**5. Overview of peripheral IV catheter complications**

As outlined above, PIV catheters are routinely used for short-term delivery of intravascular fluids and medications, thus being among the most important and the most frequent invasive 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 infusion/dosage is administered [45, 46].

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].

A 49-year-old female with type 2 diabetes mellitus and morbid obesity underwent an abdominoplasty due to recurrent lower abdominal cellulitis. Following a series of failed PIV placement attempts in the left forearm, venous access was established on the dorsum of left hand with an 18G cannula. This PIV was then used during the induction of anesthesia, without any apparent problems. The complex operation took approximately 5 h to complete. During this time, fluid replacements were given intravenously. During the procedure, there was no evidence of left upper extremity swelling, color, or temperature change. The point of insertion of the PIV cannula appeared unremarkable when the patient arrived in the postanesthesia care unit (PACU). Within 4 h, however, the patient reported severe pain in her left hand. This pain persisted despite escalating doses of analgesics. There was a mild but visible swelling in the left hand as compared to the right side, along with decreased capillary refill and distal paresthesia. When the patient's surgeon came to examine the patient, he exposed the entire left upper extremity and discovered an intravenous tourniquet still in place, hiding behind the hospital gown sleeve. The tourniquet was immediately removed, but it was too late to reverse the resultant extremity compartment syndrome. The PIV was also discontinued, and a new catheter is placed in the contralateral hand. An emergency fasciotomy was performed, allowing salvage of the left hand and forearm, at the cost of a large left forearm scar. This substantially increased the length of stay and associated costs and reduced the patient's hospital experience. Fortunately, there were no signs of ischemic injury or permanent nerve damage, and the

**4. Clinical vignette**

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patient had good functional recovery.

**5. Overview of peripheral IV catheter complications**

As outlined above, PIV catheters are routinely used for short-term delivery of intravascular fluids and medications, thus being among the most important and the most frequent invasive 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 individuals in an earlier time frame can prove beneficial to the patient [41, 50].

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

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

Subsequent paragraphs of this chapter will discuss PVCAEs grouped into "localized" or "systemic" categories.

as pH, osmolarity, and dissociability [18]. *Diagnosis*: The diagnosis of infiltration is usually made by observing local tissue edema, cool skin with blanching, and decreased (or stopped) flow rate. The patient usually complains of discomfort, burning, and tightness of the involved extremity/ anatomic location [62]. Comparison to the contralateral limb may help confirm this diagnosis. In the case of extravasation, signs and symptoms may be similar to infiltration but will additionally include burning, irritation, redness, blistering, mottling, ulceration, or permanent damage like necrosis of the affected tissue. The damage can spread to involve nerves, tendons, and joints even months after the original insult [18]. It can additionally include disfigurement, complex regional pain syndrome, and loss of function [63]. *Prevention and treatment:* Prevention of infiltration includes the avoidance of PIV placement in the hand, antecubital fossa, and upper arm, properly securing the catheter and monitoring the IV site frequently [2, 36]. It is important to check the patient's pulse and capillary refill [64]. Clinical management includes stopping the infusion, removing the PIV, elevating the limb, and general measures to alleviate patient discomfort. It has also been reported that local application of hyaluronidase may help, primarily through breaking down subcutaneous cellular components and speeding up the reabsorption of the extravasated fluids [65, 66]. Finally, the original infusion should be restarted at a different

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Prevention of extravasation includes careful placement of PIV cannula, close monitoring of active intravenous fluid infusions, flushing the catheter with sterile saline to ensure patency, and the use of suitable dressings and securements to prevent undue movement [18]. Once extravasation is recognized, the infusion needs to be stopped and the cannula removed. This is especially important when the medication/fluid being infused is potentially toxic to local tissues. Palpable effusion in the subcutaneous tissues may need to be drained, and the limb should be immobilized and elevated above the level of the heart. Application of cold packs can provide symptomatic relief. Indications for surgery include full-thickness skin necrosis, ulceration, and persistent pain [67]. If appropriate treatment is delayed, surgical debridement,

*Hemorrhage/hematoma*: Hemorrhage is defined as bleeding from the puncture site, while hematoma is a localized collection of extravasated blood, usually clotted, within an organ or tissue. Both hemorrhage and hematoma may be caused by blood leaking out of the vein into the tissue due to puncture or trauma. The COSMOS study found that PIV catheters based on a compact closed system were associated with lower rate of hematomas when compared to a mounted open system [68]. Patients who receive antiplatelet therapy or therapeutic anticoagulation are especially predisposed to hematoma/ecchymosis formation [69]. *Diagnosis*: The signs and symptoms of swelling, tenderness, and reddish discoloration at the site are usually sufficient to diagnose PIV-related hematoma. *Prevention and treatment*: The first management step is the application of appropriate localized pressure until the bleeding stops. This is followed by a sterile transparent dressing that can prevent hematoma formation or expansion. Proper PIV insertion, frequent monitoring of the site, and application of pressure after removal of cannula can help prevent hemorrhage and formation of hematoma. At the same time, patients, providers, and nurses should be mindful of using extended external compression times at the insertion site, especially in older patients with impaired skin conditions, as this can lead to further tissue injury [1]. The majority of PIV-related bleeding and hematomas are fortunately self-limited.

site, with all pertinent interventions documented in the medical record.

skin grafting, and amputation may be the end result of such an injury [18].

#### **6. Local PVCAEs**

*Phlebitis*: Phlebitis is an inflammation of the vein and causes pain, swelling, redness, and tenderness. It can be caused by various sources like mechanical, chemical, or infective insults to the vein [2]. The mechanical cause; irritation with cannula rubbing the vein, chemical cause; medications with a hypertonic or acidic/alkaline solution, or an infective phlebitis; microorganism entering the vein through the puncture site can cause the inflammation [30]. *Diagnosis:* It is one of the most talked about complication in the literature [2]. The diagnosis of superficial phlebitis can be made by physical examination of the site. Redness, warmth, tenderness, and swelling along the course of the vein can help make the diagnosis, although there are more than 70 tools used in the literature and none well validated [57]. In certain cases, an ultrasound of the affected area is needed to make or ignore the diagnosis. *Prevention and treatment*: Most complications are preventable if simple hand hygiene and safe principles are observed at every point of contact with the patient [2]. According to a recent secondary analysis, the antecubital fossa is associated with lower phlebitis rates as compared with upper arm and wrist veins [37]. Another systemic review showed that the antecubital veins had lower rate of phlebitis as compared to hand veins [58]. The treatment of phlebitis depends on the location, extent, symptom, and underlying medical conditions. Typically, it should be removed and documented with the time, date, and reason of removal [59]. Documentation can improve the staff compliance and help to improve quality of care of the patients with PIVC [60, 61]. Superficial phlebitis can be treated by applying warm compresses, elevation of the involved extremity, and oral or topical anti-inflammatory medications. External compression with fitted stockings may be beneficial for lower extremity superficial phlebitis. If left untreated, superficial phlebitis can complicate to local infection and abscess formation, clot formation, and progression to a deep venous thrombosis and pulmonary embolism. Deep vein thrombosis can further lead to postphlebitic syndrome.

*Tissue infiltration and extravasation*: Tissue infiltration occurs when the infusate solution is inadvertently administered (or leaks out) into the surrounding tissues. It can be caused by improper placement, dislodgement, or distal puncture/erosion of the catheter and can be associated with relative movement of the patient and the catheter. Extravasation arises when a solution or medication is administered and inadvertently leaks into the surrounding tissues, causing tissue damage. This unintended leakage can be caused by the same reasons as infiltration, including improper placement or dislodgement of the catheter. Certain sites are more prone to extravasation injuries like dorsum of the foot, ankle, antecubital fossa, and the areas near joints where there is little protection for underlying structures [18]. Of interest, extravasations tend to be more common during night hours and thus may be more likely to go undetected, even in closely monitored situations. Extravasation is more likely to occur in patients with fragile, mobile, thrombosed, and difficult to cannulate veins [18]. The degree of subsequent cellular injury is determined by the volume of the infiltrating solution and physiochemical characteristics, such as pH, osmolarity, and dissociability [18]. *Diagnosis*: The diagnosis of infiltration is usually made by observing local tissue edema, cool skin with blanching, and decreased (or stopped) flow rate. The patient usually complains of discomfort, burning, and tightness of the involved extremity/ anatomic location [62]. Comparison to the contralateral limb may help confirm this diagnosis. In the case of extravasation, signs and symptoms may be similar to infiltration but will additionally include burning, irritation, redness, blistering, mottling, ulceration, or permanent damage like necrosis of the affected tissue. The damage can spread to involve nerves, tendons, and joints even months after the original insult [18]. It can additionally include disfigurement, complex regional pain syndrome, and loss of function [63]. *Prevention and treatment:* Prevention of infiltration includes the avoidance of PIV placement in the hand, antecubital fossa, and upper arm, properly securing the catheter and monitoring the IV site frequently [2, 36]. It is important to check the patient's pulse and capillary refill [64]. Clinical management includes stopping the infusion, removing the PIV, elevating the limb, and general measures to alleviate patient discomfort. It has also been reported that local application of hyaluronidase may help, primarily through breaking down subcutaneous cellular components and speeding up the reabsorption of the extravasated fluids [65, 66]. Finally, the original infusion should be restarted at a different site, with all pertinent interventions documented in the medical record.

Subsequent paragraphs of this chapter will discuss PVCAEs grouped into "localized" or "sys-

*Phlebitis*: Phlebitis is an inflammation of the vein and causes pain, swelling, redness, and tenderness. It can be caused by various sources like mechanical, chemical, or infective insults to the vein [2]. The mechanical cause; irritation with cannula rubbing the vein, chemical cause; medications with a hypertonic or acidic/alkaline solution, or an infective phlebitis; microorganism entering the vein through the puncture site can cause the inflammation [30]. *Diagnosis:* It is one of the most talked about complication in the literature [2]. The diagnosis of superficial phlebitis can be made by physical examination of the site. Redness, warmth, tenderness, and swelling along the course of the vein can help make the diagnosis, although there are more than 70 tools used in the literature and none well validated [57]. In certain cases, an ultrasound of the affected area is needed to make or ignore the diagnosis. *Prevention and treatment*: Most complications are preventable if simple hand hygiene and safe principles are observed at every point of contact with the patient [2]. According to a recent secondary analysis, the antecubital fossa is associated with lower phlebitis rates as compared with upper arm and wrist veins [37]. Another systemic review showed that the antecubital veins had lower rate of phlebitis as compared to hand veins [58]. The treatment of phlebitis depends on the location, extent, symptom, and underlying medical conditions. Typically, it should be removed and documented with the time, date, and reason of removal [59]. Documentation can improve the staff compliance and help to improve quality of care of the patients with PIVC [60, 61]. Superficial phlebitis can be treated by applying warm compresses, elevation of the involved extremity, and oral or topical anti-inflammatory medications. External compression with fitted stockings may be beneficial for lower extremity superficial phlebitis. If left untreated, superficial phlebitis can complicate to local infection and abscess formation, clot formation, and progression to a deep venous thrombosis and pulmonary embolism. Deep vein thrombo-

*Tissue infiltration and extravasation*: Tissue infiltration occurs when the infusate solution is inadvertently administered (or leaks out) into the surrounding tissues. It can be caused by improper placement, dislodgement, or distal puncture/erosion of the catheter and can be associated with relative movement of the patient and the catheter. Extravasation arises when a solution or medication is administered and inadvertently leaks into the surrounding tissues, causing tissue damage. This unintended leakage can be caused by the same reasons as infiltration, including improper placement or dislodgement of the catheter. Certain sites are more prone to extravasation injuries like dorsum of the foot, ankle, antecubital fossa, and the areas near joints where there is little protection for underlying structures [18]. Of interest, extravasations tend to be more common during night hours and thus may be more likely to go undetected, even in closely monitored situations. Extravasation is more likely to occur in patients with fragile, mobile, thrombosed, and difficult to cannulate veins [18]. The degree of subsequent cellular injury is determined by the volume of the infiltrating solution and physiochemical characteristics, such

temic" categories.

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**6. Local PVCAEs**

sis can further lead to postphlebitic syndrome.

Prevention of extravasation includes careful placement of PIV cannula, close monitoring of active intravenous fluid infusions, flushing the catheter with sterile saline to ensure patency, and the use of suitable dressings and securements to prevent undue movement [18]. Once extravasation is recognized, the infusion needs to be stopped and the cannula removed. This is especially important when the medication/fluid being infused is potentially toxic to local tissues. Palpable effusion in the subcutaneous tissues may need to be drained, and the limb should be immobilized and elevated above the level of the heart. Application of cold packs can provide symptomatic relief. Indications for surgery include full-thickness skin necrosis, ulceration, and persistent pain [67]. If appropriate treatment is delayed, surgical debridement, skin grafting, and amputation may be the end result of such an injury [18].

*Hemorrhage/hematoma*: Hemorrhage is defined as bleeding from the puncture site, while hematoma is a localized collection of extravasated blood, usually clotted, within an organ or tissue. Both hemorrhage and hematoma may be caused by blood leaking out of the vein into the tissue due to puncture or trauma. The COSMOS study found that PIV catheters based on a compact closed system were associated with lower rate of hematomas when compared to a mounted open system [68]. Patients who receive antiplatelet therapy or therapeutic anticoagulation are especially predisposed to hematoma/ecchymosis formation [69]. *Diagnosis*: The signs and symptoms of swelling, tenderness, and reddish discoloration at the site are usually sufficient to diagnose PIV-related hematoma. *Prevention and treatment*: The first management step is the application of appropriate localized pressure until the bleeding stops. This is followed by a sterile transparent dressing that can prevent hematoma formation or expansion. Proper PIV insertion, frequent monitoring of the site, and application of pressure after removal of cannula can help prevent hemorrhage and formation of hematoma. At the same time, patients, providers, and nurses should be mindful of using extended external compression times at the insertion site, especially in older patients with impaired skin conditions, as this can lead to further tissue injury [1]. The majority of PIV-related bleeding and hematomas are fortunately self-limited.

*Nerve injury*: When tissue infiltration associated with a PIV catheter affects a nerve coursing the surrounding tissues, nerve injury can occur. It is also possible for the IV needle to lacerate, puncture, and potentially injure a nerve. Finally, localized bleeding/hematoma may irritate a nerve. *Diagnosis*: Patients may not experience any discomfort in the beginning, but it is possible for localized numbness or tingling, loss of sensation to pin prick to emerge later on [70, 71]. Nerve injury can range from neurapraxia with complete recovery (minor injury) to neurotmesis with Wallerian degeneration distal to the site of injury (severe injury) [70]. *Prevention and treatment*: The avoidance of nerve injury requires good procedural skills and knowledge of pertinent anatomy. The PIV placing provider should be conscious of venipuncture sites associated with the greatest risk, including the distal sensory branches of the radial and ulnar nerves for sites in the dorsal hand, the superficial radial nerve at the cephalic vein of the radial wrist, the median nerve on the volar aspects of the wrist, the median and anterior interosseous nerves at or above the antecubital fossa, and the lateral and medial antebrachial nerves for the antecubital fossa [36]. The needle insertion should be as shallow as possible, preferably at an angle of 5–15° relative to the skin and using the non-dominant arm [71]. Although nerve injury is rare, the patient should still be aware of this complication and encouraged to inform the nurse immediately if he or she experiences any strange sensation during PIV placement. Nerve damage tends to be self-limited, with typical recovery times of a few weeks or months. Surgical exploration may be required in patients with intractable pain, severe functional loss, or those without recovery signs within 3–6 months after the initial injury [72–74].

was observed in prospective observational studies [2]. At almost 10% dislodgement rate, financial dislodgement burden can be tremendous translating to 33 million, if approximately 330 million IV catheters are sold in the USA [76]. *Diagnosis:* Cannula location is estimated by the flow of IV fluids and/or IV flushes. To evaluate PIVC fiction or dislodgement, we need to ask questions like does the IV flush easily and does the IV fluid flow easily? *Prevention and treatment*: Transparent and semipermeable polyurethane or sterile gauze and tape dressing are both recommended [77, 78]. Catheters with stabilization features like wings may help to secure the catheter due of an additional adhesive dressing contact area [79]. To decrease catheter movement and increase the adhesive surface area, attaching extension tubing to the catheter hub may prove beneficial [80]. Effective securement reduces the motion within the vessel which can in turn minimize the irritation, inflammation, occlusion, and risk of infection [77, 81]. At the same time, increase in catheter complex bulk may make the catheter more

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vulnerable to displacement due to clothing grabbing onto the catheter complex [38].

a topical vasodilator, in addition to patient reassurance [82, 85] See **Table 1**.

**7. Systemic complications**

*Venous spasm*: Venous spasm is a complication of various minor procedures, including PIV insertion and arterial line placement [82]. Venous spasm can occur in the presence of cold IV fluid infusion, drug-related irritation, or trauma to the vein during insertion [82–84]. *Diagnosis:* The signs and symptoms of pain, blanching at the insertion site, slowing of IV infusion, and difficulty in palpating the vein can help facilitate the diagnosis. *Prevention and treatment:* Applying a warm compress, slowing the infusion rate, and potential application of

*Air embolism:* Air embolism is defined as an unintended venous administration of air through an intravenous access device or insertion site. It is usually associated with central venous catheters but can also occur with peripheral intravenous central catheters and less commonly with short peripheral catheters. The incidence of this complication may be low, but it is potentially fatal, with reported mortality as high as 30% [86]. Clinical signs and symptoms may vary depending on the patient, rate of infusion, volume of air, and anatomical location [87]. Physiologic injury can be due to associated ischemia, infarction, thrombotic, or inflammatory response. *Diagnosis:* Clinical signs and symptoms of air embolism may be nonspecific and not readily recognizable, yet immediate intervention is critical to adequately address the problem and prevent/minimize associated harm. Patient may present with sudden onset of dyspnea, cough, wheezing, chest or shoulder pain, tachypnea, tachycardia, hypotension, and/or neurological findings of cerebrovascular accidents [86, 88]. *Prevention and treatment*: For peripherally inserted catheters, prevention includes the avoidance of air, both primarily and by so-called "air traps" built into the IV circuit. When placing and removing central venous catheters, the patient should be placed in Trendelenburg (during catheter removal), followed by supine (subsequent 20–30 min) position. Prompt diagnosis and focused treatment are mandatory in cases of air embolism. After stabilizing the patient, immediate evaluation and management should be instituted [89]. Affected patients should be transferred to intensive care for close monitoring, with considerations given to hyperbaric oxygen therapy as an adjunct [88].

*Occlusion*: Occlusion is defined as the slowing or cessation of fluid infusion. It can occur due to the mechanical blockage within the cannula or fibrin deposition in/around the tip of the cannula. In addition, it may be due to swollen phlebitic veins, or insertion at a point of flexion, both of which may collapse the catheter and prevent flow [75]. There may be a higher incidence of occlusion associated with insertion in the hand, antecubital fossa, or upper arm, when compared to forearm placement [2, 37]. 25.6% had failed catheterization due to PIV occlusions in an analysis from a randomized controlled trial in Australia. The occlusion was associated with infusions of antibiotics, hydrocortisone, in the setting of concurrent infection, and the use of subsequent (rather than initial) catheters [37]. In a single-center prospective study done in Australia, catheter failure due to occlusion/infiltration was reported to be 14%. In the same study, flucloxacillin, female gender, and 22-gauge PIVs were significant predictors of occlusion [49]. *Diagnosis*: Occlusion can be diagnosed by the presence of discomfort, blood within the line, or PIV not running. *Prevention and treatment*: Actively checking for kinks and removing nonfunctioning cannulas will help reduce the overall duration of functional occlusion. Insertion of PIV by a trained specialist may also help reduce the risk of occlusion [37]. Various methods have been tried to prevent occlusion. In recent randomized trial, the rate of occlusion was lower with heparin infusion compared to placebo infusion [59].

*Dislodgement*: Dislodgement can occur when IV catheter was incorrectly secured with standard medical tape or another adhesive securement device. More frequently, catheters that are correctly secured become dislocated when more forces are applied upon the catheter than the securement method was intended to endure. IV dislodgement can lead to an unscheduled IV restart or more invasive central line. Dislodgement rate has been reported in the range of 3.7–9.9% in a prospective randomized study with a mean of 6.9%. Even a greater rate of 17.5% was observed in prospective observational studies [2]. At almost 10% dislodgement rate, financial dislodgement burden can be tremendous translating to 33 million, if approximately 330 million IV catheters are sold in the USA [76]. *Diagnosis:* Cannula location is estimated by the flow of IV fluids and/or IV flushes. To evaluate PIVC fiction or dislodgement, we need to ask questions like does the IV flush easily and does the IV fluid flow easily? *Prevention and treatment*: Transparent and semipermeable polyurethane or sterile gauze and tape dressing are both recommended [77, 78]. Catheters with stabilization features like wings may help to secure the catheter due of an additional adhesive dressing contact area [79]. To decrease catheter movement and increase the adhesive surface area, attaching extension tubing to the catheter hub may prove beneficial [80]. Effective securement reduces the motion within the vessel which can in turn minimize the irritation, inflammation, occlusion, and risk of infection [77, 81]. At the same time, increase in catheter complex bulk may make the catheter more vulnerable to displacement due to clothing grabbing onto the catheter complex [38].

*Venous spasm*: Venous spasm is a complication of various minor procedures, including PIV insertion and arterial line placement [82]. Venous spasm can occur in the presence of cold IV fluid infusion, drug-related irritation, or trauma to the vein during insertion [82–84]. *Diagnosis:* The signs and symptoms of pain, blanching at the insertion site, slowing of IV infusion, and difficulty in palpating the vein can help facilitate the diagnosis. *Prevention and treatment:* Applying a warm compress, slowing the infusion rate, and potential application of a topical vasodilator, in addition to patient reassurance [82, 85] See **Table 1**.
