**9. Discussion**

low occurrence of both local and bloodstream infections involving PIV catheters, severe infections can still significantly contribute to patient morbidity simply because of the ubiquitous nature of peripheral catheters [59]. *Diagnosis:* Local infection can be diagnosed by signs and symptoms of tenderness, swelling, erythema, purulent drainage, temperature, and appropriate laboratory testing (e.g., comprehensive blood count or D-dimer in cases of phlebitis) [99]. Of note, lower extremity PIVs are associated with higher incidence of infections when compared to upper extremity PIVs [100]. *Prevention and treatment*: To reduce morbidity and financial burden of PIV-related infections, appropriate education and multidisciplinary efforts should be implemented. For all PIV catheters, a clean, dry, intact dressing is recommended because any soilage will facilitate microorganism growth. Any soilage covered by nontransparent dressings can increase the risk of not detecting infection [1]. The density of skin flora at the site plays an important role in infection. From purely procedural perspective, the first and essential parts of the process should involve removal of the infected PIV cannula and cleansing of the site using sterile technique. Hand hygiene, clipping of excess hair, skin preparation with alcoholic chlorhexidine solution, proper aseptic technique, and maximal sterile barriers including cap, mask, sterile gown, and gloves during insertion can reduce the incidence of infection [59]. During the PIV insertion process, the antiseptic scrubbing technique also modulates the risk of infection [76]. Post-insertion, infection prevention is still crucial and is achieved by meticulous attention to hand hygiene, aseptic preparation of injectates and infusates, needleless connector decontamination with effective antiseptic, and technique. The insertion site requires weekly redressing (or sooner if the dressing is compromised), including recleaning of the insertion site with alcoholic chlorhexidine. Under certain circumstances, such as neutropenic patients, filling and flushing the lumen of the catheter with an antibiotic solution may provide some prophylactic benefits [59]. A final and very simple way to prevent PIVCassociated infections is to ensure the PIVC is reviewed daily and documented, and there is consideration of removal, for example, with the patient moved to oral medication [101] and

*Intra-arterial placement and injection*: An intra-arterial misplacement of PIV, including the initiation of intra-arterial infusion, occurs seldom but is considered a matter of serious concern. Although the precise number of inadvertent intra-arterial PIV cannulation and subsequent injection is unknown, the frequency has been estimated to be as low as 1 in 56,000 and as high as 1 in 3440 [102]. However, the potential consequences of missing the diagnosis can be devastating. If not promptly recognized, its consequences may include arterial spasm, distal ischemia, and eventual development of limb-threatening gangrene [103]. Risk factors associated with unintentional arterial PIV placement include morbid obesity, dark skin, lack of patient cooperation, significant hypotension, and lack of vigilance [103, 104]. *Diagnosis:* Diagnosis can be made by detecting red pulsatile blood, observing changes in capillary refill, the presence of intense pain, and/or the appearance of distal ischemia. Confirmation is done by blood gas analysis, pressure transducer placement, and ultrasound [104]. *Prevention and* 

vigilance for "idle PIVCs" See **Table 1**.

**8. Special topics**

126 Vignettes in Patient Safety - Volume 4

Due to its ubiquitous nature, IVT is associated with significant number of complications, both in terms of absolute quantity and taxonomy. In a recent survey, approximately onethird of pediatric patients and one-fourth of adult patients reported experiences involving a potentially preventable IVT-related complication. As outlined throughout this book series, patient safety is a "team sport" [111, 112]. Consequently, active participation of all stakeholders is required to optimize patient outcomes. This involves active involvement of all those who directly or indirectly participate in IVT—providers, patients, and families. Our *Clinical Vignette* demonstrates the dangers inherently associated with increasingly complex systems, where transitions of care occur frequently and where several different teams care for the same patient over a period of just several hours. In such environments, even the smallest mistake can result in catastrophic sequelae.

**Author details**

Parampreet Kaur<sup>1</sup>

University, Australia

**References**

2017;**12**(1):e0168637

**27**(2):179-188

\*, Claire Rickard2,3,4, Gregory S. Domer<sup>5</sup>

1 Department of Research and Innovation, St. Luke's University Health Network,

3 Centre for Clinical Nursing, Royal Brisbane and Women's Hospital, Australia

5 Department of Surgery, Division of Vascular Surgery, St. Luke's University Health

[1] Miliani K et al. Peripheral venous catheter-related adverse events: Evaluation from a multicentre epidemiological study in France (the CATHEVAL Project). PLoS One.

[2] Helm RE et al. Accepted but unacceptable: Peripheral IV catheter failure. Journal of

[3] Plumer AL. Plumer's Principles and Practice of Intravenous Therapy. Philadelphia, PA:

[4] Cosnett JE. The origins of intravenous fluid therapy. The Lancet. 1989;**333**(8641):768-771 [5] Barsoum N, Kleeman C. Now and then, the history of parenteral fluid administration.

[6] Foëx BA. How the cholera epidemic of 1831 resulted in a new technique for fluid resus-

[7] Jenkins M. History of fluid administration during anesthesia and operation. In:

[8] Awad S, Allison SP, Lobo DN. The history of 0.9% saline. Clinical Nutrition. 2008;

[9] Millam D. The history of intravenous therapy. Journal of Intravenous Nursing: The

Official Publication of the Intravenous Nurses Society. 1996;**19**(1):5-14

2 National Centre of Research Excellence in Nursing Interventions, Alliance for Vascular Access Teaching and Research (AVATAR), Menzies Health Institute Queensland, Griffith

Dangers of Peripheral Intravenous Catheterization: The Forgotten Tourniquet and Other Patient…

\*Address all correspondence to: parampreet.kaur@sluhn.org

4 Princess Alexandra Hospital, Woolloongabba, Australia

6 B. Braun Medical, Inc., Bethlehem, Pennsylvania, USA

Network, Bethlehem, Pennsylvania, United States

Infusion Nursing. 2015;**38**(3):189-203

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citation. Emergency Medicine Journal. 2003;**20**(4):316-318

Anaesthesia. Switzerland: Springer; 1985. pp. 102-107

Bethlehem, Pennsylvania, United States

and Kevin R. Glover<sup>6</sup>

http://dx.doi.org/10.5772/intechopen.83854

129

In this chapter, we outlined key considerations around two primary types of PVCAEs—local and systemic. We also discussed intra-arterial PIV catheter placement and the rare but devastating scenario involving the "forgotten tourniquet." Each topic was presented in a clinically relevant fashion, incorporating a brief description, diagnosis, management, and finally prevention. Clinical approach to preventing PVCAEs is multipronged and includes a broad variety of considerations, such as checklists, knowledge of procedures and equipment, proper sterile technique, and the maintenance of appropriate PIV site cleanliness. Providers must also be aware of subtle clinical signs of PVCAEs, including PIV site erythema, IVT-related tissue injury, manifestations of air embolization, and signs of PIV catheter occlusion [2, 113]. In addition, each of the sections outlined specific strategies to prevent PVCAEs and PIV catheter failure. With growing numbers of patients needing vascular access for a range IVTs, providers need to show an understanding of the broad range of vascular access devices and corresponding clinical management aspects, including specific indications for various device types. Finally, providers need to be aware of patient needs, preferences, and concerns. After all, for many patients it is not the procedure that is of maximum concern but rather the clinician's communication skills, competence, and appropriate selection of PIV insertion site [114]. Patients and their families may be greatly untapped allies in preventing, monitoring, and reporting adverse events [101].
