**3. Indications and common anatomic sites of peripheral intravenous catheterization**

PIV catheterization is indicated for short-term use across a broad range of clinical scenarios, including administration of IV fluids, drugs, blood/blood products, dyes, and contrast media [28, 29]. Several factors must be considered when selecting a site for PIV catheterization. Although common sites of insertion are generally described as the lower arm and the dorsum of the hand, superficial veins of the lower limbs can also be used for cannulation in certain clinical situations [30]. The direct and indirect risks of complications can be curtailed by a more thorough assessment of the vascular anatomy prior to choosing the optimal site, based on both infusion- and patient-related factors [31–35]. Carr et al. reported that the antecubital fossa (ACF), the most common insertion site cannulated in their study of 252 ED patients, was associated with the best rates of insertion success (54.78%), but a secondary analysis revealed that these successfully inserted PIVCs repeatedly failed to last for the intended 3-day dwell time after transfer from the ED to the general hospital units [31]. In a project to reduce infusion pump alarms, Matocha [34] reported that occlusion alarms (60%) represented the highest volume of alarms in a medical oncology unit. After intervention, occlusion alarms were reduced by 17% but still represented the highest volume of alarms, which the author hypothesized might be associated with the majority of catheter placements in the antecubital area due to flexion at the site. Decreasing antecubital area placement in the first place through staff education regarding vascular access planning and insertion competency was suggested as one way of reducing occlusion alarms. Alarm frequency may interfere with patients' sleep, cause unnecessary anxiety, and potentially negatively impact healing [32, 33]. It is imperative to consider the clinical status of the patient carefully before selecting the site. Such assessment should consider the general condition of the veins, tortuosity, locations of valves, bifurcations [36], the size of cannula, type of drug to be administered, infusion rate, and duration of the intended IVT [30]. Intravenous cannula gauge and site of placement are critical factors in defining the success and longevity of PIV cannula [37]. Of note, larger gauge (*P* = 0.0002, RR = 1.17, 95% CI 1.08–1.27) and forearm placement (*P* = 0.005, RR = 0.7, 95% CI 0.55–0.9) are among the strongest predictors of longer functional cannula life [38]. Evidence demonstrates the usefulness of multimodality methodology in improving in first-time insertion success rate [2, 37].

Overall, success rates for PIV placement range between 61 and 90%, with successful insertions being associated with visible or palpable veins, providers with greater procedural volumes, and inserters who were able to predict that placement would be successful [39]. Level of successful venous access also appears to be associated with various patient factors (e.g., age, body mass index, etc.) [40]. Difficult venous access is characterized by non-visible and non-palpable veins for various reasons, including chronic disease, history of intravenous drug use, history of chemotherapy, obesity, or malnourishment [41]. In addition to excellent technical skill and clinical knowledge, various vein visualization devices and ultrasound-based approaches can be helpful in facilitating successful PIV insertion [36]. Such devices include infrared vein visualizers and ultrasound; however, operator experience is required for optimal outcomes and success rates [42]. The ability to leverage adjunctive devices to identify more veins can lead to greater placement and successful and speedier cannulations [40]. In addition, assistive devices may help reduce the number of insertion attempts and diminish complications such as unintended arterial puncture [43, 44].

procedure performed in hospitals. However, PIVs often fail before IVT is completed, with the cited malfunction rate of about 90% [2]. A prospective observational study, the CATHEVAL Project, suggested that the incidence of PVCAEs is significantly underestimated [1]. The incidence rate of at least one PVCAE was 52.3%, with "clinical" PVCAEs occurring significantly more frequently than "mechanical" PVCAEs [1]. The most frequent clinical PVCAEs were phlebitis (20.1/100 PIVs), followed by hematoma (17.7/100 PIVs) and fluid/blood leakage (13.1/100 PIVs). In terms of mechanical complications, obstruction/occlusion of PIV was the most frequent event (12.4/100 PIVs) [1]. Of interest, the authors also reported on post-removal PVCAEs (21.7/100 PIVs) as well as infections (0.4/100 PIVs) [1]. Moreover, significant complications can occur if the incorrect quantity (volume) of IV fluids or incorrect medication

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The prevalence of difficult IV access can be substantial, with one study reporting 23% of patients classified as "moderately difficult" and 5% classified as having "difficult access" [47]. Of interest, female gender and a previous history of several IV placement attempts may be associated with greater risk of difficult venous access, which in turn can increase the overall complication risk [48, 49]. Currently, there is no internationally accepted definition of a "difficult access" patient. Based on clinical observations many have tried to develop a predictive scale to identify adult patients with difficult intravenous access: the DIVA scale [50]. Such scales can be used to recognize patients with high probability of a difficult intravenous access. In such cases various assessment devices (near-infrared and ultrasound) or call for assistance of more experienced

Globally speaking, prevention of PVCAEs should be the preferred approach, and despite ongoing efforts to improve the current state of affairs, PVCAEs continue to occur, prompting the need for maintaining awareness and reinforcing provider education in this critical important area [18]. In a multicenter prospective study of 1498 patients by Cicolini et al. [51], the authors cited that anatomical site selection and a lack of adherence to in situ PIVC placement recommended guidelines resulted in increased rates of phlebitis. They concluded that additional staff education was needed [51]. DeVries et al. reported a 19% reduction in PIVC-associated bloodstream infections after implementing a fundamental PIVC insertion and education bundle for bedside nurses that increased staff awareness of proper skin preparation, aseptic technique, and the importance of the care and maintenance of dressings [52]. Nursing education leaders in another tertiary healthcare setting developed an educational intervention to improve the recognition and reporting of infiltration and phlebitis on medicalsurgical units, which was identified by the risk management database as a concern. Although the differences between pre- and post-knowledge scores were not significant (*P* = 0.21), the unexpected results of the research served as a catalyst to develop annual PIVC procedural

individuals in an earlier time frame can prove beneficial to the patient [41, 50].

education to validate competency related to PIVC-related complications [53].

and intervene in a timely and appropriate fashion [30].

A standardized approach to education and competency assessment across the healthcare system is recommended. A simulation-based multimodal educational method should be considered, including self-study and deliberate practice, with objective outcome monitoring and feedback using well-designed, validated, and reliable checklists [36, 54–56]. After all, it is the responsibility of the entire healthcare team to monitor for signs and symptoms of PVCAEs

infusion/dosage is administered [45, 46].
