Many patients admitted to hospital or receiving care in other settings, including home care, will receive intravenous (IV) therapy at some point (NHS Scotland, 2002; Royal College of Nursing (RCN), 2016; National Institute for Health and Care Excellence (NICE), 2017). These patients will require the insertion of a peripheral intravenous catheter or cannula (PIVC), or a central venous access device (CVAD) to facilitate the delivery of treatment.
An audit of 14 hospitals across 13 countries prompted Alexandrou et al (2015) to estimate that in 2015, globally, there were over 1 billion PIVC insertions. A subsequent international study by Alexandrou et al (2018) estimated that the majority of hospitalised patients worldwide would have at least one PIVC in place. In the case of the UK, Zhang et al (2016) determined that 1 in 3 patients would have at least one PIVC in situ. The NHS spends an estimated £29 million of its annual acute sector budget on PIVC procurement, with at least 25 million devices sold annually in the UK (NHS Clinical Evaluation Team, 2018; Stanley et al, 2020).
It has been suggested that PIVC insertion is one of the most common invasive procedures performed in hospital settings (Marsh et al, 2015; Barton, 2018; Blanco-Mavillard et al, 2019; Helm, 2019). Despite their prevalence, PIVCs are associated with phlebitis, infiltration, occlusion, dislodgements and catheter-related blood stream infection (CRBSI) (Alexandrou et al, 2015; 2018; Munoz-Mozas, 2021). PIVC complications and high failure rates are costly not only to patients and healthcare practitioners, but also to the healthcare system (Munoz-Mozas, 2022). This article focuses on the features, the evidence-based guidelines and the standards for the safe and effective use of PIVCs in clinical practice (RCN, 2016; Gorski et al, 2021).
A vascular access device (VAD) is inserted into either a vein or an artery, via the peripheral or central vessels, to provide access for diagnostic purposes, for example blood sampling or central venous pressure (CVP) reading, or for therapeutic purposes, such as the administration of medications, fluids and/or blood products.
Any medicine can potentially pose a threat to vessel health when administered intravenously. The risks associated with IV insertion include pH, osmolarity, viscosity, concentration, speed of infusion, vesicant or irritant properties and vasoactivity of the medication infusion (Hallam et al, 2021). Hence, there is a need to consider the intricate relationship between the physical properties of the solution being administered, the anticipated duration of the required therapy and the quality of the patient's veins (Jackson et al, 2013). Published best practice guidelines recommend avoiding PIVC and midlines for the infusion of the following preparations:
- Continuous vesicant systemic anticancer treatment (SACT)
- Parenteral nutrition (PN)
- Solutions that have osmolarity greater 900 mOsm/l (RCN, 2016; Gorski et al, 2021).
Furthermore, the Medusa Injectable Medicines Guide (Medusa, 2023) advises central IV administration of medicines with extreme pH (<5 and >9) after appropriate dilution. This is because these medicines may cause venous irritation and tissue damage in cases of extravasation.
Devices
Central venous access devices
CVADs are catheters whose tip terminates within the lower third of the superior vena cava (SVC) and the upper portion of the right atrium (RA), ideally in the proximity of the cavo-atrial junction (CAJ) (RCN 2016; Gorski et al, 2021; Munoz-Mozas et al, 2021). CVADs available in clinical practice include peripherally inserted central catheters (PICCs), non-tunnelled central venous catheters (CVCs), skin-tunnelled catheters (STCs) and implanted ports. Depending on the relevant anatomical considerations (eg chest or neck surgery, axillary lymph node dissection, upper limb deep vein thrombosis, vein stenosis etc), their physical characteristics, advantages, disadvantages and clinical guidance, the healthcare practitioner may consider that one CVAD is better suited to a particular patient's needs over another. Table 1 provides a comprehensive range of available VADs allowing healthcare practitioners to select a device based on a patient's therapy and quality-of-life needs (RCN, 2016; Gorski et al, 2021).
Table 1. Type of vascular access devices (VADs) and their main characteristics
| Device | Material | Features | Common insertion site (veins) | Recommended indwelling life and common uses |
|---|---|---|---|---|
| Peripheral intravenous catheter or cannula (PIVC) |
|
|
|
|
| Midline catheter |
|
|
|
|
| Peripherally inserted central catheter (PICC) |
|
|
|
|
| Short-term percutaneous central venous catheter (non-tunnelled CVC) |
|
|
|
|
| Skin-tunnelled catheter (STCs) |
|
|
|
|
| Implanted ports | Catheter
|
|
|
|
Port body
|
|
Adapted from: The Royal Marsden Manual of Clinical Nursing Procedures (Lister et al, 2021)
Peripheral intravenous catheter or cannula
The UK Vessel Health and Preservation (VHP) Framework (Hallam et al, 2021) advises that clinicians apply a multifactorial assessment approach to vascular access that takes into consideration the (chemical) properties of the intended medication, the condition of a patient's peripheral veins and expected duration of treatment. If the required medication is suitable for peripheral administration and the anticipated duration of treatment is less than 1 week, a PIVC will be considered appropriate, as long as a peripheral veins assessment identifies that the patient's veins are suitable (Hallam et al, 2021).
A PIVC is a short, flexible tube containing a needle (stylet) that may be inserted into a blood vessel (Dougherty, 2008; RCN, 2016; Forsyth et al, 2019). PIVCs are VADs that are intended to be used for short periods, ie days, and are usually placed in the peripheral veins in the lower arm; they may also be placed in the veins of the foot, particularly when used with paediatric patients (Weinstein and Hagle, 2014). However, the veins in the lower extremities should not be used routinely in adult patients due to the risk of embolism and thrombophlebitis (RCN, 2016; Gorski et al, 2021).
The ‘over-the-needle’ type of cannula is the most commonly used PIVC for peripheral venous access. It is available in various gauge sizes, lengths and materials, and devices differ in their design features. For use with adult patients, these PIVCs range in size from the smallest (blue, 22 G) to the largest (orange, 14 G); for paediatric patients and adults with fragile veins an even smaller PIVC can be used (yellow, 24 G) (Table 2). Most of the literature and guidelines recommend using the smallest gauge possible in any given situation (RCN, 2016; Bitmead and Oliver, 2018; Gorski et al, 2021; Frank, 2023) as the placement of a large-bore PIVC is known to increase the incidence of malfunction that leads to failure (Alexandrou et al, 2018).
Table 2. Example of gauge sizes and average flow rates, using water
| Gauge (G) | Flow rate (ml/min) | General uses |
|---|---|---|
| 14 | 350–250 | In theatres and emergencies for rapid large-volume fluid replacement (transfusion of blood, viscous fluids) |
| 16 | 215–180 | Trauma, major surgery, gastrointestinal bleeds, high-volume fluids |
| 18 | 104–90 | Blood products, irritant medications, arterial phase contrast studies, stem cell harvesting and cell separation, and large volumes of fluids |
| 20 | 60 | General use, maintenance volumes of fluids, intravenous antibiotics and most medications |
| 22 | 36 | As 20 G in smaller veins |
| 24 | 24 | Medications, short-term infusions, fragile veins and children |
NB: Flow rates will differ between peripheral intravenous catheter from different manufacturers
A smaller gauge PIVC will minimise trauma to the vein and increase blood flow around the device, promoting dilution and reducing the risk of mechanical phlebitis (Bitmead and Oliver, 2018; Munoz-Mozas et al, 2021). The walls of the PIVC should therefore be thin to provide the largest possible internal diameter and ensure maximum flow rates, while reducing irritation. Flow rate through a PIVC is related to its internal diameter and is inversely proportional to its length (Munoz-Mozas et al, 2021). Flow rate will vary between devices available from different manufacturers (Table 2).
Most PIVCs are made of polyvinyl chloride (PVC), Teflon, Vialon and various polyurethane and elastomeric hydrogel materials: they are non-irritant and do not increase the risk of thrombus formation, and in addition have radiopaque properties (Bitmead and Oliver, 2018; Munoz-Mozas et al, 2021). PIVCs can be winged or non-winged, ported or non-ported. Wings can help to secure the device in situ to prevent dislodgment and mechanical phlebitis, while ported PIVCs allow drug administration without interfering with an ongoing continuous infusion and are favoured for emergency situations and anaesthesia during surgery (for example, if a patient has an IV solution being delivered (eg, propofol during surgery), another IV drug could be administered through the port in the PIVC without having to disconnect the continuous infusion) (Mörgeli et al, 2022). Most clinical guidelines (RCN 2016; Gorski et al, 2021) recommend the use of PIVCs with a safety mechanism, either active or passive, that minimises the risk of needlestick injury during insertion.
PIVCs can be inserted under direct vision and palpation; however, the use of ultrasound is helpful in cases of difficult cannulation (eg difficult intravenous access (DIVA)) (Forsyth et al, 2019).
Safetouch
Nipro's Safetouch Cath Winged with Injection Port is a sterile, single-use catheter with a safety device for IV infusion and has been available through NHS Supply Chain since March 2023. Its features include:
- Irreversible, passive safety mechanism
- Audible click to confirm locking of safety device
- Radiopaque
- Ultra sharp three-bevelled needle to minimize discomfort
- Siliconisation of needle minimizes penetration and gliding force
- Flexible wings for easy grip
- Colour-coded wings and hub to indicate gauge
- Transparent polyurethane catheter tube for quick visualization of blood in the flashback
- Chamber to facilitate insertion
- Flashback in hub means the needle is correctly in the vein
- Flashback in catheter means the catheter is correctly in the vein
- Not made with latex, di-2-ethylhexyl phthalate (DEHP) or PVC
- Available in 16-24 G
- IV infusion duration: hours to several days.
The step-by-step guide to PIVC insertion (using Nipro Safetouch Cath Winged with Injection Port) (Figure 1) illustrates the procedure for PIVC insertion in accordance with best evidence-based guidelines. To ensure successful placement of a PIVC and vessel health preservation, it is essential to undertake a proactive patient assessment and to identify the best device for the patient's needs and physical characteristics, and to take into account the duration and type of IV therapy required (Bitmead and Oliver, 2018; Munoz-Mozas et al, 2021; Hallam et al 2021).
Case studies
Nipro's Safetouch Cath Winged with Injection Port is a cost-effective, safety ported PIVC with wings (Figure 2). The IV port facilitates a simultaneous bolus infusion if required, while its wings allow for better device securement to prevent accidental dislodgment. Another beneficial feature of this PIVC is the safety mechanism: this automatically activates on stylet removal, shielding the needle tip to minimise the risk of needlestick injury.
Case study 1. Adjuvant therapy
Sally Barton (not her real name) is a 43-year-old patient receiving adjuvant bisphosphonate (zolodronic acid) for breast cancer, which was administered via a 22 G (0.8x25 mm) Safetouch Cath Winged with Injection Port.
Patient information
Sally, a full-time mother of two young sons, was diagnosed in the winter of 2021 following attendance at a one-stop breast clinic. She had noticed a lump in her right breast the week before her appointment. Following mammography and ultrasound-guided biopsies during the clinic visit, she was diagnosed with grade 2 invasive ductal carcinoma. Her case was discussed at the next weekly breast multidisciplinary team (MDT) meeting, where it is was recommended that she be advised to undergo wide local excision (WLE) and sentinel lymph-node biopsy (SLNB).
Subsequent histology confirmed invasive ductal carcinoma, with one of four lymph nodes biopsied containing micrometastic disease. Sally's oncotype DX recurrence score was 37, predicting a distant recurrence risk of 29%. The recommendation of the breast MDT was that Sally should receive adjuvant systemic anti-cancer therapy (SACT) involving epirubicin, cyclophosphamide and paclitaxel. This should be followed by radiotherapy, and administration of zolondronic acid and tamoxifen.
To facilitate the administration of the SACT, which involved vesicant cytotoxic drugs, Sally had an implantable injection port placed. When the SACT was completed at the end of 6 months, Sally was keen to have the port removed, which she viewed as a constant reminder of her treatment. She was aware that she would require an intravenous infusion of zolondronic acid every 6 months for 3 years, but was happy to have this administered via a peripheral intravenous cannula.
Product used
In May 2023, Sally attended the oncology day unit for a third infusion of zolondronic acid. A 22 G Safetouch ported cannula was placed in her left median vein, and was inserted with ease. The integral sharps protection device was automatically activated as the stylet was withdrawn. The cannula was flushed with 0.9% sodium chloride and a sterile, needle free injection hub was applied to the cannula.
As the infusion would take about 30 minutes in total, the cannula was secured with a dedicated sterile, transparent film IV dressing (Figure 2b). When the medication had been checked against Sally's prescription and her identity confirmed, the infusion was commenced.
Results
Sally reported that the cannula and cannulation process did not cause undue discomfort. The nurse inserting the cannula found the device straightforward to place and easy to secure. The infusion was completed uneventfully and Sally was able to leave the department without any visual reminders of her treatment over the summer/autumn.
Her fourth zolondronic acid infusion is due just before Christmas 2023.
Case study 2. Blood transfusion for anaemia
Doreen Brown (not her real name) is 90 years old and has chronic anaemia of unknown cause, and she depends on blood transfusions. Her most recent transfusion of one unit was facilitated by the placement of a 22 G (0.8x25 mm) Safetouch Cath Winged with Injection Port.
Patient information
Doreen was diagnosed with metastatic breast cancer more than 5 years previously but, apart from this, she is relatively fit and lives independently. Her metastatic breast cancer is stable, as confirmed by recent PET scan images, and is managed with fulvestrant, a hormone treatment, and palbociclib, a targeted cancer therapy, both of which she tolerates well.
In early 2021, Doreen's routine blood tests showed iron deficiency anaemia: she had a haemoglobin level of 70 g/l. Faecal occult bloods were positive. She experienced no change in bowel habit. Her weight was stable. Doreen was advised to undergo a colonoscopy and gastroscopy to help identify a cause for her anaemia following assessment by a gastroenterologist. She declined both investigations, citing her age as the reason for refusal. She also declined a bone marrow trephine biopsy.
Her iron and vitamin B12 levels were corrected through vitamin B12 injections and oral iron supplementation. However, the anaemia persisted, and it is being managed with regular blood transfusions.
Product used
When Doreen attends for blood transfusions, a cannula is inserted. Her right arm is avoided because she had a mastectomy when she was in her late seventies and had a full axillary lymph node dissection. Taking her age into consideration, Doreen has a reduction in connective tissue, as well as dry, ‘papery’ skin, which makes her a challenge to cannulate.
For Doreen's most recent blood transfusion, a Safetouch 22 G cannula was placed in her left basilic vein. The cannula was sited with ease, the stylet withdrawn activating the automatic needle protection sheath, and the cannula connected to the 0.9% sodium chloride infusion. No swelling was observed around the cannulation site when the infusion was commenced, and Doreen did not report any discomfort. The cannula was secured using a sterile, transparent dedicated IV dressing.
Results
Doreen's transfusion passed uneventfully. At the conclusion of the transfusion, the giving set was flushed with 0.9% sodium chloride and the cannula removed. Her son who accompanied her on this occasion was able to drive his mother home on discharge.
Case study 3: managing sepsis
Sonia Walker (not her real name) is a 77-year-old patient who has metastatic breast cancer involving multiple vertebrae. She presented with cellulitis of her left arm when she attended for a routine blood test for cytotoxic chemotherapy. She required blood samples as part of the sepsis screening tool. The Sepsis Six (Daniels and Nutbeam, 2022) screening tool was applied, indicating the need for a series of blood tests. As sepsis was suspected following initial screening, IV antibiotics and IV fluids were administered. These were facilitated by the placement of a 22 G (0.8 x 25 mm) Safetouch ported cannula.
Patient information
Sonia was diagnosed with invasive ductal cancer in her left breast in 2007, presenting with bone metastases in 2018 after 11 years of disease-free remission. Her original treatment involved wide local excision, axillary lymph node clearance, followed by postoperative cytotoxic chemotherapy and radiotherapy. She subsequently developed mild lymphoedema in her left arm.
Her breast disease is currently being managed with capecitabine (oral cytotoxic chemotherapy).
Sonia presented on a Monday morning for a routine blood test and assessment prior to dispensing her next cycle of capecitabine. She complained of feeling generally unwell and that her left arm was hot, painful and itchy. Her temperature was 38.1°C, blood pressure was 130/60 mmHg, pulse 100 beats per minute and blood oxygen saturation was 97%. Sepsis was suspected.
Product used
To facilitate the Sepsis Six screening tool, a cannula was cited in Sonia's right basilic vein. This allowed bloods to be taken for the following:
- Blood cultures
- Blood glucose level
- Lactate levels
- Full blood count
- Urea and electrolytes
- C-reactive protein level
- Clotting factor.
The same cannula was used to administer IV antibiotics as per the sepsis protocol, followed by 500 ml IV infusion of 0.9% sodium chloride. She also received 1 g of paracetamol orally.
Results
One hour later Sonia's blood results were available, including her lactate levels, which were >2.0 mmol/l. She had a score of 0, according to the National Early Warning Score (NEWS, version 1) (Royal College of Physicians, 2012). Following discussion with the consultant, Sonia was discharged home with oral antibiotics and advice on how to contact the hospital if she had any concerns before her planned follow-up the following day. Her cannula was removed uneventfully, having facilitated blood sampling, IV antibiotics and fluids.
Conclusion
The selection of the right vascular access device for IV drug administration, taking into consideration the type and anticipated length of therapy, in addition to a patient's other associated factors, such as quality of peripheral veins, lifestyle and clinical setting, remains key for the safe administration of IV therapy. IV therapy administered via peripheral veins is deemed safe and appropriate, and PIVCs remain widely used in clinical practice.
This article has discussed the features, the evidence-based guidelines and standards for the safe and effective use of PIVCs in clinical practice. The step-by-step guide to PIVC insertion and the case studies provided illustrate how the Nipro Safetouch winged PIVC can be used safely and with excellent results in clinical practice.
KEY POINTS
- Vascular access continues to be a key factor for the reliable and safe delivery of intravenous (IV) therapy to patients in any healthcare setting
- The right vascular access device selection is essential for reducing avoidable complications, while improving efficiency and reducing costs
- Peripheral intravenous cannulas (PIVCs), when appropriate and clinically indicated, remain widely used for gaining vascular access in all clinical settings, with both adults and children, because they provide a relatively cheap and simple way to provide blood sampling and the prompt administration of IV medications
- Nipro's Safetouch Cath Winged with Injection Port, which is available from NHS Supply Chain, is a cost-effective choice of PIVC
CPD reflective questions
- Are PIVCs always indicated and safe to use in your clinical practice?
- Do you apply the principles of the UK Vessel Health and Preservation (VHP) Framework (eg consideration of the (chemical) properties of the intended medication, the condition of a patient's peripheral veins and expected duration of treatment) to help you decide what vascular access device is most suitable for the administration of necessary IV therapy?
- How can you identify the best vascular access device for patient's needs within your clinical practice?