7.4 Peripheral Venous Catheters, IV Therapy & the PVC Care Bundle
Key Takeaways
- RCSI lists Peripheral Venous Catheter (PVC) and associated procedures as a topic heading covering priming IV tubing, changing IV fluids and tubing, scrub the hub, the fluid balance chart, IV line infection and the PVC insertion and maintenance care bundle, and IV is one of its photographed OSCE equipment categories.
- Scrub the hub means vigorously disinfecting the needle-free connector with an alcohol-based antiseptic and allowing it to dry fully before every access.
- A PVC care bundle combines aseptic non-touch insertion, a documented clinical indication, a secure transparent dressing allowing visual inspection, daily documented site assessment using a visual infusion phlebitis score, and prompt removal when no longer needed.
- Phlebitis presents as pain, erythema, swelling, a palpable venous cord and warmth, and any sign of phlebitis, infiltration or extravasation requires the device to be stopped and removed immediately.
- Priming the administration set expels all air before connection, and the fluid balance chart must record every intravenous volume given as well as oral intake and all output.
Peripheral Venous Catheters, IV Therapy & the PVC Care Bundle
RCSI devotes a whole topic heading to Peripheral Venous Catheter (PVC) and associated procedures, listing priming IV tubing and changing IV fluids and tubing, scrub the hub, the fluid balance chart, a sample IV bag, IV line infection and the PVC insertion and maintenance care bundle. IV is also one of the equipment categories RCSI photographs for the OSCEs.
A peripheral cannula is the commonest invasive device in a hospital and one of the most frequently mismanaged. It is a direct breach of the skin's defences into the bloodstream, and treating it as trivial is how Staphylococcus aureus bacteraemia happens.
Before You Cannulate: Is It Indicated?
Every PVC needs a documented clinical indication. "In case we need it" is not one. The commonest source of avoidable line infection and phlebitis is the cannula that was inserted for a single dose of antibiotics four days ago and has been sitting idle ever since.
Ask at every ward round and every shift: is this device still needed, and is it still being used? If not, remove it.
Aseptic Insertion
- Check the indication, gain informed consent, and explain the procedure.
- Assess the veins. Prefer the non-dominant arm, the forearm over the hand or antecubital fossa (flexion at a joint shortens dwell time and increases phlebitis), and avoid limbs with lymphoedema, an arteriovenous fistula, recent axillary surgery, paralysis, infection, or existing phlebitis.
- Select the smallest gauge that will deliver the required therapy - a larger cannula in a small vein causes turbulent flow, endothelial trauma and phlebitis.
- Gather equipment and clean the trolley; perform hand hygiene and apply gloves and apron.
- Apply a tourniquet, palpate the vein, then decontaminate the skin with 2% chlorhexidine in 70% isopropyl alcohol for the time local policy specifies, and allow it to dry completely. The drying time is the antisepsis - wiping it dry or cannulating through wet skin defeats the whole step.
- Do not re-palpate the cleaned site. If you must, the site has to be cleaned again.
- Insert using aseptic non-touch technique, protecting the key parts - the cannula tip, the hub, the connector and the syringe tip.
- Release the tourniquet, advance and secure, attach a needle-free connector, and flush with sterile 0.9% sodium chloride to confirm patency, watching for swelling, pain or resistance.
- Dispose of the sharp immediately into the sharps container at the point of use - never re-sheath, never pass it to someone else, never leave it on the trolley.
- Apply a sterile transparent semi-permeable dressing so that the insertion site remains visible at all times, and secure the extension set so tension is not transmitted to the cannula.
- Document: date, time, site, gauge, number of attempts, who inserted it, and the dressing applied. Many units use a cannula care sticker or chart for this.
The PVC Insertion and Maintenance Care Bundle
A care bundle is a small set of evidence-based practices which, performed together and every time, produce better outcomes than any one alone. Compliance is measured as all-or-nothing: doing four of five elements scores zero for that bundle.
Insertion bundle elements
| Element | Requirement |
|---|---|
| Indication | A documented clinical reason for the device |
| Hand hygiene | Performed immediately before the procedure |
| Skin antisepsis | 2% chlorhexidine in 70% alcohol, applied correctly and allowed to dry |
| Aseptic technique | ANTT maintained; key parts protected throughout |
| Dressing | Sterile, transparent, intact, site visible |
| Documentation | Date, time, site, gauge, inserter |
Maintenance bundle elements
| Element | Requirement |
|---|---|
| Daily review of need | Documented decision that the device is still required |
| Site assessment | Inspected and scored at least daily using a visual infusion phlebitis (VIP) score, and before each use |
| Dressing integrity | Clean, dry, intact and adherent; changed if loose, wet or soiled |
| Scrub the hub | Before every access |
| Flush | Sterile 0.9% sodium chloride before and after use to maintain patency |
| Administration sets | Changed at the intervals local policy specifies, and labelled with the date |
| Prompt removal | As soon as the device is no longer needed, or immediately if any complication appears |
Scrub the Hub
Scrub the hub is the practice of disinfecting the needle-free connector before every single access.
- Use an alcohol-based antiseptic wipe - commonly 2% chlorhexidine in 70% alcohol.
- Scrub vigorously with friction for the time local policy specifies - frequently cited as around 15 seconds - covering the top and the sides of the connector.
- Allow it to dry completely before connecting. Drying is not a delay; it is when the disinfection happens.
- Repeat before every subsequent access, including every flush, every drug and every reconnection.
The connector is the key part that touches the bloodstream. An unscrubbed hub delivers whatever has colonised it directly into the vein.
Priming and Changing the Administration Set
Priming fills the administration set with fluid and expels all air before connection.
- Check the prescription: patient, fluid, volume, additives, rate and duration, and the prescriber's signature. Check the patient's allergies and identity.
- Inspect the fluid bag: correct fluid and strength, expiry date, clarity, absence of particles, and intact packaging and ports.
- Perform hand hygiene, clean the trolley, and work aseptically, protecting the spike and the connector as key parts.
- Close the roller clamp, remove the port cover, insert the spike fully without touching it, and hang the bag.
- Squeeze the drip chamber to about one third to one half full - too full and you cannot count the drops, too empty and air enters the line.
- Open the roller clamp slowly and let fluid run through to the end, expelling all air, including from any injection ports and side arms; tap gently to release trapped bubbles.
- Close the clamp, keep the end sterile and capped until connection.
- Label the set with the date and time it was hung, and set the rate or programme the volumetric pump.
- Record the fluid on the fluid balance chart and check the site before and after connection.
Changing fluids and tubing: change bags before they run dry; change administration sets at the intervals local policy specifies, with shorter intervals for blood and blood products and for lipid-containing infusions. Never top up or re-spike a partly used bag with a new one.
Calculating a gravity drip rate, where no pump is used:
drops per minute = (volume in mL x drop factor in drops per mL) ÷ time in minutes
For example, 1000 mL over 8 hours using a standard set with a drop factor of 20 drops/mL: (1000 x 20) ÷ 480 = 41.7, so approximately 42 drops per minute.
Complications
| Complication | Signs | Action |
|---|---|---|
| Phlebitis | Pain or tenderness, erythema tracking along the vein, swelling, warmth, a palpable hard venous cord, purulence in severe cases | Stop the infusion and remove the cannula immediately. Apply a warm compress, elevate, document the VIP score, escalate, and re-site in a different limb where possible |
| Infiltration | Swelling, coolness, tightness, leakage, blanching, sluggish or absent flow, pain | Stop and remove; elevate the limb; monitor. Non-vesicant fluid has entered the tissue |
| Extravasation | As above but with a vesicant drug - severe pain, burning, blistering, and potential tissue necrosis | Medical emergency. Stop immediately, do not remove the cannula yet - aspirate what you can through it first - escalate urgently, follow the local extravasation policy and antidote protocol, mark the area, photograph if policy allows, and document as an incident |
| Occlusion | Resistance to flushing, alarms, no flow | Never force a flush - a clot can be embolised. Check for kinks and clamps; remove if occluded |
| Haematoma | Bruising and swelling at or around the site | Pressure, elevation, document; particular caution in anticoagulated patients |
| Local or bloodstream infection | Redness, purulence, tenderness, plus fever, rigors and a rising INEWS with no other source | Remove the device, send the tip for culture where policy directs, take blood cultures, screen for sepsis and escalate immediately |
Air embolism is rare but catastrophic: it is prevented by proper priming, secure connections and never allowing a bag to run dry.
Fluid Balance Charting
RCSI lists the fluid balance chart among the documents candidates must be able to complete and interpret.
- Record every input: oral fluids, intravenous fluids and flushes, medication volumes, enteral feed and flushes, blood products.
- Record every output: urine, vomit and aspirate, drains, stoma, diarrhoea, and estimate significant losses such as heavy wound exudate and sweating during fever.
- Total the chart at the agreed times and calculate the running balance. An untotalled chart is a chart nobody has used.
- Interpret the trend, not a single day. A cumulative positive balance with peripheral oedema, rising weight, breathlessness and basal crackles suggests overload; a cumulative negative balance with oliguria, tachycardia, hypotension, thirst and dry mucous membranes suggests depletion.
- Weigh the patient where fluid status is critical - daily weight is more reliable than a chart maintained by several people across three shifts.
- Act on it. A urine output below 0.5 mL/kg/hour is oliguria and requires assessment and escalation, not just an entry on a page.
A nurse is about to administer an intravenous antibiotic through a peripheral cannula with a needle-free connector. What must be done immediately before connecting the syringe?
During an infusion of a vesicant drug the patient reports burning pain and the nurse sees swelling and blanching around the cannula site. What is the correct immediate action?
A patient requires 1000 mL of 0.9% sodium chloride over 8 hours by gravity using a set with a drop factor of 20 drops per mL. What rate should be set?