine gluconate in 70% isopropyl alcohol (ACSQHC standard) - allow 30 sec dry time
• Sterile gloves (non-touch technique mandated)
• Local anesthetic (optional): 1% lidocaine intradermal (0.1-0.2 mL), EMLA cream (pediatrics, applied 60 min prior)

Securement and Dressing

• Transparent semi-permeable dressing (Tegaderm™, OpSite™) - allows site visualization
• Securing device: StatLock™ (adhesive stabilization device), reduces 50% catheter migration (PMID: 17241750)
• Sterile gauze (if site oozing blood, but change to transparent dressing within 2 hours)

Flushing and Maintenance

• 0.9% Sodium Chloride (normal saline) for flush - 5-10 mL pre/post medication
• Injection cap (needleless) - Luer-lock connector
• Extension set (optional) - Reduces hub manipulation, allows easier access

Ultrasound Equipment (for DIVA)

• High-frequency linear probe (8-12 MHz) - superficial vessels less than 3cm depth
• Sterile probe cover and gel
• "Hockey-stick" probe (13-18 MHz) - small habitus, pediatrics

Difficult Access Adjuncts

• Heat packs (40-42°C) - Apply 10-15 minutes prior, vasodilation increases vein diameter 20-30% (PMID: 18728573)
• Near-infrared vein finder (AccuVein™, VeinViewer™) - Mixed evidence, better for superficial visualization, does NOT improve first-attempt success in adults (PMID: 23369563)
• Vein illuminator (TransLite™) - Cold LED transillumination

---

Technique: Standard Landmark Peripheral IV Cannulation

Pre-Procedure Preparation

1. Patient Assessment

• Indication: Confirm need for IV access (ACSQHC Quality Statement 1)
• DIVA Score: Assess vein palpability, visibility, history
• Contraindications: Check limb, skin integrity, coagulation
• Allergies: Chlorhexidine, adhesive dressings
• Patient position: Arm abducted 30-45°, supported on pillow, well-lit room

2. Site Selection Hierarchy (Distal to Proximal)

1. Forearm veins (cephalic, basilic) - First choice, allows proximal resiting if needed
2. Antecubital fossa - Large veins, highest success, but restricts elbow movement
3. Dorsal hand - Fragile, painful, avoid in elderly/long-term use
4. Upper arm (cephalic) - Good for long-term, but requires ultrasound if deep

Avoid:

• Sites of flexion (wrist, ACF in mobile patients) - mechanical phlebitis
• Veins below previous IV sites - damaged endothelium
• Limb with AV fistula, lymphedema, paralysis
• Lower limb unless no alternative

3. Hand Hygiene and PPE

• WHO 5 Moments: Before patient contact (ACSQHC standard)
• Sterile gloves (or ANTT - Aseptic Non-Touch Technique)

Insertion Technique (Step-by-Step)

Step 1: Apply Tourniquet

• Position 10-15 cm proximal to intended site
• Tightness: Should occlude venous return but NOT arterial flow (radial pulse palpable)
• Maximum time: 60 seconds (prolonged tourniquet → hemoconcentration, petechiae)

Step 2: Vein Selection

• Palpate before looking - bouncy, compressible, refills after compression
• Avoid: Pulsatile (artery), hard/cord-like (thrombosed), bifurcations (valves)
• Enhance venous filling: Tap vein gently, ask patient to clench fist, gravity (hang arm below heart), heat pack

Step 3: Skin Preparation

• 2% Chlorhexidine/70% Alcohol - Apply with friction for 30 seconds
• Allow to air dry completely (30 seconds) - maximal antimicrobial effect, prevents stinging
• Do NOT palpate vein after skin prep (re-contamination)

Step 4: Stabilize Vein

• Non-dominant hand: Place thumb 5 cm distal to puncture site, pull skin taut distally
• Purpose: Prevents vein rolling, especially in elderly (loose subcutaneous tissue)

Step 5: Needle Insertion

• Angle: 10-30° to skin (steeper for deep veins 30°, shallow for superficial 10-15°)
• Bevel up (visualizes flashback sooner)
• Direct method: Puncture skin and vein in one motion
• Indirect method: Puncture skin first (1-2mm), then redirect and puncture vein (better control in fragile veins)

Step 6: Confirm Venous Entry

• Flashback of blood in chamber - confirms needle in vein lumen
• Advance needle 2mm further into vein (ensures catheter tip also in lumen, not just needle)

Step 7: Catheter Advancement

• Lower angle to 5-10° (aligns with vessel)
• Advance catheter off needle into vein using hub (NOT touching catheter shaft - asepsis)
• Smooth advancement - if resistance, STOP (valve or vessel wall):
  • Do NOT force (vein perforation risk)
  • Withdraw 5mm and try advancing again
  • If still resistant, withdraw entire assembly and try different site

Step 8: Release Tourniquet and Secure Catheter

• Release tourniquet before needle withdrawal (prevents blood backflow)
• Occlude vein proximally with finger (prevents blood spillage)
• Withdraw needle into safety shield (activates with click)
• Attach extension set or flush immediately

Step 9: Flush and Confirm Patency

• Flush with 5-10 mL 0.9% NaCl
• Confirm: No resistance, no swelling at site, patient denies pain
• If infiltrated: Remove immediately, apply pressure, restart at different site

Step 10: Secure and Dress

• Clean blood from insertion site with sterile gauze
• Secure with StatLock™ or sterile tape (do NOT circumferentially wrap - tourniquet effect)
• Apply transparent semi-permeable dressing (ACSQHC Quality Statement 6)
• Label: Date, time, gauge, operator initials

Step 11: Document

• Site, gauge, number of attempts, complications, patient tolerance
• VIP score 0 at baseline

Post-Insertion Care

Flushing Protocol

• Before medication: 5 mL 0.9% NaCl (confirm patency)
• After medication: 10 mL 0.9% NaCl (clear drug from catheter, prevent drug interactions)
• Intermittent use: Flush every 8-12 hours (prevents occlusion)
• Pulsatile flush (push-pause technique) creates turbulence, clears catheter better than continuous flush

VIP Score Assessment (PMID: 21157098)

• Frequency: Minimum every 8-12 hours (every shift), more frequent (2-4h) if vesicant infusion
• Document score in patient chart

Clinically-Indicated Replacement (Cochrane 2019, PMID: 30695087)

• Replace ONLY when:
  • VIP score ≥2
  • Catheter malfunction (occlusion, leaking)
  • Catheter no longer required
  • Suspected CRBSI
• Do NOT routinely replace at 72-96 hours if functioning well and site healthy
• Evidence: No difference in CRBSI (RR 0.97, 95% CI 0.84-1.12) or phlebitis (RR 1.00, 95% CI 0.84-1.18)

---

Ultrasound-Guided Peripheral IV Access

Indications for Ultrasound Guidance

DIVA Score ≥2 (50% first-attempt failure risk)

• No vein palpable after tourniquet
• No vein visible after tourniquet
• History of difficult access (>3 attempts previously)
• IV drug use, dialysis, obesity (BMI >40), chemotherapy

Failed Standard Technique

• ≥2 failed attempts in elective setting
• ≥3 failed attempts in emergency (before escalating to IO/CVC)

Evidence for Ultrasound Guidance

• Heinrichs RCT (2013, PMID: 24156914): DIVA patients - USS 87% first-attempt success vs 33% standard (RR 2.61, 95% CI 1.60-4.26)
• Egan RCT (2013, PMID: 23369563): Emergency department - USS 97% overall success vs 85% standard (p=0.003)
• Cochrane 2013 meta-analysis (PMID: 23846447): USS reduces failed attempts (RR 0.41, 95% CI 0.28-0.60) in DIVA

Ultrasound Technique

Equipment

• High-frequency linear probe (8-12 MHz)
• Sterile probe cover and gel
• Long PIVC (5-8 cm) for deep veins >1.5 cm depth

Vessel Identification

• Vein characteristics:
  • Compressible (complete collapse with probe pressure)
  • Non-pulsatile flow
  • Thin-walled, oval/elliptical shape
  • Augmentation (increases size with distal compression)
• Artery characteristics:
  • Non-compressible (thick muscular wall)
  • Pulsatile flow (color Doppler shows pulsatile waveform)
  • Circular shape, smaller diameter than adjacent vein
  • "Color Doppler: Red/blue pulsatile signal (vein shows respiratory variation)"

Target Vessels for USS-PIVC

1. Deep basilic vein (medial upper arm) - 4-6mm diameter, 1.5-2.5cm depth, straight course - BEST target
2. Deep brachial vein (medial upper arm) - accompanies brachial artery (lateral to artery)
3. Cephalic vein (lateral forearm) - if >3mm diameter, less than 1.5cm depth

Static vs Dynamic Approach

Dynamic Ultrasound-Guided Cannulation (Step-by-Step)

Step 1: Identify and Mark Vessel

• Transverse (short-axis) view - vein appears as circular structure
• Compress to confirm (vein collapses, artery does not)
• Measure depth (from skin to center of vein)
• Mark skin entry point (5-10mm proximal to probe)

Step 2: Probe and Needle Alignment

• Transverse approach (probe perpendicular to vessel, needle in long axis of vein):
  • "Advantages: Easier to see vein, confirm compression"
  • Disadvantages: See only needle tip (hyperechoic dot), easy to "lose" needle, posterior wall puncture risk
• Longitudinal approach (probe parallel to vessel):
  • "Advantages: See entire needle path, visualize tip in lumen"
  • "Disadvantages: Harder to keep vessel in view, requires steady hand"
  • PREFERRED for beginners

Step 3: Needle Insertion

• Angle: Depth (cm) × 2 = distance (cm) from probe. Example: 2cm deep vein = insert 4cm proximal to probe at ~30° angle
• Advance slowly under real-time USS - visualize needle tip as hyperechoic (white) structure
• Target posterior wall of vein (anterior wall puncture can cause catheter to "tent" wall and not advance)

Step 4: Confirm Intraluminal Position

• Compress vein gently - should see collapse around catheter (confirms intraluminal, not extraluminal)
• Flashback in chamber (may be delayed 2-3 seconds in deep veins)

Step 5: Advance Catheter

• Visualize catheter advancement in longitudinal view - hyperechoic line within vein lumen
• If resistance: Check USS - catheter may be against valve or posterior wall. Withdraw 2-3mm, rotate 90°, advance again.

Step 6: Confirm Position with Flush

• Inject 2-3 mL saline while visualizing on USS - turbulent flow within vein confirms intraluminal position
• No extravasation in surrounding tissue

Complications Specific to USS-PIVC

• Posterior wall puncture (15-20%) - through-and-through technique, withdraw slowly until flashback, then advance catheter
• Arterial puncture (1-2%) - if pulsatile flow, remove immediately, apply pressure 5 minutes, document
• Hematoma (5-10%) in deep veins - usually self-limiting, compressive dressing
• LPIV dislodgement - higher than standard PIVC if standard 3cm catheter used in >1.5cm deep vein. Use 5-8cm LPIV.

---

Complications

Early Complications (Insertion-Related)

1. Arterial Puncture (Incidence 0.1-0.5% in ACF)

Recognition

• Pulsatile blood return
• Bright red blood (vs dark venous blood)
• High-pressure backflow into extension set

Management

• REMOVE catheter immediately if small gauge (20-22G), apply pressure 5 minutes
• DO NOT REMOVE if large-bore (14-18G), especially in ACF (brachial artery)
  • Leaving catheter prevents expanding hematoma
  • Consult vascular surgery immediately
  • May require surgical exploration if expanding hematoma, distal ischemia, or nerve compression
• Radial artery puncture (wrist) - remove, apply pressure 10 minutes, check distal pulses
• Document in medical record, neuro-vascular observations

2. Hematoma (Incidence 5-15%)

Risk Factors

• Coagulopathy (INR >3, aspirin, clopidogrel)
• Multiple attempts
• Fragile veins (elderly, steroids)
• Inadequate pressure after removal

Management

• Remove catheter, apply pressure 5 minutes (10 minutes if coagulopathy)
• Elevate limb
• Cold compress for 20 minutes (vasoconstriction)
• If expanding or neurovascular compromise, vascular surgery consult

3. Vasovagal Syncope (Incidence 1-5%)

Recognition

• Bradycardia, hypotension, diaphoresis, nausea, syncope
• Usually during/immediately after insertion (pain, anxiety)

Management

• Supine position, legs elevated
• Atropine 0.6 mg IV if severe bradycardia (HR less than 40)
• Usually self-limiting within 1-2 minutes

4. Nerve Injury (Incidence less than 0.1%)

Anatomy at Risk

• Median nerve - Deep to median cubital vein in ACF, at wrist (palmar approach)
• Radial nerve (superficial branch) - Lateral wrist (anatomical snuffbox)
• Ulnar nerve - Medial elbow, medial wrist

Recognition

• Sharp shooting pain during insertion (pathognomonic)
• Paresthesia (tingling, numbness) in nerve distribution
• Motor weakness (rare, indicates deep injury)

Management

• STOP insertion immediately, remove needle
• Document distribution of symptoms
• Neurology/hand surgery consult if persistent >24 hours
• Most resolve spontaneously (neuropraxia from needle proximity, not transection)

Late Complications (Dwell-Time Related)

1. Phlebitis (Incidence 5-70%, mean 30%)

See VIP Score section above for grading.

Risk Factors (PMID: 21157098)

• Catheter-related: Large gauge (14-16G), long dwell time (>72h), insertion site at joint
• Infusate-related: pH less than 5 or >9, osmolality >600 mOsm/L, particulate matter
• Patient-related: Female sex, smoking, immunosuppression

Prevention

• Smallest gauge catheter adequate for therapy
• Forearm site (avoid ACF if long-term)
• Dilute irritant medications
• Clinically-indicated replacement
• ANTT for hub access

Management

• VIP score ≥2: Remove catheter
• VIP score 3-4: Warm compress, elevation, NSAIDs (topical diclofenac gel)
• VIP score 5: Blood cultures (draw from different site), remove catheter and send tip for culture (roll-plate method), empirical antibiotics if sepsis criteria met

2. Infiltration and Extravasation (Incidence 20-30%)

Infiltration Grading (INS Scale)

Vesicant Extravasation Management (PMID: 25533770)

Immediate Steps (ALL vesicants)

1. STOP infusion immediately
2. DO NOT remove catheter yet (may need for antidote administration)
3. Aspirate residual drug via catheter (5-10 mL)
4. Photograph affected area (medicolegal documentation)
5. Mark borders with pen (track progression)

Antidote Administration (Within 60 Minutes Optimal)

After Antidote

• Remove catheter (no longer needed)
• Elevate limb 45° above heart
• Cooling (noradrenaline, anthracyclines) - ice pack 15-20 min every 4-6 hours × 24-48h
• Warming (vinca alkaloids) - warm compress 15-20 min every 4-6h × 24-48h
• Plastic surgery consult if:
  • Blistering develops
  • Full-thickness skin loss
  • Area >5cm diameter
  • Overlying joint or neurovascular structures
• Surgical debridement may be required for necrotic tissue (7-14 days post-extravasation)

3. Catheter-Related Bloodstream Infection (CRBSI) (Incidence 0.5-2.6 per 1000 catheter-days)

Diagnosis (CDC/NHSN Criteria)

• Positive blood culture (same organism from peripheral and catheter tip culture)
• Differential time to positivity (catheter blood culture positive ≥2 hours before peripheral)
• Quantitative culture (≥5:1 colony count ratio catheter:peripheral)
• Catheter tip culture (≥15 CFU by semi-quantitative roll-plate method)

Common Organisms

• Staphylococcus epidermidis (40-50%) - Skin flora, biofilm formation
• Staphylococcus aureus (20-30%) - More virulent, complications (endocarditis, abscess)
• Candida spp (5-10%) - Prolonged antibiotics, TPN, immunosuppression
• Gram-negatives (10-20%) - Enterobacter, Klebsiella, Pseudomonas

Risk Factors

• Dwell time >4 days (PMID: 22449262)
• Insertion site (lower limb > ACF > forearm)
• Non-sterile insertion technique
• Hub manipulation without "scrub the hub" (70% alcohol, 15 seconds)
• Immunosuppression (neutropenia, diabetes, steroids)

Management

• Remove catheter, send tip for culture
• Blood cultures × 2 sets (peripheral sites, before antibiotics)
• Empirical antibiotics if sepsis (SIRS ≥2 criteria):
  • Vancomycin 25-30 mg/kg IV loading (covers MRSA)
  • Piperacillin-tazobactam 4.5g IV 6-hourly (covers Gram-negatives)
  • De-escalate based on culture results
• Source control: Remove ALL vascular access devices if persistent bacteremia >72h
• Complications: Suppurative thrombophlebitis (requires surgical excision of vein), endocarditis (TOE, 4-6 weeks antibiotics)

4. Thrombophlebitis (Incidence 2-5%)

Pathophysiology

• Phlebitis + thrombus formation within vein lumen
• Endothelial damage → platelet activation → fibrin deposition → occlusive thrombus

Recognition

• Palpable cord along vein (VIP score ≥4)
• Persistent pain, erythema after catheter removal
• Systemic signs (fever, leukocytosis) if septic thrombophlebitis

Investigation

• Ultrasound Doppler - confirms thrombus, extent
• Blood cultures if febrile

Management

• Uncomplicated: NSAIDs, warm compress, elevation - usually resolves in 7-14 days
• Septic thrombophlebitis: IV antibiotics (vancomycin + piperacillin-tazobactam), anticoagulation (LMWH), surgical excision if abscess

5. Catheter Occlusion (Incidence 10-20%)

Causes

• Thrombotic (90%) - Fibrin sheath, blood clot
• Non-thrombotic (10%) - Drug precipitate (phenytoin + dextrose), lipid occlusion (TPN)

Management

• Flush with 10 mL saline using push-pause technique
• Alteplase (tissue plasminogen activator) 2 mg in 2 mL, dwell 30 minutes (for thrombotic occlusion) - NOT routine, expensive, limited evidence for peripheral lines
• Remove and replace - most cost-effective if occlusion persists

---

Difficult IV Access (DIVA) Strategies

Stepwise Approach

Step 1: Optimize Conditions (Before First Attempt)

• Patient position: Arm below heart level, dependent position (gravity venous filling)
• Heat pack: 40-42°C for 10-15 minutes (vasodilation increases vein diameter 20-30%) - PMID: 18728573 - RCT showed 73% → 94% first-attempt success
• Hydration: 500 mL IV bolus if hypovolemia suspected (increases venous filling)
• Lighting: Optimize room lighting, headlamp for examiner

Step 2: Standard Landmark Technique (Maximum 2 Attempts)

• ALWAYS attempt standard technique first before escalating to USS (skill maintenance)
• Two different operators if first attempt fails
• Document attempts (site, gauge, operator)

Step 3: Ultrasound-Guided Peripheral Access (If ≥2 Failed Attempts)

• Target: Deep basilic vein (4-6mm, 1.5-2.5cm depth)
• Use long PIVC (5-8cm) to prevent dislodgement
• Success rate: 85-97% (PMID: 24156914, 23369563)

Step 4: Alternative Sites

• External jugular vein (EJ) - Large (5-8mm), superficial, no USS needed
  • "Technique: Head turned contralateral, Trendelenburg 15°, insert at mid-neck level advancing caudally towards clavicle"
  • "Complications: Pneumothorax (rare, less than 0.1%), carotid artery puncture (if too medial)"
  • "Success rate: 85-90% if vein visible"
• Dorsal foot/saphenous vein - Avoid if possible (higher infection, DVT), only in dire emergency (no upper limb access, IO not available)

Step 5: Intraosseous (IO) Access (If Shock/Cardiac Arrest)

• If ≥3 failed attempts AND hemodynamically unstable (shock, cardiac arrest)
• Sites: Proximal humerus (5L/h), proximal tibia (2.5L/h), distal tibia
• Complications: Compartment syndrome (1-2%), osteomyelitis (less than 0.5%), fat embolism (rare)
• Dwell time: less than 24 hours (replace with CVC when patient stabilized)

Step 6: Central Venous Catheter (If Long-Term Access Needed)

• Indications: DIVA + requirement for >2 weeks therapy, vesicant medications, TPN
• USS-guided internal jugular (safest, highest success, lowest pneumothorax)

Adjuncts: Evidence Summary

Heat Packs ✅ RECOMMENDED

• Lansdowne RCT (Lancet 2014, PMID: 18728573): 40°C heat × 10 min → first-attempt success 94% vs 73% control
• Mechanism: Vasodilation (nitric oxide release), vein diameter ↑ 20-30%
• Cost: Under $1 per heat pack, universally available

Ultrasound Guidance ✅ RECOMMENDED for DIVA

• Cochrane 2013 meta-analysis (PMID: 23846447): USS reduces first-attempt failure RR 0.41 (95% CI 0.28-0.60)
• Heinrichs RCT (PMID: 24156914): DIVA patients - USS 87% vs standard 33% first-attempt success
• Learning curve: 25-50 supervised insertions to achieve competence (PMID: 26475246)

Near-Infrared Vein Finders ❌ NOT RECOMMENDED (Mixed Evidence)

• Juvin RCT (Pediatrics 2012, PMID: 22869833): No difference in success rate adults (66% vs 64%, p=0.78)
• Cuper meta-analysis (Anesthesiology 2012, PMID: 23103795): Benefit in children (RR 1.23), no benefit in adults
• Limitations: 2D image, does not show depth, overshoot/undershoot common

Nitroglycerin Patch ❓ INSUFFICIENT EVIDENCE

• Mechanism: Topical nitrate → local vasodilation
• Riker RCT (PMID: 17095948): Marginal benefit (vein diameter ↑ 8%), not clinically significant
• Not routinely recommended

---

Special Populations

Obesity (BMI >40)

Challenges

• Veins deeper (subcutaneous adipose tissue)
• Palpation difficult (fat obscures landmarks)
• Standard catheter length (2.5-4.5cm) may be inadequate

Strategies

• Ultrasound guidance - First-line for BMI >40 (PMID: 26475246)
• Long PIVC (5-8cm) for deep veins
• External jugular vein - Less affected by obesity, easily visualized
• ACF - Deepest veins here are still accessible (basilic/brachial 2-3cm)

Elderly (Age >75)

Challenges

• Fragile veins (decreased elastin, collagen)
• Vein rolling (loose subcutaneous tissue)
• Tortuous veins (atherosclerotic changes)
• Skin tears (fragile skin)

Strategies

• Minimize tourniquet time (less than 30 seconds, or no tourniquet if veins visible)
• Low insertion angle (10-15°) to prevent posterior wall puncture
• Stabilize vein with maximal skin traction
• Avoid dorsal hand (fragile, painful, high failure)
• Consider 22G even for maintenance fluids (balance flow vs vein trauma)

Chronic Kidney Disease / Dialysis Patients

Challenges

• Venous sclerosis (repeated fistula needles, previous catheters)
• Vein preservation for future dialysis access (KDIGO 2012)
• AV fistula arm - absolute contraindication for PIVC

Strategies (KDIGO 2012 Guideline)

• Avoid non-dominant arm (preserve for future fistula creation)
• Avoid ACF veins (prime sites for fistula)
• Preferred sites: Dorsal hand (non-dominant), forearm (non-dominant)
• Consider CVC if long-term access needed (do NOT use peripheral veins unnecessarily)

Intravenous Drug Users (IVDU)

Challenges

• Venous sclerosis (repeated injection, adulterants)
• Scarring, thrombosis of ACF veins
• Abscess/cellulitis at usual sites
• Patient anxiety (often poor experiences with access)

Strategies

• Engagement: Explain procedure, involve patient in site selection (they often know their "best" veins)
• Ultrasound-guided deep veins - Basilic/brachial often spared
• External jugular - Usually preserved
• Consider CVC early if multiple failed attempts (avoid tissue trauma, preserve relationship)

Oncology / Chemotherapy Patients

Challenges

• Venous sclerosis (previous chemotherapy)
• Thrombocytopenia (bone marrow suppression) - hematoma risk
• Vesicant extravasation risk (anthracyclines, vinca alkaloids) - tissue necrosis

Strategies

• Large, proximal veins (ACF, upper arm cephalic)
• Avoid small, distal veins (dorsal hand) for vesicants
• Consider PICC or port for long-term chemotherapy (>4 cycles)
• Strict monitoring: VIP score every 2 hours during vesicant infusion

---

Indigenous Health Considerations

Aboriginal and Torres Strait Islander Populations

Epidemiology

• Higher rates of chronic disease requiring IV access:
  • "Chronic kidney disease: 10× general population (PMID: 30761655)"
  • "Diabetes: 3× general population"
  • "Rheumatic heart disease: 5-8× general population (especially remote communities)"
• Difficult IV access more common (CKD, dialysis, dehydration)

Cultural Considerations

• Involve Aboriginal Health Worker (AHW) or Aboriginal Hospital Liaison Officer (AHLO):
  • Explanation in language if limited English
  • Cultural safety and trust-building
  • Family/community spokesperson may need to be present
• Gender considerations: Male health worker for male patient, female for female patient (especially in traditional communities)
• Pain tolerance: Stoicism common - do NOT assume no pain if patient not vocalizing. Ask explicitly.
• Decision-making: Often communal/family-based, not individual. Allow time for family discussion.
• Previous trauma: Historical forced medical interventions → distrust of healthcare system. Obtain explicit consent, explain clearly, do NOT rush.

Communication Strategies

• Use plain language: Avoid medical jargon ("we need to put a tube in your vein" NOT "we need to insert a peripheral intravenous cannula")
• Visual aids: Show equipment before insertion
• Interpreter services: Use qualified interpreters for Aboriginal languages (NOT family members - confidentiality)
• Check understanding: Ask patient to explain back what will happen

Remote/Rural Challenges

• Limited equipment: May not have ultrasound, heat packs, or long PIVCs
• Telehealth: Use RFDS or state retrieval service telemedicine for guidance
• Transport delays: If PIVC essential for retrieval (medication, fluids), consider IO access if multiple attempts failing
• Environmental factors: Extreme heat (dehydration common), dust (infection risk)

Māori Health (New Zealand)

Cultural Considerations

• Whānau (family) involvement: Expect extended family at bedside, collective decision-making
• Kaumātua (Elders) may lead health decisions
• Tikanga (cultural protocols):
  • Karakia (prayer) before procedure - allow time
  • Tapu and noa (sacred/profane) - head is tapu (sacred), explain why not accessing jugular unless necessary
• Manaakitanga (respect, hospitality): Warm greeting, introduce self, explain role

Health Disparities

• 2-2.5× higher rates of diabetes, CVD, CKD than non-Māori
• DIVA more common (as per Aboriginal populations)
• Access barriers: Rural/remote populations (Northland, East Coast), transport costs

Communication

• Te Reo Māori (Māori language) - use interpreter if patient prefers
• Māori Health Workers - involve where available

---

Australian Guidelines and Standards

ACSQHC Management of PIVC Clinical Care Standard (2021)

10 Quality Statements

1. Assess need: Only insert if clear clinical indication, avoid if oral therapy possible
2. Patient information: Inform patient of procedure, risks, care requirements
3. Site selection: Choose site minimizing infection/displacement risk (avoid flexion sites if long-term)
4. Vascular access device selection: Smallest gauge, shortest dwell time anticipated
5. Aseptic technique: ANTT for insertion and maintenance, 2% chlorhexidine/70% alcohol skin prep
6. Securement and dressing: Transparent semi-permeable dressing, secure to prevent dislodgement
7. Assessment: VIP score minimum every 8-12 hours, document
8. Accessing the device: Scrub the hub 15 seconds with 70% alcohol, allow to dry
9. Flushing: 0.9% NaCl before/after medication, pulsatile flush technique
10. Clinically indicated removal: Remove when no longer needed, VIP score ≥2, or malfunction (NOT routine time-based)

Target Outcome

• Reduce Staphylococcus aureus bacteraemia (SAB) from PIVCs
• Reduce phlebitis rates to less than 5% (currently 5-70% depending on setting)

ANZICS-CORE Statement 3.2 - Vascular Access Devices

Key Recommendations

• Ultrasound guidance: RECOMMENDED for DIVA (>2 failed attempts)
• Insertion site: Upper limb preferred, avoid lower limb unless no alternative
• Skin antisepsis: 2% chlorhexidine in 70% alcohol (>30 sec application, allow to dry)
• Replacement: Clinically-indicated, NOT routine time-based
• Documentation: Site, date, time, gauge, VIP score, operator

CDC Guidelines for Prevention of Intravascular Catheter-Related Infections (2011)

Peripheral IV Catheter Specific Recommendations

• Hand hygiene: Before and after insertion/manipulation (WHO 5 Moments)
• Aseptic technique: Clean gloves for insertion (sterile gloves NOT required for PIVC)
• Skin antisepsis: Chlorhexidine >0.5% preferred (superior to povidone-iodine) - PMID: 12234811
• Replacement: Remove when clinically indicated, NOT routinely at 72-96h
• Administration sets: Replace no more frequently than 96h (unless blood/lipids - 24h)

---

SAQ Practice Questions

SAQ 1: Difficult Peripheral IV Access

Question (20 marks)

A 68-year-old woman with metastatic breast cancer is admitted to ICU with septic shock. She requires noradrenaline infusion and broad-spectrum antibiotics. She has a history of multiple chemotherapy cycles. Examination reveals no palpable or visible peripheral veins in both arms. Attempts at dorsal hand cannulation have failed twice.

A) List four (4) risk factors for difficult intravenous access (DIVA) in this patient. (4 marks)

B) Describe two (2) adjuncts you would use before attempting further peripheral IV access, including the evidence supporting their use. (6 marks)

C) Describe the ultrasound-guided technique for deep basilic vein cannulation, including vessel identification and catheter insertion. (6 marks)

D) You successfully insert an 18G peripheral cannula in the antecubital fossa and commence noradrenaline infusion. Four hours later, the patient complains of severe pain at the IV site, and you notice tissue swelling. Outline your immediate management of this complication. (4 marks)

---

Model Answer

A) Four risk factors for DIVA in this patient: (4 marks - 1 mark each)

1. Age >65 years - Fragile, sclerosed veins, reduced elastin/collagen
2. Previous chemotherapy - Venous sclerosis from repeated vesicant administration, thrombophlebitis
3. Septic shock - Hypovolemia/vasoconstriction → collapsed, non-palpable veins
4. Multiple previous failed attempts - Endothelial damage, hematoma, patient anxiety

(Also accept: Female sex, chronic disease, dehydration, obesity if mentioned)

---

B) Two adjuncts before further attempts: (6 marks - 3 marks each: method 1 mark, evidence 2 marks)

1. Heat Packs (40-42°C) Applied for 10-15 Minutes (1 mark)

• Evidence: Lansdowne RCT (Lancet 2014, PMID: 18728573) - 40°C heat for 10 minutes increased first-attempt success from 73% to 94% (pless than 0.001). Mechanism: Local vasodilation (nitric oxide release) increases vein diameter 20-30%, improves vein visibility and palpability. (2 marks)

2. Ultrasound Guidance (1 mark)

• Evidence: Heinrichs RCT (2013, PMID: 24156914) - In DIVA patients, ultrasound-guided PIVC achieved 87% first-attempt success vs 33% standard technique (RR 2.61, 95% CI 1.60-4.26). Cochrane 2013 meta-analysis (PMID: 23846447) showed ultrasound reduces first-attempt failure (RR 0.41, 95% CI 0.28-0.60). Allows access to deep brachial/basilic veins (4-6mm diameter, 1.5-2.5cm depth) not accessible via landmark technique. (2 marks)

---

C) Ultrasound-guided deep basilic vein cannulation technique: (6 marks)

Vessel Identification (2 marks)

• Use high-frequency linear probe (8-12 MHz), transverse (short-axis) view of medial upper arm (mid-humerus level)
• Identify basilic vein medially (4-6mm diameter, compressible with probe pressure, non-pulsatile) and brachial artery laterally (non-compressible, pulsatile on color Doppler)
• Confirm vein compressibility (complete collapse = venous), measure depth from skin (typically 1.5-2.5cm)

Catheter Insertion (4 marks)

• Use long PIVC (5-8cm length) for deep veins >1.5cm to prevent dislodgement
• Dynamic longitudinal approach (probe parallel to vessel): Allows visualization of entire needle path
• Insert needle 5-10mm proximal to probe at 30-45° angle (depth × 2 = distance from probe)
• Advance needle under real-time USS, visualizing hyperechoic needle tip entering vein lumen (target posterior third of vein to prevent "tenting" of anterior wall)
• When flashback seen, advance needle 2mm further, then advance catheter off needle while visualizing on USS
• Confirm intraluminal position: Compress vein around catheter (should partially collapse), inject 2-3 mL saline under USS (turbulent flow in lumen, no extravasation)

---

D) Immediate management of suspected noradrenaline extravasation: (4 marks)

1. STOP noradrenaline infusion immediately (1 mark)
2. DO NOT remove catheter yet - Aspirate 5-10 mL residual drug through catheter to minimize tissue exposure (1 mark)
3. Administer phentolamine (α-adrenergic blocker antidote): 5-10 mg diluted in 10 mL 0.9% NaCl, inject subcutaneously in 5 sites around extravasation area (reverses α1-mediated vasoconstriction, prevents tissue ischemia). Optimal if given within 60 minutes. (1 mark)
4. Remove catheter after antidote administration, photograph affected area, mark borders with pen (track progression), elevate limb, apply cold compress (15-20 min every 4-6h × 24-48h), consult plastic surgery if blistering or area >5cm, and establish alternative IV access (preferably central venous catheter for ongoing vasopressor requirement). (1 mark)

---

SAQ 2: PIVC Complications and Evidence-Based Practice

Question (20 marks)

You are the ICU consultant reviewing hospital policies for peripheral intravenous catheter (PIVC) management.

A) Define phlebitis and outline the three types of phlebitis with one example of each. (5 marks)

B) Describe the VIP (Visual Infusion Phlebitis) Score system, including the scoring criteria and actions required for scores 0, 2, and 5. (6 marks)

C) Summarize the evidence for routine replacement of PIVCs every 72-96 hours versus clinically-indicated replacement, including the key findings of the Cochrane 2019 review. (6 marks)

D) List three (3) recommendations from the ACSQHC (Australian Commission on Safety and Quality in Health Care) Management of PIVC Clinical Care Standard 2021 to reduce catheter-related infections. (3 marks)

---

Model Answer

A) Phlebitis definition and three types: (5 marks - 1 mark definition, 4 marks for types)

Definition: Phlebitis is inflammation of the vein wall associated with a peripheral intravenous catheter, characterized by pain, redness, swelling, and in severe cases, palpable venous cord. (1 mark)

Three Types:

1. Mechanical Phlebitis (60-70% of cases) - Caused by catheter trauma to vein endothelium. Examples: Catheter too large for vein lumen (catheter:vein ratio >45%), insertion site at joint (elbow/wrist), excessive catheter movement. (1.5 marks)

2. Chemical Phlebitis (20-30%) - Caused by irritant properties of infusate. Examples: Extreme pH solutions (vancomycin pH 2.5-4.5, phenytoin pH 12), high osmolality fluids (TPN 900-1200 mOsm/L, >600 mOsm/L threshold), prolonged continuous infusion >24h. (1.5 marks)

3. Bacterial Phlebitis (5-10%) - Caused by microbial contamination. Examples: Skin flora introduced during insertion (Staphylococcus epidermidis, S. aureus), hub contamination from inadequate aseptic technique, leading to catheter-related bloodstream infection (CRBSI) 0.5-2.6 per 1000 catheter-days. (1 mark)

---

B) VIP Score system: (6 marks - 3 marks criteria, 3 marks for actions at scores 0, 2, 5)

VIP Score Criteria (3 marks)

Actions Required (3 marks - 1 mark each score)

• Score 0: No action required, continue routine monitoring every 8-12 hours (every shift)

• Score 2 (Early phlebitis): Remove cannula immediately, apply warm compress, elevate limb, consider topical NSAIDs (diclofenac gel). Resite at different location if IV therapy still required.

• Score 5 (Thrombophlebitis/sepsis): Remove cannula immediately, send catheter tip for semi-quantitative culture (roll-plate method), draw blood cultures × 2 sets from peripheral sites (before antibiotics), commence empirical IV antibiotics if sepsis criteria met (vancomycin 25-30 mg/kg loading + piperacillin-tazobactam 4.5g 6-hourly to cover MRSA and Gram-negatives), ultrasound Doppler to assess thrombus extent, consider anticoagulation if extensive thrombophlebitis.

---

C) Evidence for routine vs clinically-indicated PIVC replacement: (6 marks)

Historical Practice: Routine replacement every 72-96 hours was recommended based on early studies suggesting increased infection risk beyond this timeframe. (1 mark)

Cochrane 2019 Systematic Review (Webster et al., PMID: 30695087) - Most authoritative evidence (2 marks):

• Included: 7 randomized controlled trials, >7,000 patients
• Compared: Clinically-indicated replacement (remove only when signs of complications, malfunction, or no longer needed) vs routine replacement every 72-96 hours
• Key Findings:
  • "CRBSI: No significant difference (RR 0.97, 95% CI 0.84-1.12, moderate-certainty evidence)"
  • "Phlebitis: No significant difference (RR 1.00, 95% CI 0.84-1.18, high-certainty evidence)"
  • "Cost: Clinically-indicated replacement significantly cheaper (fewer catheters used, less nursing time, fewer painful procedures)"
  • "Patient satisfaction: Higher with clinically-indicated (fewer needle sticks)"

Current Recommendation (1 mark): Clinically-indicated replacement is now the gold standard (CDC 2011, ACSQHC 2021, ANZICS-CORE). Replace ONLY when:

• VIP score ≥2 (phlebitis)
• Catheter malfunction (occlusion, leaking)
• Catheter no longer required
• Suspected CRBSI

Caveat (1 mark): This applies to well-functioning catheters with healthy sites. Daily assessment (VIP score) is mandatory - do NOT leave catheter in situ without monitoring.

Mechanism for Safety (1 mark): No increase in infection because biofilm formation (primary infection mechanism) occurs within 24 hours of insertion, not progressively over days. If site remains healthy, prolonged dwell does not increase risk.

---

D) Three ACSQHC recommendations to reduce PIVC-related infections: (3 marks - 1 mark each)

1. Aseptic Non-Touch Technique (ANTT) for insertion and maintenance - Use 2% chlorhexidine gluconate in 70% alcohol for skin antisepsis (apply with friction for 30 seconds, allow to air dry 30 seconds before insertion). Use clean gloves for insertion.

2. "Scrub the Hub" before accessing device - Vigorously clean injection port with 70% isopropyl alcohol for minimum 15 seconds, allow to dry before accessing (reduces microbial contamination from hub, major source of CRBSI).

3. Transparent semi-permeable dressing - Allows continuous visualization of insertion site to detect early signs of infection (redness, purulent discharge), change dressing only if loose, soiled, or damp (unnecessary changes increase infection risk).

(Also accept: Clinically-indicated removal when no longer needed; hand hygiene before/after access; administration set changes every 96h for continuous infusions)

---

Hot Case Scenarios

Hot Case 1: DIVA in Septic Shock

Scenario

You are called to assess a 72-year-old man in the Emergency Department with urosepsis. He has a history of type 2 diabetes, chronic kidney disease (eGFR 25), and previous left forearm AV fistula (not currently used, thrombosed). Observations: BP 85/50, HR 115, RR 28, SpO₂ 92% on room air, temperature 38.9°C. The ED nurse reports three failed attempts at peripheral IV access (dorsal hand × 2, right forearm × 1). The patient is agitated and distressed.

Examiner Questions and Expected Discussion Points

1. What is your immediate management priority, and how will you establish vascular access?

Expected Answer:

• Immediate priority: Establish vascular access urgently for fluid resuscitation and antibiotics (septic shock, Sepsis-6 bundle)
• Approach:
  • "Step 1: Apply heat packs to both upper limbs (non-fistula arm preferred) for 5-10 minutes while preparing equipment - vasodilation may reveal previously non-visible veins"
  • "Step 2: Attempt ultrasound-guided peripheral access in right arm (avoid left due to thrombosed fistula):"
    • Target: Deep basilic vein (medial upper arm, 4-6mm diameter, 1.5-2.5cm depth)
    • Use long PIVC (5-8cm, 18-20G) to prevent dislodgement
    • Dynamic longitudinal approach - visualize entire needle path
  • "Step 3: If USS-PIVC fails or equipment unavailable, consider external jugular vein cannulation (large, superficial, success 85-90%)"
  • "Step 4: If still unsuccessful and patient deteriorating, place intraosseous (IO) access (proximal humerus or tibia) - allows immediate resuscitation while preparing for CVC insertion"
  • "Definitive: Once stabilized, consider central venous catheter (USS-guided internal jugular) if vasopressors required or prolonged therapy anticipated"

2. The patient is refusing further attempts, stating "no more needles." How do you approach this?

Expected Answer:

• Capacity assessment: Is patient able to understand information, retain it, weigh options, and communicate decision? (Agitation, sepsis, possible delirium - capacity may be impaired)
• Emergency situation: Life-threatening septic shock requires urgent intervention. If capacity is impaired (likely given agitation, sepsis), can proceed with treatment in patient's best interests (emergency doctrine, duty of care)
• Communication:
  • Explain urgency: "Mr. Smith, I understand you're frustrated. You have a serious infection and we need to give you antibiotics and fluids urgently to save your life."
  • Acknowledge distress: "I can see this has been difficult. We're going to use a different technique with ultrasound that has a much higher success rate."
  • "Involve support: Family member if present, nursing staff patient trusts"
  • "Minimize further trauma: One more attempt with USS (highest success), then escalate to IO/CVC (avoid repeated failed attempts)"
• Document: Capacity assessment, discussion, rationale for proceeding

3. You successfully insert an 18G peripheral cannula in the deep basilic vein using ultrasound. The patient requires noradrenaline. Is a peripheral line appropriate?

Expected Answer:

• Short-term peripheral noradrenaline is acceptable with caveats:
  • "Dose-dependent: Low-moderate dose (less than 0.2-0.3 mcg/kg/min) can be given peripherally short-term (PMID: 22024828)"
  • "Large vein: Deep basilic vein (4-6mm) is suitable - NOT small dorsal hand veins"
  • "Close monitoring: VIP score every 1-2 hours, alarm limits on infusion pump, educate nursing staff to report ANY pain/swelling immediately"
  • "Extravasation risk: Noradrenaline is a vesicant (α1-vasoconstriction → tissue ischemia, necrosis). Have phentolamine 10mg available at bedside."
  • "Time-limited: Use peripheral access to bridge to central line insertion (ideally within 2-4 hours)"
  • "Pragmatic: In septic shock, benefits of immediate vasopressor (restore perfusion) outweigh short-term risk if no alternative access available"
• Definitive: Place CVC (USS-guided IJ) once patient stabilized - safer for ongoing vasopressors, allows CVP monitoring

---

Hot Case 2: Phlebitis at PIVC Site

Scenario

You are reviewing a 55-year-old woman in ICU Day 3 post-emergency laparotomy for perforated diverticulitis. She has a 20G peripheral cannula in the right forearm inserted on admission, now 72 hours old. She reports pain at the IV site. Examination: 3cm area of erythema around insertion site, palpable vein cord extending 5cm proximally, no purulent discharge. Temperature 37.8°C (baseline 37.2°C), WCC 14 × 10⁹/L (down from 22 on admission), CRP 95 (down from 220).

Examiner Questions and Expected Discussion Points

1. What is your VIP Score assessment, and what action is required?

Expected Answer:

• VIP Score:

  • "Pain at IV site: ✓"
  • "Redness (erythema): ✓"
  • "Swelling: Not mentioned"
  • "Streak formation: Not mentioned (but palpable cord = advanced phlebitis)"
  • "Palpable venous cord: ✓"
  • "Pyrexia: No (37.8°C is low-grade, likely related to surgery/infection, not phlebitis per se)"
  • "Assessment: VIP Score 4 (Pain + redness + palpable cord = advanced stage phlebitis)"

• Immediate Action:

  • Remove cannula immediately (VIP score ≥2 is absolute indication)
  • Do NOT send catheter tip for culture routinely (low yield, not indicated unless suspicion of CRBSI - systemic signs, positive blood cultures, purulent discharge)
  • Apply warm compress (15-20 min every 4-6h), elevate arm
  • Topical NSAIDs (diclofenac gel) for symptomatic relief
  • Resite IV at different location (left arm) if ongoing therapy required

2. Should you investigate for catheter-related bloodstream infection (CRBSI)? What would change your threshold?

Expected Answer:

• Current scenario: CRBSI unlikely

  • Localized phlebitis (VIP 4) without systemic signs (no high fever >38.5°C, no rigors)
  • WCC and CRP are downtrending (consistent with resolving intra-abdominal sepsis)
  • No purulent discharge at site
  • "Diagnosis: Likely mechanical or chemical phlebitis (catheter at 72h, possible irritant medications, movement at site)"

• Do NOT routinely send catheter tip or draw blood cultures at this stage (low pre-test probability, high false-positive rate causing antibiotic overuse)

• Red flags that would change threshold and prompt CRBSI investigation:

  • Pyrexia >38.5°C or new fever spike after initial improvement
  • Purulent discharge from insertion site (high specificity for infection)
  • Positive blood cultures from another source with organism consistent with skin flora (S. aureus, S. epidermidis)
  • Sepsis that does not improve despite source control of intra-abdominal infection
  • Persistent bacteremia >72h after appropriate antibiotics (suggests intravascular source)

• If CRBSI suspected:

  • Remove catheter, send tip for semi-quantitative culture (roll-plate method, ≥15 CFU = significant)
  • Draw paired blood cultures (one from different peripheral site, one from catheter if multi-lumen) - differential time to positivity (DTTP ≥2h earlier from catheter = CRBSI)
  • Empirical antibiotics (vancomycin + piperacillin-tazobactam) if sepsis criteria met

3. The patient asks, "Why wasn't my cannula changed after 3 days like it usually is?" How do you respond?

Expected Answer:

• Acknowledge concern: "That's a good question. Guidelines for IV cannula care have changed based on recent evidence."

• Explain evidence-based practice:

  • "Previously, we replaced all cannulas routinely every 3 days (72-96 hours), thinking this prevented infection."
  • "Large research studies (Cochrane Review 2019, over 7,000 patients) showed that routine replacement does NOT reduce infection or phlebitis compared to replacing only when there's a problem."
  • "In fact, clinically-indicated replacement (replacing when needed, not on a schedule) is safer - fewer needle sticks, less pain, lower cost, and same infection risk."
  • "We check the IV site every shift (every 8-12 hours) using a scoring system. If any signs of problems develop - redness, pain, swelling - we remove it immediately."

• Explain what happened:

  • "In your case, the cannula developed phlebitis (inflammation of the vein), which is a recognized complication. This can happen at any time, not just after 3 days."
  • "The important thing is we caught it during our regular checks, and we're removing it now to prevent it getting worse."
  • "Phlebitis can be caused by the catheter rubbing on the vein (mechanical), irritating medications (chemical), or infection (bacterial). In your case, it's most likely mechanical or chemical given you've had antibiotics and strong pain medications running through it."

• Reassure and plan:

  • "We'll insert a new IV in your other arm. The phlebitis will settle down with warm compresses over the next few days."
  • "If you notice ANY pain, redness, or swelling at the new IV site, please tell the nursing staff immediately - we take this seriously."

---

Viva Scenarios

Viva 1: Applied Anatomy and Physiology

Examiner: "Describe the superficial venous anatomy of the upper limb relevant to peripheral IV access."

Expected Answer:

• Origin: Digital veins → dorsal metacarpal veins → dorsal venous arch (back of hand)
• Two major veins:
  1. Cephalic vein: Lateral (radial) side of forearm/arm, travels up deltopectoral groove → axillary vein
  2. Basilic vein: Medial (ulnar) side of forearm/arm, pierces deep fascia at mid-humerus → joins brachial veins → axillary vein
• Median cubital vein: Communication vein across antecubital fossa (ACF) connecting cephalic and basilic - most common venipuncture site (large, superficial, stabilized by bicipital aponeurosis)
• Valves: Bicuspid cusps prevent retrograde flow, more numerous distally (hand/wrist 1 per 2cm), fewer proximally (ACF/upper arm) - explains resistance during catheter advancement

Examiner: "Why is a 16G peripheral cannula better than a triple-lumen central venous catheter for rapid fluid resuscitation in trauma?"

Expected Answer:

• Poiseuille's Law: Flow rate ∝ (radius⁴) / length
• 16G peripheral IV:
  • "Internal diameter: 1.8mm"
  • "Length: 4.5 cm"
  • "Flow rate: ~180 mL/min (gravity-driven, water)"
• Triple-lumen CVC (each lumen):
  • "Internal diameter: ~1.5mm (16G equivalent)"
  • "Length: 15-20 cm (4× longer than peripheral)"
  • "Flow rate: ~45 mL/min per lumen = 135 mL/min total"
• Two 16G PIVs = 360 mL/min vs triple-lumen CVC = 135 mL/min
• ATLS Recommendation: Two large-bore peripheral IVs (14-16G) in antecubital fossae for trauma resuscitation
• Exception: If peripheral access impossible, use large-bore introducer sheath (Cordis 8.5F) - shorter, wider than standard CVC

Examiner: "What factors increase the risk of phlebitis?"

Expected Answer:

• Catheter factors:
  • Large gauge (14-16G) - more endothelial trauma
  • Long dwell time (>72-96h) - progressive endothelial damage
  • Insertion site at joint (elbow, wrist) - movement causes friction
  • Catheter material (Teflon > polyurethane in thrombogenicity)
• Infusate factors:
  • "Extreme pH (less than 5 or >9): vancomycin (pH 2.5-4.5), phenytoin (pH 12)"
  • "High osmolality (>600 mOsm/L): 10% dextrose, TPN (900-1200 mOsm/L)"
  • Particulate matter (drug incompatibilities, precipitation)
  • Vesicants (chemotherapy, vasopressors)
• Patient factors:
  • Female sex (smaller vein caliber)
  • Smoking (endothelial dysfunction)
  • Immunosuppression (higher bacterial phlebitis risk)
  • Previous phlebitis (damaged endothelium)
• Prevention: Smallest adequate gauge, dilute irritant drugs, forearm site (not ACF for long-term), clinically-indicated replacement

---

Viva 2: Evidence-Based Practice and Guidelines

Examiner: "What is the evidence for ultrasound-guided peripheral IV access in difficult access patients?"

Expected Answer:

• Cochrane 2013 meta-analysis (PMID: 23846447): USS reduces first-attempt failure RR 0.41 (95% CI 0.28-0.60) vs landmark technique in DIVA patients
• Heinrichs RCT 2013 (PMID: 24156914): Emergency department DIVA patients - USS 87% first-attempt success vs 33% standard (RR 2.61, 95% CI 1.60-4.26, pless than 0.001)
• Egan RCT 2013 (PMID: 23369563): 401 patients ED - USS 97% overall success vs 85% standard (p=0.003), fewer attempts (1.3 vs 2.1), faster time to success (10 vs 15 min)
• Indications: DIVA Score ≥2, ≥2 failed standard attempts, obesity (BMI >40), IVDU, chronic kidney disease, oncology patients
• Target vessels: Deep basilic vein (4-6mm, 1.5-2.5cm depth, mid-upper arm), deep brachial vein
• Catheter: Long PIVC (5-8cm) to prevent dislodgement from deep veins
• Learning curve: 25-50 supervised insertions for competence (PMID: 26475246)
• Cost-effectiveness: Reduces need for CVC (higher cost, complication risk), reduces delays in therapy

Examiner: "Should peripheral IV catheters be routinely replaced every 72-96 hours?"

Expected Answer:

• No - Current recommendation: Clinically-indicated replacement only (CDC 2011, ACSQHC 2021, ANZICS-CORE Statement 3.2)
• Cochrane 2019 Review (Webster et al., PMID: 30695087):
  • 7 RCTs, >7,000 patients
  • "CRBSI: No difference (RR 0.97, 95% CI 0.84-1.12, moderate-certainty evidence)"
  • "Phlebitis: No difference (RR 1.00, 95% CI 0.84-1.18, high-certainty evidence)"
  • "Cost: Clinically-indicated replacement saves money (fewer catheters, less nursing time)"
  • "Patient satisfaction: Higher (fewer painful needle sticks)"
• Rationale for safety: Biofilm forms within 24h of insertion, not progressively over days. If site healthy at 72h, risk does not increase with longer dwell.
• Essential caveat: Requires daily VIP score assessment (minimum every 8-12h). Remove immediately if VIP ≥2, malfunction, or no longer needed.
• Replace when:
  • VIP score ≥2 (phlebitis)
  • Catheter malfunction (occlusion, leaking)
  • Suspected CRBSI
  • No longer clinically required

Examiner: "Outline the ACSQHC 2021 Clinical Care Standard for PIVC management."

Expected Answer:

• ACSQHC = Australian Commission on Safety and Quality in Health Care
• Purpose: Reduce Staphylococcus aureus bacteraemia (SAB) and phlebitis from PIVCs
• 10 Quality Statements (key ones):
  1. Assess need: Only insert if clear indication (avoid if oral therapy possible)
  2. Aseptic technique: ANTT for insertion, 2% chlorhexidine/70% alcohol skin prep (30 sec application, 30 sec dry time)
  3. Site selection: Minimize infection/displacement risk (avoid flexion sites if long-term)
  4. Securement: Transparent semi-permeable dressing (allows site visualization)
  5. Assessment: VIP score every 8-12 hours (minimum every shift), document
  6. Hub access: "Scrub the hub"
• 70% alcohol for 15 seconds, allow to dry before accessing 7. Flushing: 0.9% NaCl before/after medication, pulsatile flush technique 8. Clinically-indicated removal: Remove when VIP ≥2, malfunction, or no longer needed (NOT routine time-based)
• Evidence base: Cochrane 2019 (clinically-indicated replacement), CDC 2011 (chlorhexidine skin prep), multiple RCTs (ANTT, hub disinfection)

---