Intravenous therapy

IV bags on a pole connected to IV lines.

1 Infused substances

Infusion therapy: A patient receiving medication via intravenous

therapy.

Substances that may be infused intravenously include volume expanders, blood-based products, blood substitutes,
medications and nutrition.
Intravenous therapy (IV therapy or iv therapy in short)
is the infusion of liquid substances directly into a vein.
Intravenous simply means within vein. Therapies administered intravenously are often called specialty pharmaceuticals. It is commonly referred to as a drip because many systems of administration employ a drip
chamber, which prevents air from entering the blood
stream (air embolism), and allows an estimation of ow
rate.

1.1 Volume expanders

Main article: Volume expander

There are two main types of volume expander; crystalloids and colloids. Crystalloids are aqueous solutions of
mineral salts or other water-soluble molecules. Colloids
Intravenous therapy may be used to correct electrolyte contain larger insoluble molecules, such as gelatin. Blood
imbalances, to deliver medications, for blood transfu- is a colloid.
sion or as uid replacement to correct, for example,
dehydration. Intravenous therapy can also be used for
Colloids preserve a high colloid osmotic pressure in
chemotherapy.
the blood, while, on the other hand, this parameter
is decreased by crystalloids due to hemodilution.[1]
There does not appear to be a benet of using
colloids over crystalloids.[1] Crystalloids generally

Compared with other routes of administration, the intravenous route is the fastest way to deliver uids and medications throughout the body.
1

1 INFUSED SUBSTANCES
saline, a solution of sodium chloride at 0.9% concentration, which is close to the concentration in the
blood (isotonic). Lactated Ringers (also known as
Ringers lactate) and the closely related Ringers acetate, are mildly hypotonic solutions often used in
those who have signicant burns.
Volume expanders may either be isotonic, hypotonic, or hypertonic. Hypotonic uids are not generally recommended in children due to increased risk
of adverse eects.[2]
Advancements in IV Infusions: Polypropylene packaging (instead of LDPE and PVC) crystal clear bottles of
polyproplylene (instead of Opaques) unmatched collapsibility (reduces the need of pricking bottle for smooth ow
of uid) impermeable to water vapours and reactive gases
to prevent leaching [3]

1.2 Blood-based products

Further information: Blood product and Blood transfusion
A patient receiving intravenous uid

A blood product (or blood-based product) is any component of blood which is collected from a donor for use
in a blood transfusion. Blood transfusions can be lifesaving in some situations, such as massive blood loss due
to trauma, or can be used to replace blood lost during
surgery. Blood transfusions may also be used to treat a
severe anaemia or thrombocytopenia caused by a blood
disease. People with hemophilia usually need a replacement of clotting factor, which is a small part of whole
blood. People with sickle-cell disease may require frequent blood transfusions. Early blood transfusions consisted of whole blood, but modern medical practice commonly uses only components of the blood, such as fresh
frozen plasma or cryoprecipitate.

1.3 Blood substitutes

Main article: Blood substitute
Blood substitutes (also called articial blood or blood surrogates) are articial substances aiming to provide an alternative to blood-based products acquired from donors.
Saline and 5% Glucose solution (Left), Levooxacin 750mg
(Right)

The main blood substitutes used today are volume expanders such as crystalloids and colloids mentioned
above. Also, oxygen-carrying substitutes are emerging.

are much cheaper than colloids.[1] (blood, albumin, 1.4 Buer solutions
plasma, etc.)
Buer solutions are used to correct acidosis or alkalosis.
The most commonly used crystalloid uid is normal Lactated Ringers solution also has some buering eect.

2.2

Peripheral cannula

A solution more specically used for buering purpose is

intravenous sodium bicarbonate.

1.5

Other medications

Medications may be mixed into the uids mentioned

above. Certain types of medications can only be given intravenously, such as when there is insucient uptake by
other routes of administration such as enterally. Examples include intravenous immunoglobulin and propofol.

1.6

Other

Parenteral nutrition is feeding a person intra- 20 gauge peripheral IV in hand

venously, bypassing the usual process of eating and
digestion. The person receives nutritional formulas containing salts, glucose, amino acids, lipids and
added vitamins.
Drug injection used for recreational substances usually enters by the intravenous route.

Intravenous access devices

These can all be used to obtain blood (e.g. for testing),

also known as phlebotomy as well as for the administration of medication/uids.

2.1

Hypodermic needle

The simplest form of intravenous access is by passing a

hollow needle through the skin directly into the vein. This
needle can be connected directly to a syringe (used either
to withdraw blood or deliver its contents into the bloodstream) or may be connected to a length of tubing and
thence whichever collection or infusion system is desired.
The most convenient site is often the arm, especially the
veins on the back of the hand, or the median cubital vein
at the elbow, but any identiable vein can be used. Often it is necessary to use a tourniquet which restricts the
venous drainage of the limb and makes the vein bulge.
Once the needle is in place, it is common to draw back
slightly on the syringe to aspirate blood, thus verifying
that the needle is really in a vein. The tourniquet should
be removed before injecting to prevent extravasation of
the medication.

2.2

Peripheral cannula

A nurse inserting an 18-gauge IV needle with cannula.

the chest or abdomen). This is usually in the form of

a cannula-over-needle device, in which a exible plastic
cannula comes mounted over a metal trocar. Once the tip
of the needle and cannula are introduced into the vein via
venipuncture, the cannula is advanced inside the vein over
the trocar to the appropriate position and secured, the trocar is then withdrawn and discarded. Blood samples may
be drawn directly after the initial IV cannula insertion.

Any accessible vein can be used although arm and hand

A peripheral cannula is the most common intravenous veins are used most commonly, with leg and foot veins
access method utilized in both hospitals and pre-hospital used to a much lesser extent. In infants the scalp veins
services. A peripheral IV line (PVC or PIV) consists of are sometimes used.
a short catheter (a few centimeters long) inserted through The caliber of cannula is commonly indicated in gauge,
the skin into a peripheral vein (any vein not situated in with 14 being a very large cannula (used in resuscitation

settings) and 24-26 the smallest. The most common sizes

are 16-gauge (midsize line used for blood donation and
transfusion), 18- and 20-gauge (all-purpose line for infusions and blood draws), and 22-gauge (all-purpose pediatric line). 12- and 14-gauge peripheral lines are capable of delivering large volumes of uid extremely fast
accounting for their popularity in emergency medicine.
These lines are frequently called large bores or trauma
lines.

INTRAVENOUS ACCESS DEVICES

Catheter shearing is a very infrequent complication, but a

very real danger. Shearing is when part of the catheter is
cut by the sharp bevelled edge of the trochar. The sheared
section may completely separate from the main body of
the catheter, and become free oating in the blood stream.
The large majority of the time it is due to poor technique, but infrequently a poorly manufactured catheter
may break from the hub or shear. Infection, and a foreign body embolus are the two threats to the patient.

To make the procedure more tolerable for children medical sta may apply a topical local anaesthetic (such as
2.3 Central lines
EMLA or Ametop) to the skin of the chosen venipuncture area about 45 minutes beforehand.
Main article: Central venous catheter
The part of the catheter that remains outside the skin is
called the connecting hub; it can be connected to a syringe
Central IV lines ow through a catheter with its tip within
or an intravenous infusion line, or capped with a heplock
a large vein, usually the superior vena cava or inferior vena
or saline lock, a needleless connection lled with a small
cava, or within the right atrium of the heart. This has
amount of heparin or saline solution to prevent clotting,
several advantages over a peripheral IV:
between uses of the catheter. Ported cannulae have an
injection port on the top that is often used to administer
It can deliver uids and medications that would be
medicine.
overly irritating to peripheral veins because of their
In cases of shock, a central venous catheter, PICC (peconcentration or chemical composition. These inripherally inserted central catheter), venous cutdown or
clude some chemotherapy drugs and total parenteral
intraosseous infusion may be necessary.
nutrition.
2.2.1

Complications

Medications reach the heart immediately, and are

quickly distributed to the rest of the body.

There is room for multiple parallel compartments

If the cannula is not sited correctly, or the vein is partic(lumen) within the catheter, so that multiple mediularly fragile and ruptures, blood may leak into the surcations can be delivered at once even if they would
rounding tissues, this situation is known as a tissuing or
not be chemically compatible within a single tube.
a blown vein. Using this cannula to administer medications causes extravasation of the drug which can lead to
Caregivers can measure central venous pressure and
edema, causing pain and tissue damage, and even necrosis
other physiological variables through the line.
depending on the medication. The person attempting to
obtain the access must nd a new access site proximal to
the blown area to prevent extravasation of medications Central IV lines carry risks of bleeding, infection,
through the damaged vein. For this reason it is advisable gangrene, thromboembolism and gas embolism (see
to site the rst cannula at the most distal appropriate vein. Risks below). They are often more dicult to insert correctly as the veins are not usually palpable and rely on
If a patient needs frequent venous access, the veins may an experienced clinician knowing the appropriate landscar and narrow, making any future access extremely dif- marks and/or using an ultrasound probe to safely locate
cult or impossible.
and enter the vein. Surrounding structures, such as the
A peripheral IV cannot be left in the vein indenitely, pleura and carotid artery are also at risk of damage with
because of the risk of insertion-site infection leading to the potential for pneumothorax or even cannulation of the
phlebitis, cellulitis and sepsis. The US Centers for Dis- artery.
ease Control and Prevention updated their guidelines and There are several types of central IVs, depending on the
now advise the cannula need to be replaced every 96 route that the catheter takes from the outside of the body
hours.[4] This was based on studies organised to iden- to the vein.
tify causes of Methicillin-resistant Staphylococcus aureus (MRSA) infection in hospitals. In the United Kingdom, the UK Department of health published their nd- 2.3.1 Peripherally inserted central catheter
ing about risk factors associated with increased MRSA
infection, now include intravenous cannula, central ve- PICC lines are used when intravenous access is required
nous catheters and urinary catheters as the main factors over a prolonged period of time or when the material to
increasing the risk of spreading antibiotic resistant strain be infused would cause quick damage and early failure of
bacteria.
a peripheral IV and when a conventional central line may

5
be too dangerous to attempt. Typical uses for a PICC in- there is greater blood ow past the tip of the catheter
clude: long chemotherapy regimens, extended antibiotic meaning irritant drugs are more rapidly diluted with
therapy, or total parenteral nutrition.
less chance of extravasation. It is commonly believed
The PICC line is inserted through a sheath into a pe- that uid can be pushed faster through a central venous
ripheral vein sometimes using the Seldinger technique catheter but as they are often divided into multiple luor modied Seldinger technique, under ultrasound guid- mens then the internal diameter is less than that of a largeance, usually in the arm, and then carefully advanced up- bore peripheral cannula. They are also longer, which as
ward until the catheter is in the superior vena cava or the reected in Poiseuilles law, requires higher pressure to
achieve the same ow, all other variables being equal.
right atrium. This is usually done by measuring the distance to an external landmark, such as the suprasternal
notch, to estimate the optimal length. An X-ray must be
2.3.3 Tunnelled lines
used to verify that the tip is in the right place when uoroscopy was not used during the insertion.
Another type of central line, called a Hickman line or
A PICC may have a single (single-lumen) tube and con- Broviac catheter, is inserted into the target vein and then
nector, two(double-lumen) or three (triple-lumen) com- tunneled under the skin to emerge a short distance
partments, each with its own external connector. Power- away. This reduces the risk of infection, since bacteria
injectable PICCs are now available as well. From the out- from the skin surface are not able to travel directly into
side, a single-lumen PICC resembles a peripheral IV, ex- the vein; these catheters are also made of materials that
cept that the tubing is slightly wider.
resist infection and clotting.
The insertion site requires better protection than that of
a peripheral IV, due to the higher risk of serious infection if bacteria travel up the catheter. However, a PICC
poses less of a systemic infection risk than other central
IVs, because the insertion site is usually cooler and dryer
than the sites typically used for other central lines. This
helps to slow the growth of bacteria which could reach the
bloodstream by traveling under the skin along the outside
of the catheter.
The chief advantage of a PICC over other types of central lines is that it is safer to insert with a relatively low
risk of uncontrollable bleeding and essentially no risks of
damage to the lungs or major blood vessels. Although
special training is required, a PICC does not require the
skill level of a physician or surgeon. It is also externally
unobtrusive, and with proper hygiene and care can be left
in place for months to years if needed for patients who
require extended treatment.
The chief disadvantage is that it must be inserted and then
travel through a relatively small peripheral vein which can
take a less predictable course on the way to the superior
vena cava and is therefore somewhat more time consuming and more technically dicult to place in some patients. Also, as a PICC travels through the axilla, it can
become kinked causing poor function.
2.3.2

Central venous lines

2.3.4 Implantable ports

A port (often referred to by brand names such as Port-aCath or MediPort) is a central venous line that does not
have an external connector; instead, it has a small reservoir that is covered with silicone rubber and is implanted
under the skin. Medication is administered intermittently
by placing a small needle through the skin, piercing the
silicone, into the reservoir. When the needle is withdrawn
the reservoir cover reseals itself. The cover can accept
hundreds of needle sticks during its lifetime. It is possible to leave the ports in the patients body for years; if
this is done however, the port must be accessed monthly
and ushed with an anti-coagulant, or the patient risks it
getting plugged up. If it is plugged it becomes a hazard
as a thrombus will eventually form with an accompanying
risk of embolisation. Removal of a port is usually a simple outpatient procedure; however, installation is more
complex and a good implant is fairly dependent on the
skill of the radiologist. Ports cause less inconvenience
and have a lower risk of infection than PICCs, and are
therefore commonly used for patients on long-term intermittent treatment.

3 Other equipment

There are several types of catheters that take a more di- A standard IV infusion set consists of a pre-lled, sterrect route into central veins. These are collectively called ile container (glass bottle, plastic bottle or plastic bag)
of uids with an attachment that allows the uid to ow
central venous lines.
one drop at a time, making it easy to see the ow rate
In the simplest type of central venous access, a catheter is (and also reducing air bubbles); a long sterile tube with a
inserted into a subclavian, internal jugular, or (less com- clamp to regulate or stop the ow; a connector to attach
monly) a femoral vein and advanced toward the heart until to the access device; and Y-sets to allow piggybacking
it reaches the superior vena cava or right atrium.
of another infusion set onto the same line, e.g., adding a
Because all of these veins are larger than peripheral veins dose of antibiotics to a continuous uid drip.

5 ADVERSE EFFECTS
into the bloodstream; however, a second uid injection is
sometimes used, a ush, following the injection to push
the medicine into the bloodstream more quickly.

5 Adverse eects
5.1 Pain and invasiveness of injection
An injection inherently causes pain and is medically invasive. In cases in which a choice between intravenous
therapy and oral treatment may be made to achieve the
same outcome, such as in the case of mild or moderate dehydration treatment in which oral rehydration therapy is an option, then avoid using intravenous therapy in
place of the less invasive oral option.[5] In particular, children in emergency departments being treated for dehydration have better outcomes with oral treatment because
it does not cause the pain or risk the complications of an
injection.[5]

An infusion pump suitable for a single IV line

5.2 Infection

Any break in the skin carries a risk of infection. Although IV insertion is an aseptic procedure, skin-dwelling
organisms such as Coagulase-negative staphylococcus or
Candida albicans may enter through the insertion site
around the catheter, or bacteria may be accidentally introduced inside the catheter from contaminated equipment.
Moisture introduced to unprotected IV sites through
washing or bathing substantially increases the infection
A rapid infuser can be used if the patient requires a high risks.
ow rate and the IV access device is of a large enough Infection of IV sites is usually local, causing easily visdiameter to accommodate it. This is either an inatable ible swelling, redness, and fever. If bacteria do not recu placed around the uid bag to force the uid into the main in one area but spread through the bloodstream, the
patient or a similar electrical device that may also heat the infection is called septicemia and can be rapid and lifeuid being infused.
threatening. An infected central IV poses a higher risk
of septicemia, as it can deliver bacteria directly into the
central circulation.
An infusion pump allows precise control over the ow rate
and total amount delivered, but in cases where a change
in the ow rate would not have serious consequences, or
if pumps are not available, the drip is often left to ow
simply by placing the bag above the level of the patient
and using the clamp to regulate the rate; this is a gravity
drip.

Intermittent infusion

Intermittent infusion is used when a patient requires medications only at certain times, and does not require additional uid. It can use the same techniques as an intravenous drip (pump or gravity drip), but after the complete
dose of medication has been given, the tubing is disconnected from the IV access device. Some medications are
also given by IV push or bolus, meaning that a syringe
is connected to the IV access device and the medication
is injected directly (slowly, if it might irritate the vein or
cause a too-rapid eect). Once a medicine has been injected into the uid stream of the IV tubing there must be
some means of ensuring that it gets from the tubing to the
patient. Usually this is accomplished by allowing the uid
stream to ow normally and thereby carry the medicine

5.3 Phlebitis
Phlebitis is inammation of a vein that may be caused by
infection, the mere presence of a foreign body (the IV
catheter) or the uids or medication being given. Symptoms are warmth, swelling, pain, and redness around the
vein. The IV device must be removed and if necessary
re-inserted into another extremity.
Due to frequent injections and recurring phlebitis, scar
tissue can build up along the vein. The peripheral veins
of intravenous drug addicts, and of cancer patients undergoing chemotherapy, become sclerotic and dicult to
access over time, sometimes forming a hard, painful venous cord.

5.4

Inltration / extravasation

nearly impossible to inject air through a peripheral IV at

a dangerous rate. The risk is greater with a central IV.

Inltration occurs when an IV uid or medication accidentally enters the surrounding tissue rather than the vein.
It may occur when the vein itself ruptures (the elderly are
particularly prone to fragile veins due to a paucity of supporting tissues), when the vein is damaged during insertion of the intravascular access device, when the device is
not sited correctly or when the entry point of the device
into the vein becomes the path of least resistance (e.g. if
a cannula is in a vein for some time, the vein may scar
and close and the only way for uid to leave is along the
outside of the cannula where it enters the vein). Inltration is an inadvertent administration of a nonvesicant solution/drug into the tissue, which happens so often when
the tourniquet isn't removed in a timely fashion. Inltration is characterized by coolness and pallor to the skin as
well as localized swelling or edema. It is treated by removing the intravenous access device and elevating the
aected limb so that the collected uids can drain away.
Sometimes injections of hyaluronidase can be used to
speed the dispersal of the uid/drug. Inltration is one of
the most common adverse eects of IV therapy[6] and is
usually not serious unless the inltrated uid is a medication damaging to the surrounding tissue, most commonly
a vesicant or chemotherapeutic agent, in which case it is
called extravasation and extensive necrosis can occur.[7][8]

Air bubbles of less than 30 microliters are thought to dissolve into the circulation harmlessly. A larger amount
of air, if delivered all at once, can cause life-threatening
damage, or, if extremely large (3-8 milliliters per kilogram of body weight), can stop the heart.

5.5

Administering a too-dilute or too-concentrated solution

can disrupt the patients balance of sodium, potassium,
magnesium, and other electrolytes. Hospital patients usually receive blood tests to monitor these levels.

Intravenous therapy knowledge and skills among healthcare providers vary greatly. While initial exposure to I.V.
therapy is usually through formal nursing education programs, I.V. starting skills only develop from a combination of theoretical instruction and on the job practice.
However, employers usually expect potential employees
to be procient on this area of clinical practice prior to
becoming hired. The gap between actual and expected
knowledge and skills can be extremely wide, especially in
I.V. therapy. Part of this gap comes from the lack of educational experiences and/or the inaccessibility to these
oerings. While not widely oered, interactive multimedia I.V. education such as hybrid courses combining
online theory with hands-on practice such as the one offered, to name some, by National Healthcare Institute,
can provide a way to narrow that gap in a quick and costeective manner which will represent an improvement on
patient safety and treatment outcomes.[13] Simulated intravenous solutions used for training purposes only have
been manufactured; in at least one case, the routing of
training solutions into a standard medical setting has led
to patient adverse events.[14]

5.8

8 See also

Fluid overload

This occurs when uids are given at a higher rate or in

a larger volume than the system can absorb or excrete.
Possible consequences include hypertension, heart failure, and pulmonary edema.

5.6

Hypothermia

The human body is at risk of accidentally induced hypothermia when large amounts of cold uids are infused.
Rapid temperature changes in the heart may precipitate
ventricular brillation.

5.7

Electrolyte imbalance

Embolism

A blood clot or other solid mass, as well as an air bubble,

can be delivered into the circulation through an IV and
end up blocking a vessel; this is called embolism. It is

One reason veins are preferred over arteries for intravascular administration is because the ow will pass through
the lungs before passing through the body. Air bubbles
can leave the blood through the lungs. A patient with a
right-to-left shunt is vulnerable to embolism from smaller
amounts of air. Fatality by air embolism is rare, although
this is in part because it is so dicult to diagnose.

6 History
Intravenous technology stems from studies on cholera
treatment in 1831 by Dr Thomas Latta of Leith.[9]
Intravenous therapy was further developed in the 1930s
by Hirschfeld, Hyman and Wanger[10][11] but was not
widely available until the 1950s.[12]

7 Education

Blood substitutes
Blood transfusion

11
Bolus (medicine)
Dialysis
Hypodermic needle
Life support
Oral rehydration therapy
Saline ush
Fluid warmer

References

[1] An Update on Intravenous Fluids by Gregory S. Martin,

MD, MSc
[2] Systematic Review of Hypotonic Versus Isotonic Intravenous Fluids. 2013.
[3] Ramington the science and practice of pharmacy volume
1-21st edition, page no 1051
[4] CDC Morbidity and Mortality Weekly Report Aug 2002.
Guidelines for the Prevention of Intravascular CatheterRelated Infections. Retrieved 2008-03-13.
[5] American College of Emergency Physicians, Five Things
Physicians and Patients Should Question, Choosing
Wisely: an initiative of the ABIM Foundation (American
College of Emergency Physicians), retrieved January 24,
2014, which cites
Hartling, Lisa; Bellemare, Steven; Wiebe, Natasha;
Russell, Kelly F; Klassen, Terry P; Craig, William
Raine; Craig, William Raine (2006).
Oral
versus intravenous rehydration for treating dehydration due to gastroenteritis in children.
doi:10.1002/14651858.CD004390.pub2.
[6] Schwamburger NT, Hancock RH, Chong CH, Hartup GR,
Vandewalle KS (2012). The rate of adverse events during
IV conscious sedation. General dentistry 60 (5): e3414.
PMID 23032244.
[7] Hadaway L (2007). Inltration and extravasation.
AJN, American Journal of Nursing 107 (8): 64
72. doi:10.1097/01.NAJ.0000282299.03441.c7. PMID
17667395.
[8] Know The Dierence: Inltration vs.
Extravasation http://w3.rn.com/news/clinical_insights_details.
aspx?Id=34318 Accessed 3/21/2014
[9] MacGillivray, Neil (2009). Dr Thomas Latta: the
Journal
father of intravenous infusion therapy.
of Infection Prevention 10 (Suppl.
1):
36.
doi:10.1177/1757177409342141.
[10] Stanley, Autumn (1995). Mothers and daughters of invention: notes for a revised history of technology. Rutgers
University Press. p. 708. ISBN 978-0-8135-2197-8. Retrieved 2011-06-05. Wanger and colleagues had in eect
invented the modern I.V.-drip method of drug delivery
[...]

EXTERNAL LINKS

[11] Hirschfeld, Samuel; Hyman, Harold Thomas; Wanger,

Justine J. (February 1931).
Inuence of velocity on the response to intravenous injections.
Archives of Internal Medicine 47 (2): 259287.
doi:10.1001/archinte.1931.00140200095007. Retrieved
2011-06-05.
[12] Laura Geggel (3 December 2012), A Royal Spotlight on
a Rare Condition The New York Times
[13] Intravenous Therapy Certication.
Coral Gables,
Florida, United States: National Healthcare Institute. Retrieved 2015-01-31.
[14] FDAs investigation into patients being injected with
simulated IV uids continues (Press release). United
States Food and Drug Administration. 30 January 2015.
FDA warns health care professionals not to inject patients
with IV solutions from Wallcur, of San Diego.

10 Further reading
Royal College of Nursing Standards for infusion
therapy 3rd. edition 2010

11 External links
IVTEAM.com
IV-Therapy.net

12
12.1

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