Peripheral IV Insertion & Maintenance

A PIV site that looked fine at 0800 can cause phlebitis by noon — knowing what to assess, when to rotate, and when to pull the line separates routine care from a complication waiting to happen.

Peripheral IV catheters are the most common vascular access device, typically 18–24 gauge. Gauge selection matters: 18–20 gauge for rapid fluid resuscitation or blood products, 22–24 gauge for routine medications and maintenance fluids in adults (and pediatrics). Insert distal-to-proximal on the nondominant hand or forearm; if a site fails, the next attempt should move proximal or to the opposite extremity — never distal to a failed site, because the prior puncture can leak. Avoid the antecubital fossa for long-term access (limits mobility and increases infiltration risk with bending). Current INS and CDC guidelines favor clinically indicated replacement over routine scheduled rotation; some facilities still use a 72–96 hour timeframe. Assess the site at least every shift and with each medication administration. Flush with preservative-free normal saline before and after each use and at least every 8–12 hours for intermittent locks per facility policy. Use a turbulent (push-pause) flush technique to clear the catheter lumen. Dressings should be transparent semipermeable membrane (TSM) and changed when soiled, damp, loose, or per facility policy. Document gauge, site location, number of attempts, date, time, and the patient's tolerance.

Key Distinctions

Infiltration (IV fluid leaking into tissue — cool, pale, swollen, no blood return) is not the same as phlebitis (vein inflammation — warm, red, tender along the vein, with or without a palpable cord). Students confuse extravasation with simple infiltration: extravasation involves vesicant medications causing tissue necrosis and is an emergency. A saline lock is not the same as a heparin lock — most adult peripheral lines now use saline-only flushes per evidence-based practice.

Clinical Pearl

Cool and pale means infiltration — fluid is in the tissue. Warm and red along the vein means phlebitis — the vein is angry. Stop the infusion for either one.