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INTRAVENOUS CANNULATION Introduction

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

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

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

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

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

Contraindications No absolute contraindications to intravenous cannulation exist. Peripheral venous access in an injured, infected, or burned extremity should be avoided if possible. Some vesicant and irritant solutions (pH < 5, pH >9, or osmolarity >600m Osm/L) can cause blistering and tissue necrosis if they leak into the tissue, including sclerosing solutions, some chemotherapeutic agents, and vasopressors. These solutions are more safely infused into a central vein. They should only be given through a peripheral vein in emergency situations or when a central venous access is not readily available.

Periprocedural Care Equipment Equipment for intravenous cannulation includes the following: Nonsterile gloves Tourniquet Antiseptic solution (2% chlorhexidine in 70% isopropyl alcohol) Local anesthetic solution 1-ml syringe with a 30-G needle 2 2 gauze Venous access device Vacuum collection tubes and adaptor (see image below) Saline or heparin lock Saline or heparin solution

Transparent dressing Paper tape

Equipment for intravenous cannulation is shown in the images below.

Some of the equipment required for intravenous cannulation

Some of the equipment required for intravenous cannulation.

Vacuum collection tubes and adaptor for intravenous cannulation.

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

Make sure the patient is in a comfortable position and place a pillow or a rolled towel under the patients extended arm. The patients skin should be washed with soap and water if visibly dirty. Periprocedural and Postprocedural Complications Complications may include the following: Pain Failure to access the vein Blood stops flowing into the flashback chamber Difficulty advancing the catheter over the needle and into the vein Difficulty flushing after the catheter was placed in a vein Arterial puncture Thrombophlebitis Peripheral nerve palsy Compartment syndrome Skin and soft tissue necrosis

For pain, use of an anesthetic cream 30 minutes prior to insertion attempt and/or subcutaneous infiltration of an anesthetic solution should be used prior to peripheral intravenous insertion whenever possible. Collapse of the vein, inadequate skin traction, incorrect positioning, and incorrect angle of penetration can all lead to a failed attempt at accessing the vein. In this case, either attempt insertion at a different site or, if you believe that the selected vein should be accessible, withdraw the venous access device to just beneath the skin and reattempt to insert.

If blood stops flowing into the flashback chamber, vein collapse, venospasm, needle hub position against a venous valve, or penetration of the posterior wall of the vein might be the cause. Observation of a developing hematoma will necessitate removal of the catheter. In this case, release and then reapply the venous tourniquet and attempt to gently stroke the vein to engorge it with blood and release venospasm. Finally, attempt to withdraw the needle a few millimeters to move it away from a valve. Failure to release the catheter from the needle before insertion, encountering a venous valve, removing the needle too far with the catheter being too soft to advance into the vein, poor skin traction, or venous collapse can all be the cause of difficulty advancing the catheter over the needle and into the vein. In this case, release the tourniquet and then reapply it to help engorge the vein. Connect a syringe with normal saline (0.9%) solution to the hub, then attempt to float the device in place by flushing the catheter and advancing it at the same time. Difficulty flushing after the catheter was placed in a vein can be caused by the catheter tip position against a venous wall or a valve, blood clot, or piercing of the venous wall. Observation of a hematoma will necessitate removal of the catheter. In this case, withdraw the catheter slightly to release it from a wall/valve and attempt to flush it back in. In the case of arterial puncture, palpate the vein carefully before attempting to insert a venous access device to ensure that there is no palpable pulse in the vessel. If an accidental arterial puncture occurred, as evidenced by arterial pulsation of blood out of the catheter, remove the catheter and apply direct pressure using gauze for at least 10 minutes.

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

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

ntravenous sites for intravenous cannulation

Intravenous site for intravenous cannulation.

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

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

Application of antiseptic solution for intravenous cannulation. While the skin is allowed to dry, flush the saline or heparin lock with the appropriate solution. The syringe may be left attached to the tubing, as shown in the image below.

Flushing of intravenous tubing with normal saline for intravenous cannulation. Unless in an emergent situation, if the patient is interested in local anesthesia, infiltrate 0.5-1 ml of a local anesthetic using a 25- or 30-G needle to raise a wheal at the site of catheter insertion, as shown in the image below.

Subcutaneous injection of a local anesthetic for intravenous cannulation. Stabilize the vein using your nondominant hand (thumb) to apply traction to the skin distal to the chosen site of insertion, as shown in the image below. This will prevent superficial veins from rolling away from the needle. Stabilization should be maintained throughout the procedure.

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

Angle of insertion with bevel up for intravenous cannulation. Upon entry into the vein, the practitioner might feel a giving way sensation. Blood should appears in the chamber of the venous access device (ie, flashback), as shown in the image below.

Flashback of blood into the venous access device for intravenous cannulation. The angle of the venous access device should be reduced to prevent puncturing the posterior wall of the vein. It should be advanced gently and smoothly an additional 2-3 mm into the vein. If no blood is observed in the flashback chamber, the device should be withdrawn to just beneath the skin level and another attempt to recatheterize the

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

Sliding the hub of the catheter over the needle and into the vein for intravenous cannulation. Use your nondominant middle finger to apply pressure over the catheter to prevent blood spill and hold the hub in place using your nondominant index and thumb fingers. Then use your dominant hand to withdraw the needle, as shown in the image below.

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

Using the blood sampling adaptor for intravenous cannulation. Release the tourniquet.

While applying pressure to the catheter to prevent blood spillage and while continuously stabilizing the hub and wings to the skin as described before, disconnect the blood sampling adaptor or syringe and securely attach the preflushed saline or heparin lock to the hub of the venous access device. Secure the venous access device to the skin using the transparent dressing and tape, as shown in the image below.

Securing a saline lock with a transparent dressing for intravenous cannulation. Using the saline or heparin flush syringe, withdraw a small amount of blood to verify that the catheter is still inside the vein. Immediately flush the tubing with the remainder solution. Slide the plastic tubing lock and continue to lock the tubing (if such a lock is available), as shown in the images below.

Flushing and locking the venous access device for intravenous cannulation. Finish securing the tubing to the skin using tape. Place a label indicating date, time, and other facility-specific required information over the transparent dressing, as shown in the image below.

Labeling for intravenous cannulation. An intravenous cannulation is shown in the video below. Video of intravenous cannulation. Video courtesy of Gil Z Shlamovitz, MD. Removal of peripheral intravenous catheters can be performed as clinically indicated and they should not be routinely replaced on a fixed schedule.[13]

Intravenous Catheter Removal Stop infusion solution and disconnect tubing leaving just the saline/heparin lock tubing connected to the venous access device. Release the adhesive tape and transparent dressing from the skin.

Withdraw the catheter outside of the vein, as shown in the image below, and apply direct pressure with gauze for at least 5 minutes.

Intravenous catheter removal. Inspect the catheter for fragmentation. Document in the patients chart the date, time, and reason for catheter removal and the integrity of the catheter as inspected. Place a 2 2 gauze pad or a cotton ball with a paper tape over the intravenous insertion site. Instruct the patient to continue manual pressure for 10 more minutes in order to minimize hematoma formation.

Intravenous therapy
Intravenous therapy or IV therapyis the infusion of liquid substances directly into a vein. The wordintravenous simply means "within avein". Therapies administered intravenously are often calledspecialty pharmaceuticals. It is commonly referred to as a dripbecause many systems of administration employ a drip chamber, which prevents air from entering the blood stream (air embolism), and allows an estimation of flow rate. Intravenous therapy may be used to correct electrolyte imbalances, to deliver medications, for blood transfusion or as fluid replacement to correct, for

example, dehydration. Intravenous therapy can also be used for chemotherapy (The treatment for any kind of cancer.) Compared with other routes of administration, the intravenous route is the fastest way to deliver fluids and medications throughout the body Infused substances Substances that may be infused intravenously include volume expanders, blood based products, blood substitutes, medications, nutrition. Volume expanders There are two main types of volume expander; crystalloids and colloids. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. Colloids contain larger insoluble molecules, such as gelatin.Blood is a colloid. Colloids preserve a high colloid osmotic pressure in the blood, while, on the other hand, this parameter is decreased by crystalloids due to hemodilution.[1] However, there is still controversy with regard to the actual

difference in efficacy between colloids and crystalloids.[1] Crystalloids generally are much cheaper than colloids.[1] The most commonly used crystalloid fluid is normal saline, a solution ofsodium chloride at 0.9% concentration, which is close to the concentration in the blood (isotonic). Lactated Ringer's (also known as Ringer's lactate) and the closely related Ringer's acetate, are mildly hypotonic solutions often used for large-volume fluid replacement.

Blood-based products A blood product (or blood-based product) is any component of blood which is collected from a donor for use in a blood transfusion. Blood transfusions can be life-saving in some situations, such as massive blood loss due to trauma, or can be used to replace blood lost during surgery. Blood transfusions may also be used to treat a severe anaemia or thrombocytopenia caused by a blood disease. People with hemophilia usually need a replacement of clotting factor, which is a small part of whole blood. People with sickle-cell disease may require frequent blood transfusions. Early blood transfusions consisted of whole blood, but modern medical practice commonly uses only components of the blood, such as fresh frozen plasma or cryoprecipitate.

Blood substitutes Blood substitutes (also called artificial blood or blood surrogates) are artificial substances aiming to provide an alternative to blood-based products acquired from donors.

The main blood substitutes used today are volume expanders such as crystalloids and colloids mentioned above. Also, oxygen-carrying substitutes are emerging.

Buffer solutions Buffer solutions are used to correct acidosis or alkalosis. Lactated Ringer's solution also has some buffering effect. A solution more specifically used for buffering purpose is intravenous sodium bicarbonate.

Other medications Medications may be mixed into the fluids mentioned above. Certain types of medications can only be given intravenously, such as when there is insufficient uptake by other routes of administration such as enterally. Examples includeintravenous immunoglobulin and propofol.

Other Parenteral nutrition is feeding a person intravenously, bypassing the usual process of eating and digestion. The person receives nutritional formulas containing salts, glucose, amino acids, lipids and added vitamins. Drug injection used for recreational substances usually enters by the intravenous route.

Intravenous access devices

These can all be used to obtain blood (e.g. for testing), also known asphlebotomy as well as for the administration of medication/fluids.

Hypodermic needle The simplest form of intravenous access is by passing a

hollow needle through the skin directly into the vein. This needle can be connected directly to a syringe (used either to withdraw blood or deliver its contents into the bloodstream) or may be connected to a length of tubing and thence whichever collection or infusion system is desired. The most convenient site is often the arm, especially the veins on the back of the hand, or the median cubital vein at the elbow, but any identifiable vein can be used. Often it is necessary to use a tourniquet which restricts the venous drainage of the limb and makes the vein bulge. Once the needle is in place, it is common to draw back slightly on the syringe to aspirate blood, thus verifying that the needle is really in a vein. The tourniquet should be removed before injecting to prevent extravasation of the medication.

Peripheral cannula

20 gauge peripheral IV in hand

A nurse inserting a 18-gauge IV needle with cannula.

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intravenous

access IV line

method (PVC

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both hospitals andpre-hospital services.

A peripheral

PIV) consists of a short catheter (a few centimeters long) inserted through the skin into aperipheral vein (any vein not inside the chest or abdomen). This is usually in

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form

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a cannula-over-needle

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flexible

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

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

Central IV lines Central IV lines flow through a catheter with its tip within a large vein, usually thesuperior vena cava or inferior vena cava, or within the right atrium of the heart. This has several advantages over a peripheral IV:

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

Peripherally inserted central catheter PICC lines are used when intravenous access is required over a prolonged period of time or when the material to be infused would cause quick damage and early failure of a peripheral IV and when a conventional central line may be too

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

left in place for months to years if needed for patients who require extended treatment. The chief disadvantage is that it must be inserted and then travel through a relatively small peripheral vein which can take a less predictable course on the way to the superior vena cava and is therefore somewhat more time consuming and more technically difficult to place in some patients. Also, as a PICC travels through the axilla, it can become kinked causing poor function.

Central venous lines There are several types of catheters that take a more direct route into central veins. These are collectively called central venous lines. In the simplest type of central venous access, a catheter is inserted into asubclavian, internal jugular, or (less commonly) a femoral vein and advanced toward the heart until it reaches the superior vena cava or right atrium. Because all of these veins are larger than peripheral veins there is greater blood flow past the tip of the catheter meaning irritant drugs are more rapidly diluted with less chance of extravasation. It is commonly believed that fluid can be pushed faster through a central venous catheter but as they are often divided into multiple lumens then the internal diameter is less than that of a large -bore peripheral cannula. They are also longer, which as reflected in Poiseuille's law, requires higher pressure to achieve the same flow, all other variables being equal.

Tunnelled Lines

Another type of central line, called a Hickman line or Broviac catheter, is inserted into the target vein and then "tunneled" under the skin to emerge a short distance away. This reduces the risk of infection, since bacteria from the skin surface are not able to travel directly into the vein; these catheters are also made of materials that resist infection and clotting.

Implantable ports A port (often referred to by brand names such as Port-a-Cath or MediPort) is a central venous line that does not have an external connector; instead, it has a small reservoir that is covered with silicone rubber and is implanted under the skin. Medication is administered intermittently by placing a small needle through the skin, piercing the silicone, into the reservoir. When the needle is withdrawn the reservoir cover reseals itself. The cover can accept hundreds of needle sticks during its lifetime. It is possible to leave the ports in the patient's body for years; if this is done however, the port must be accessed monthly and flushed with an anti coagulant, or the patient risks it getting plugged up. If it is plugged it becomes a hazard as a thrombus will eventually form with an accompanying risk of embolisation. Removal of a port is usually a simple outpatient procedure; however, installation is more complex and a good implant is fairly dependent on the skill of the radiologist. Ports cause less inconvenience and have a lower risk of infection than PICCs, and are therefore commonly used for patients on long -term intermittent treatment.

Other equipment

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

inflatable cuff placed around the fluid bag to force the fluid into the patient or a similar electrical device that may also heat the fluid being infused.

Intermittent infusion Intermittent infusion is used when a patient requires medications only at certain times, and does not require additional fluid. It can use the same techniques as an intravenous drip (pump or gravity drip), but after the complete dose of medication has been given, the tubing is disconnected from the IV access device. Some medications are also given by IV push or bolus, meaning that a syringe is connected to the IV access device and the medication is injected directly (slowly, if it might irritate the vein or cause a too-rapid effect). Once a medicine has been injected into the fluid stream of the IV tubing there must be some means of ensuring that it gets from the tubing to the patient. Usually this is accomplished by allowing the fluid stream to flow normally and thereby carry the medicine into the bloodstream; however, a second fluid injection is sometimes used, a "flush", following the injection to push the medicine into the bloodstream more quickly.

Adverse effects Infection Any break in the skin carries a risk of infection. Although IV insertion is an aseptic procedure, skin-dwelling organisms such as Coagulase-negative staphylococcus or Candida albicans may enter through the insertion site around the catheter, or bacteria may be accidentally introduced inside the catheter from

contaminated equipment. Moisture introduced to unprotected IV sites through washing or bathing substantially increases the infection risks. Infection of IV sites is usually local, causing easily visible swelling, redness, and fever. If bacteria do not remain in one area but spread through the bloodstream, the infection is called septicemia and can be rapid and life-threatening. An infected central IV poses a higher risk of septicemia, as it can deliver bacteria directly into the central circulation.

Phlebitis Phlebitis is inflammation of a vein that may be caused by infection, the mere presence of a foreign body (the IV catheter) or the fluids or medication being given. Symptoms are warmth, swelling, pain, and redness around the vein. The IV device must be removed and if necessary re-inserted into another extremity. Due to frequent injections and recurring phlebitis, scar tissue can build up along the vein. The peripheral veins of intravenous drug addicts, and of cancer patients undergoing chemotherapy, become sclerotic and difficult to access over time, sometimes forming a hard, painful venous cord.

Infiltration / Extravasation Infiltration occurs when an IV fluid or medication accidentally enters the surrounding tissue rather than the vein. This occurs more frequently withchemotherapeutic agents and people who have tuberculosis It is also known as extravasation (which refers to something escaping the vein). It may occur when the vein itself ruptures (the elderly are particularly prone to fragile veins due to a

paucity of supporting tissues), where the vein is damaged during insertion of the intravascular access device or the device is not sited correctly or where the entry point of the device into the vein becomes the path of least resistance (e.g. if a cannula is in a vein for some time, the vein may scar and close and the only way for fluid to leave is along the outside of the cannula where it enters the vein). It is characterized by coolness and pallor to the skin as well as localized swelling or edema. It is usually not painful. It is treated by removing the intravenous access device and elevating the affected limb so that the collected fluids can drain away. Sometimes injections of hyaluronidase can be used to speed the dispersal of the fluid/drug. Infiltration is one of the most common adverse effects of IV therapy[and is usually not serious unless the infiltrated fluid is a medication damaging to the surrounding tissue, in which case extensive necrosis can occur.

Fluid overload This occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete. Possible consequences include hypertension,heart failure, and pulmonary edema.

Hypothermia The human body is at risk of accidentally induced hypothermia when large amounts of cold fluids are infused. Rapid temperature changes in the heart may precipitate ventricular fibrillation.

Electrolyte imbalance

Administering a too-dilute or too-concentrated solution can disrupt the patient's balance of (sodium) (potassium) (magnesium), and other electrolytes. Hospital patients usually receive blood tests to monitor these levels.

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

History

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