Intravenous therapy: a guide

to good practice
Katie Scales

n Severity of the patient’s illness

n Urgency with which the medicinal effect is needed
Abstract n Part of the body to be treated
This article provides an overview of the principles of good practice n Patient’s general health, e.g. their ability to take oral
that underpin intravenous (IV) therapy. The indications for choosing medications (Henry, 2004).
the IV route and selecting an appropriate vascular access device When the oral route is not available, alternative routes
(VAD) are explained. Common insertion sites for VAD placement should be considered before selecting the IV route,
and the care and management of VADs are reviewed. Infection e.g. nasogastric or subcutaneous administration. The
control aspects of IV therapy are be highlighted, including the intramuscular route is also possible but may be associated
management of IV equipment and the importance of the nurse’s role with a level of discomfort that is unacceptable to patients.
in the prevention of infection associated with IV therapy. Common Some drugs cannot be given orally because the molecules
complications of IV therapy are explained and strategies suggested are too large to be absorbed (Whittington, 2008) or because
for their prevention. The article addresses the issues associated with they are destroyed by digestion. The IV route achieves an
general IV therapy, it does not address specialist subjects such as immediate effect that can be titrated against the patient’s
parenteral nutrition, chemotherapy or blood transfusion. clinical condition.
The licensed used of the medication should also be
Key words: Dressings n Infection control n Intravenous devices n considered when selecting the route of administration.
Intravenous therapy n Vascular access Nurses should understand the indications for IV
administration, and when a route of lower risk becomes
available this should be discussed with the medical team.
ntravenous (IV) therapy is an integral part of modern

I medicine and is practised in virtually every healthcare

setting, from critical care to the community. The
majority of IV drugs are administered by nurses, who
are increasingly involved in the insertion of peripheral and
central vascular access devices (VADs). The widespread
Vascular access devices (VADs)
Once the indication for IV administration has been justified
the correct device must be used to administer the prescribed
therapy. VADs broadly fall into three main categories:
n Peripheral cannulae
use of IV therapy can lead to complacency about the risks n Midline catheters
(Weinstein and Lawrence, 2006) and may result in poor n Central VADs (Gabriel, 2008a).
standards of practice, putting patients at risk of clinical harm Nurses must understand the care and management of the
and making nurses vulnerable to a claim of negligence. devices used in their practice area.
This article presents an overview of general IV therapy and
provides an opportunity for nurses to benchmark their IV Peripheral cannulae
practice against the recommendations made. These are short devices, less than 7.5 cm long, placed in a
peripheral vein (RCN, 2005). In general there are three types
Indications for IV therapy of peripheral device:
IV therapy carries a range of risk, from phlebitis to death n Straight (non-ported, non-winged)
(Gabriel, 2008a). The IV route should only be used when no n Winged
other route is available (Royal College of Nursing [RCN]/ n Ported and winged.
British Medical Association [BMA], 1993). The route of drug Peripheral devices are available in a range of gauge
administration depends on the: sizes and lengths. Many incorporate safety features for
sharps injury prevention, and the use of a safety cannula is
recommended (RCN, 2005). The smallest gauge and shortest
Katie Scales is Consultant Nurse Critical Care, Anaesthetics Department, length of cannula should be selected for the prescribed
Imperial College Healthcare NHS Trust, Charing Cross Hospital, London therapy (RCN, 2005). Emergency situations, such as trauma
or haemorrhage, require short, large-bore cannulae, e.g. 14 g
Accepted for publication: September 2008 for rapid administration of fluids and blood (Scales 2008);
hydration fluids and antibiotics can be delivered through
much smaller cannulae, e.g. 20 g or 22 g. Smaller cannulae are

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 IV THERAPY

less likely to cause mechanical phlebitis (irritation of the vein

wall by the cannula) and are less likely to obstruct blood flow Box 1. Good practice in peripheral cannula management
within the vein (Tagalakis et al, 2002).
Good blood flow past the cannula helps disperse injected • Select a vein that is not over a joint and use the smallest cannula for the therapy
drugs and reduces the risk of chemical phlebitis (irritation • Use safety cannulae to prevent needlestick injury
of the vein wall by chemicals). Chemical phlebitis is more • Clean skin with 2% chlorhexidine in 70% isopropyl alcohol and allow to dry
likely to occur with irritant or vesicant drugs. An irritant before cannulation
is a drug with an extreme pH (< 5 or > 9) or extreme • Stabilize the cannula before covering with a transparent intravenous (IV) dressing
osmolarity (> 600 mOsmol/litre) (Infusion Nurses Society • Monitor the IV site using a phlebitis scoring tool
[INS], 2006). A vesicant is a drug which causes blistering • Decontaminate the device before giving medications or manipulating IV equipment
and necrosis if the drug leaks out of the vein into the • Change peripheral cannulae every 72 hours or earlier if there are signs of phlebitis
tissues (RCN, 205). • The peripheral administration of irritants and continuous vesicant chemotherapy
Therapies not appropriate for peripheral administration should be avoided
include continuous vesicant chemotherapy and drugs that • Remove when no longer required
are classified as irritants (RCN, 2005). Nurses should know Adapted from: Royal College of Nursing (2005)
the risks associated with the medications that they administer
(Nursing and Midwifery Council, 2008), this includes
checking the pH and osmolarity and ensuring that drugs are Removal
administered via the appropriate route. Cannulae should not Peripheral cannulae should be removed or replaced at
be placed over joints (i.e. wrist or elbow) as the movement of 72 hours (Department of Health [DH] 2003; 2007; RCN,
the joint may produce mechanical phlebitis and increase the 2005). Peripheral cannulae inserted in emergency situations,
risk of the cannula kinking (Gabriel, 2008a). However, the where the level of asepsis cannot be guaranteed, should be
use of a large vein in the antecubital fossa may be appropriate removed within 24 hours of insertion (RCN, 2005). See
in emergency situations as the veins are easy to visualize and Box 1 for good practice in peripheral cannula management.
palpate (Scales, 2008). Phlebitis scoring should be used to
monitor the cannula site and vein (RCN, 2005). Midline catheters
These are increasing in popularity as their benefits begin
Insertion to be recognized. Adult midline catheters are usually made
Non-sterile gloves should be worn for cannulation (RCN, of silicone or polyurethane and may be single or double
2005). Two per cent chlorhexidine in 70% isopropyl alcohol lumen, they are flexible and 7.5–20 cm in length (INS,
is recommended for skin cleansing prior to cannulation 2006). Midline catheters are inserted just above or just below
(RCN, 2005; Pratt et al, 2007) unless the patient is known the antecubital fossa (inner aspect of the elbow) and the tip
to have an allergy to chlorhexidine, in which case 70% of the catheter should not extend beyond the axillary vein
alcohol may be used. Prefilled skin cleansing devices (Gabriel, 2008a). The advantage of a midline catheter is
are available, e.g. ChloraPrep® 1.5 ml Frepp applicator
(Cardinal Health, Surrey). Once the skin has been cleaned
it should not be re-palpated (RCN, 2005).

Device stabilization
The cannula should be stabilized before applying the
dressing. The VAD insertion site provides direct access to Tape
the circulation, and anything in contact with the insertion Cannula
site must be sterile (RCN, 2005). Cannulae can be stabilized
with tape or with purpose designed stabilization devices
e.g. StatLock® (Bard, West Sussex) or CliniFix® (CliniMed,
Buckinghamshire). Moureau and Iannucci (2003) reviewed
a number of studies and found that stabilization devices
reduced cannula dislodgement by 67%, and reduced
cannula complications by 50%. The vein entry site should
remain visible to allow assessment of the site (Figure 1).

Dressings
The device should be covered with a sterile, transparent,
moisture-permeable dressing, such as Tegaderm™ (3M
Bracknell) or IV3000® (Smith & Nephew, Hull). The
dressing can remain in situ until the cannula is changed
at 72 hours, providing the dressing is intact, clean and dry
(RCN, 2005). Dressing changes require an aseptic non-
touch technique. Figure 1. Peripheral cannnula secured with tape. Insertion site visible.

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 that the large veins of the upper arm have good blood flow recorded (RCN, 2005) to ensure that the device is changed
which rapidly disperses the injected fluids or drugs reducing or removed appropriately. Non-tunnelled devices may be
the risk of chemical phlebitis. electively changed by rewiring the device, providing there is
The insertion of a midline catheter is a sterile procedure no clinical evidence of infection (Pratt et al, 2007). If infection
(Dougherty, 2008) and is usually undertaken by nurses with is suspected a new insertion site should be identified.
additional specialist training. Although the optimal dwell
time for a midline catheter is unknown (RCN, 2005), Tunnelled devices
midlines can remain in situ longer than a peripheral cannula, These are selected for long-term IV therapy (Gabriel, 2008a).
typically 4 weeks (Dougherty, 2008). Midline catheters have The devices may be single- or multi-lumen and are usually
fewer complications than central venous devices and are made from silastic (a silicone elastomer) or polyurethane.
suitable for both hospital and community use. When midline In tunnelled devices the skin insertion site is usually several
catheters are removed the catheter should be checked to centimetres away from the vein insertion site, which reduces
ensure it is intact; if the catheter has fractured a medical the risk of bacteria entering the blood from the skin entry
officer must be informed immediately (RCN, 2005). site – this helps to reduce the risk of CRBSI.
Tunnelled devices (Figure 2) may be open-ended or may
Central venous access device (CVAD) contain a valve at the distal end. In open-ended CVADs
CVAD is the term used to describe any VAD where the tip blood may reflux into the lumen of the device causing
terminates in a central vein. CVADs are classified as: thrombus and device occlusion; the use of a valve prevents
n Non-tunnelled devices blood reflux, e.g. Groshong® catheters, whereby the valve
n Tunnelled devices open with the positive pressure of an infusion, or the
n Implantable ports negative pressure of aspiration, and in the absence of pressure
n Peripherally inserted central catheters (PICCs). remains closed (Gabriel, 2008b). Tunnelled catheters usually
CVADs allow the delivery of drugs and fluids into a fast- incorporate a subcutaneous Dacron® cuff 3–5 cm away from
flowing central circulation, reducing the risk of chemical the skin entry site (Green, 2008). The Dacron cuff causes
phlebitis and ensuring rapid distribution and immediate fibrosis within the skin tunnel, which anchors the catheter
clinical effect. While there are some clear advantages to the preventing dislodgement; it also acts as a barrier preventing
use of a CVAD there are also some recognized and potentially bacterial migration along the path of the catheter to the vein
life-threatening complications (RCN, 2005; Scales, 2008): (Green, 2008). The Dacron cuff may take 21 days to become
n Air embolism secure, until then the device must be secured to prevent
n Haemorrhage dislodgement (RCN, 2005).
n Thrombosis Tunnelled devices carry an added risk of tunnel infection
n Pneumothorax. and nurses should report any signs of infection, inflammation
Nurses should be familiar with these potential complications or pain in the region of the subcutaneous tunnel.
and should have the skills to prevent them where possible.
Nurses must be able to recognize the signs of complications Implantable ports
to ensure prompt treatment should complications occur These are small reservoirs surgically implanted under the skin,
(RCN, 2005). usually on the chest wall, and secured to muscle to stabilize it
(Gabriel, 2008b). A catheter is connected to the reservoir and
Non-tunnelled devices tunnelled to a more distal entry site in a central vein. Ports
These are usually selected for short-term use in acute care may be single- or double-lumen and the catheter may be
settings (Gabriel, 2008a). Devices may be single- or multi- valved or open-ended. To administer drugs/fluids the reservoir
lumen (up to five lumens) and incorporate integral extension is palpated and a ‘Huber’ needle (non-coring) is used to
sets. The most common insertion sites are the internal jugular puncture the silastic membrane on top of the port (Figure 3).
and the subclavian veins; the femoral vein may also be used Extravasation, which is defined as the inadvertent infiltration
though this is not a true central venous catheter and cannot of vesicant fluids or medication into the surrounding tissues
be used to record central venous pressure (Scales, 2008). (RCN, 2005), is possible if the tip of the needle is not correctly
Femoral devices are associated with an increased risk of placed into the reservoir (Gabriel, 2008b).
infection (Pratt et al, 2007) due to their location in the groin.
In non-tunnelled devices the skin puncture site and vein Peripherally inserted central catheter (PICC)
puncture site are adjacent. Should the device or the entry PICC is the term given to a catheter that is inserted in
site become infected there is significant risk that septicaemia a peripheral vein – usually the antecubital fossa – and
will occur – this is termed catheter-related bloodstream advanced until the catheter tip lies within a central vein.
infection (CRBSI) (Pratt et al, 2007). Consequently, non- PICCs may be single, double or triple lumen and are
tunnelled devices are intended for short term use, usually available in a range of gauge sizes (Gabriel, 2008a). PICCs
5-10 days; however, routine replacement of CVADs is not may be used for the administration of vesicant and irritant
recommended as a strategy to prevent catheter-related drugs, and may remain in situ for many months; the
infection (Pratt et al, 2007). maximum dwell time is unknown.
It is important to monitor the insertion site and to report For all CVAD insertions the skin should be cleaned
any redness or discharge, and the date of insertion should be with 2% chlorhexidine in 70% alcohol and allowed to

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 Figure 2. Tunnelled catheter. Note that skin insertion site is away from vein insertion site. Methods of intravenous administration
Drugs may be administered intravenously using bolus
injection, intermittent infusion or continuous infusion. Most
Superior vena cava drugs can be given centrally or peripherally but may require
Vein entry site different dilution and varying administration times depending
on the route that is chosen.
Subcutaneous
tunnel Bolus injection
This generates a high blood concentration and allows
Dacron cuff the administration of medicines without fluid overload
(Lavery and Ingram, 2008). Bolus injection is associated
with an increased risk of chemical phlebitis as concentrated
medication is injected. In the UK the majority of bolus
Skin entry site injections are prepared in the clinical area and care is needed
to ensure aseptic drug preparation. Bolus injections must be
given rapidly over a short period of time (RCN, 2005) at the
correct speed – usually 3–5 minutes.

Intermittent infusions
These are given over several minutes to several hours, the
principle being that the infusion stops and is restarted later.
Many intermittent infusions are prepared in the clinical area
and strict asepsis is essential. Intermittent infusion is used for
dry – unless the patient has an allergy to chlorhexidine, drugs that require dilution or slow administration, and can be
in which case single patient use povidone iodine solution administered with an infusion pump or by gravity with drop
may be used (Pratt et al, 2007). Once the CVAD has been control. Wherever possible, pre-mixed infusion fluids should
inserted it must be secured. Securement devices, such as be used, and adding drugs to infusion fluids should be avoided
StatLock and CliniFix, are gaining popularity as increasing to reduce the potential for contamination and also to reduce
evidence links sutures with catheter infection (Maki and the risk of error associated with drug preparation (National
Crnich, 2002). The skin should be cleaned and dried and a Patient Safety Agency [NPSA], 2007).
sterile transparent moisture permeable dressing applied. The
dressing should be replaced if loose, wet or soiled (Pratt et Continuous infusion
al, 2007). The dressing and the CVAD insertion site should Continuous infusion ensures a constant blood concentration
be visually inspected prior to drug administration or at least of the drug being administered; therefore, the effect of the
once per shift. drug should be constant (Lavery and Ingram, 2008). This is
the most common method of administration for IV fluids
and parenteral nutrition, and for the administration of drugs
that have a short half-life, i.e. inotropes and vasodilators.
Continuous drug infusions are given through an infusion
Surface of skin pump. The type of pump may vary depending on the
Non-coring needle risks of the drug being infused, and the Medicines and
Re-sealable septum Healthcare products Regulatory Agency (2003) guidance
on infusion pumps should be followed. IV fluids may be
given by infusion pump or gravity with drop control. If the
gravity method is used nurses must check the progress of
Reservoir of port Catheter the infusion regularly to ensure the fluids run to time (Scales
and Pilsworth, 2008).

Administration sets
The correct administration set should be used for the product
Sutures Vein entry being infused, and all sets should have a Luer-Lok design
securing device site (RCN, 2005). Blood and fresh frozen plasma should be
to underlying
muscle administered through a blood transfusion set containing a
200 micron filter to remove microaggregates. Platelets may be
Large vein
administered through a platelet set or a blood transfusion set.
Blood sets should be changed 12 hourly (RCN, 2005).
Clear fluids should be administered through a solution
set incorporating a 5–15 micron filter to remove particles
Figure 3. Implanted port in a subcutaneous pocket, accessed by a Huber needle. generated during the manufacturing process. Solution sets

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 are used for the administration of crystalloid solutions, Manipulation of a peripheral cannula should be kept to
e.g. 0.9% sodium chloride, Hartman’s solution, human a minimum to prevent mechanical phlebitis (Dougherty,
albumin, gelofusine and pre-prepared medications such as 2008). The use of a short extension set can help to
metronidazole and paracetamol. Solution sets should be reduce cannula movement as drug administration and
changed every 72 hours provided the set is continuously administration set changes take place away from the cannula
connected to the patient and providing the medication entry site (RCN, 2005).
it contains is stable (RCN, 2005). If the set is used for A 3-way tap or a multi-way connector may be required
an intermittent infusion, and is disconnected, it must be if several infusions are administered simultaneously, e.g.
discarded (RCN, 2005). Lipid solutions should be infused an intermittent infusion of antibiotics and a continuous
through a set with a 1.2 micron filter and the set should be infusion of maintenance fluids. If this treatment regimen is
changed every 24 hours (RCN, 2005). anticipated, the connector should be attached at the time of
Extension sets are used to connect a syringe pump to a cannula insertion and should remain in situ until the cannula
VAD, they do not routinely contain filters and consideration is removed at 72 hours (RCN, 2005). Connectors used on
should be given to the use of filter needles when preparing CVADs should be changed every 72 hours. Labelling IV
the medications to be infused (RCN, 2005). Extension sets equipment with the date and time ensures that equipment
should be changed every 72 hours providing the infusion can be changed appropriately (RCN, 2005).
is stable. Needleless devices have gained in popularity over the last
decade and have two main advantages:
Add-on devices n They allow medication administration without the use of a
This term covers a range of infusion equipment, including needle, reducing the risk of needlestick injury
needleless devices, bungs, 3-way taps, stopcocks, short n They ensure that the patient’s IV system remains closed.
extensions, filters, injectable hubs and multi-way connectors A closed system is an important principle of infection
(RCN, 2005). All add-on devices should be Luer-Lok design control in IV therapy. There are two main routes through
for safety. The majority of add-on devices should not be used which VADs can become infected:
routinely and should only be selected if they are required n The intraluminal route – the inside of the VAD and the
(DH, 2003). Each additional piece of equipment in an fluid pathway to the patient
infusion system is a portal of entry for infection, connections n The extraluminal route – the cutaneous tract from the skin
should be kept to a minimum (RCN, 2005; INS, 2006). entry site to the vein entry site.
Nurses are key to the prevention of CRBSI because
they are the main professional group who administer IV
Box 2. Good practice to reduce infection medications, change IV administration sets and perform IV
in intravenous (IV) therapy dressings. The VAD and any connections attached to it will
become colonized with microorganisms from the patient’s
skin or from the hands of healthcare professionals. It is
• Wash hands, wear a new pair of non-sterile disposable gloves and use an
essential that the VAD is thoroughly decontaminated prior
aseptic non-touch technique for all aspects of IV therapy, including preparation,
to use. Decontamination may be achieved through the use
administration and site care
of a large sterile wipe impregnated with 2% chlorhexidine in
• Prepare IV fluids and drugs in a designated clean area
70% isopropyl alcohol, and if this is not available the device
• Use pre-mixed solutions and avoid additives to fluid bags if possible should be cleaned with 70% isopropyl alcohol (Pratt et al,
• Ensure all IV fluid containers are labeled with the date and time they are opened, 2007). If alcohol is not compatible with the IV device then
discard within 24 hours an aqueous solution of chlorhexidine or iodine may be used
• Ensure all IV administration sets are labeled with the date and time and change (Pratt et al, 2007). The device must be cleaned for several
them appropriately: solution sets – change at 72 hours; blood sets – change at seconds, using friction to dislodge any microorganisms. The
12 hours; lipid-containing solutions – change at 24 hours device should then be left to dry before it is used.
• Administration sets that are disconnected should be discarded When blind hubs are used in IV therapy they have to
be removed in order to attach administration sets or give
• Add-on devices should be kept to a minimum and changed as recommended by
the manufacturer. In general, 3-way taps should be changed every 72 hours, bungs
medications; this opens the IV system and exposes the
(single use, or change at 72 hours if not removed from device), and needleless intraluminal pathway. This method of IV administration
devices should be changed according to manufacturers’ instructions. carries the highest risk of infection. By using a needleless
device instead of a blind hub the end of the needless
• Needleless devices should replace the use of bungs to maintain a closed IV system
device can be decontaminated and medications administered
• All administration ports should be thoroughly decontaminated with 2%
without exposing the intraluminal pathway. Blind hubs are
chlorhexidine in 70% alcohol and allowed to dry prior to use; they should also
single-use items; if a blind hub is removed from an IV system
be cleaned after use.
it must be disposed of and not re-used.
• IV dressings should be replaced when loose, wet or soiled It is important to follow the manufacturer’s guidance on
• Central VAD insertion sites should be inspected twice a day and any signs of needleless devices. Licensed use varies from 3–7 days and
infection should be reported the number of device activations (number of times the
• VADs should be removed when no longer required mechanism within the device can be depressed/used) varies
from 100–600 activations depending on the specific device.

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 Needleless devices placed on peripheral cannulae at the CVAD the exit site should be cleaned and dressed with an
time of insertion can usually be left in situ for the life of the occlusive dressing to prevent air embolism, and the dressing
cannula, providing the cannula is changed at 72 hours. If a should be left in situ for 72 hours (Scales, 2008).
needleless device is used on a CVAD the device can be left
in situ for as long as it is licensed. Nurses must ensure that Conclusion
there are systems in place to ensure the needleless device is Nurses are increasingly responsible for most aspects of IV
changed appropriately. This can be difficult when patients therapy. IV devices provide direct entry for microorganisms
have multiple VADs with multiple needless devices, for into the bloodstream, and infection related to IV devices is an
example in critical care units. By selecting a 7-day needleless important cause of morbidity and mortality (Maki and
device with a high activation record (i.e. >200 activations) Crnich, 2002). Good practice in IV therapy is vital and nurses
it should be possible to develop practice within the clinical have a key role in the prevention of infection associated with
area that ensures safety. A needless device record may be IV devices. Nurses must understand why their patients have
required, or alternatively nursing management in the clinical IV devices, and when the device is no longer needed should
area may pragmatically decide to change all needleless devices ensure that it is removed. Meticulous attention to asepsis is
on CVADs on a specific day of the week to ensure that they essential in all aspects of IV care, and nurses should have a
are not left in situ more than 7 days. Good practice to reduce greater awareness of the part that they play in the prevention
infection risks of IV therapy are listed in Box 2. of CRBSI. The range and depth of knowledge required by an
There is no evidence to support the routine use of individual nurse will depend upon the scope of their
additional filters in IV therapy (RCN, 2005), and their use individual practice (Scales, 2008). BJN

should be restricted to specific particle filtration for named

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