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An Overview of Peripheral Catheter Types and the New Standards of Practice

Many considerations are made before the initiation of a prescribed I.V. therapy. Selection of the most appropriate VAD occurs as a collaborative process involving the patient and all members of the healthcare team. The device selection is based upon:
• The prescribed therapy or treatment regimen
• Anticipated duration of therapy
• Vascular characteristics
• Patient age
• Comorbidities
• History of infusion therapy
• Preference for VAD location
• Ability and resources to care for the device

Therapies that are not appropriate for peripheral administration are:
• Continuous vesicant administration
• Parenteral Nutrition (TPN)
• Infusates with an osmolality of greater than 900 mOsm/L

In the past medication pH was a factor in determining appropriateness of a medication to be delivered peripherally or by central line. This is no longer a sole determining factor, you may see IV Medications, pH, and Phlebitis for more on this topic.

The VAD selected should be the smallest gauge catheter, with the fewest lumens and the least invasive device needed for the prescribed therapy. Preservation of peripheral veins should also be a consideration with VAD selection.

Types of Peripheral Access

There are 3 types of peripheral access: steel winged infusion set or butterfly, short peripheral catheter and midline.

Steel Winged Infusion Set

This type of device may also be called a butterfly. This type of peripheral device is only appropriate for single dose, very short term infusions of up to 1 to 4 hours in length. This device is not appropriate for use in areas of flexion due to the risk of infiltration and this device is removed after use.

Short Peripheral Catheters

A short peripheral catheter is defined as a catheter up to 3 inches in length. A safety engineered device should always be selected and consistently activated or used.  Organizations should consider the use of passive safety engineered devices, when possible, as these devices do not require the active deployment of the safety mechanism by the clinician.

Short peripheral catheters are:
• Not appropriate for areas of flexion due to infiltration risk
• For therapies lasting up to 6  days
• Site rotations are performed when clinically indicated with signs of complications, or when the patient reports discomfort or pain
 
Always select the smallest gauge peripheral device that will accommodate the prescribed therapy:
• Consider a 20-24 gauge catheter for most infusion therapies. Peripheral catheter larger than 20 gauge are more likely to cause phlebitis
• Consider a 22 to 24 gauge catheter for neonates, pediatric patients and older adults to minimize insertion related trauma
• Consider a larger 16 to 20 gauge catheter when rapid fluid replacement is required, such as with trauma patients or a fenestrated catheter for a contrast based radiographic study
• Use a 20 to 24 gauge catheter based on vein size for blood transfusions. If a rapid transfusion is required a larger size catheter gauge is recommended
 
You may view and print our Peripheral Catheter IV Chart as a reference for peripheral catheter size choice and recommendations. 

Midline Catheters

A midline catheter is defined as a peripheral catheter 3 to 8 inches in length with the tip terminating in either the basilic, cephalic or brachial vein, distal to the shoulder. Placement in the basilic vein is preferred due to vein diameter. The tip does not enter the central vasculature. The clinician should consider the selection of a midline catheter for therapies anticipated to last 1 to 4 weeks. A midline catheter should be used for hydration, intravenous solutions, pain medications, some antibiotics, and analgesics that are well tolerated by peripheral veins. Therapies not appropriate for midline catheters include continuous vesicant therapy, parenteral nutrition, and infusates with an osmolality greater than 900  mOsm/L. Use with caution with intermittent vesicant administration due to the risk of undetected extravasation. The administration of Vancomycin for less than 6 days through a midline catheter was found to be safe in one study. Midline catheters are available as a single or double lumen and are made of polyurethane or silicone material.  Use of midlines should be avoided in patients who have a medical history of thrombosis, hypercoagulability, decreased venous flow to the extremities, or end stage renal disease requiring vein preservation. Midlines are inserted by clinicians with specific education and competency demonstration. Midlines are not typically used for blood draws.

Pedagogy has recently updated our Basics of Peripheral IV Therapy 2016 course to match the new guidelines set forth by the INS. 

Click here to learn more about the course.

Pedagogy blog written by Capra Dalton, RN,CEO. 

Capra has more than 28 years of experience in infusion therapy and the instruction of licensed nurses in infusion therapy continuing education. Her experience comes from multiple infusion settings: acute care, ambulatory infusion centers, home infusion, long term care continuing education provider, and long term care pharmacy quality assurance consultant.  
Posted: 8/16/2016 12:30:38 PM
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