Decreasing IV Catheter Problems

IV catheter placement is a common procedure that can be the cause of multiple problems for our patients. Meredith Rose, CVT, VTS(ECC), gives some simple tips to decreasing these problems.

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Placing peripheral catheters is something technicians do everyday. With this article I hope I can give you some new techniques on placing them aseptically which will help them run trouble free. These are techniques that will decrease the chance of insertion site infection, thrombophlebitis, catheter occlusions, fluids going subcutaneously and patients licking and chewing their catheters.

  1. Wash your hands. The most common source of contamination for IVC is the hands of personnel.
  2. Choose the vein. Don’t just choose ANY peripheral vein. There is definitely a hierarchy when it comes to which veins are best for IV catheter placement.
    Cephalic vein - These are usually the first choice due to the superiority for ease of placement, ease of maintenance and decreased likelihood of urine and fecal contamination.
    Medial branch of the cephalic vein - Sometimes the cephalic accessory vein can be used but it is not ideal. Even though it is often easier to see than the cephalic, it is a smaller vein. Also, due to the angle, it is difficult to tape the catheter in alignment with the vein. Using this accessory vein often requires tape to be placed over the animal’s carpus which is uncomfortable and can lead to peripheral edema (mega-paw).  A misaligned catheter can kink easily, decreasing the lifespan of the catheter and putting pressure on the vein wall, increasing likelihood of thrombophlebitis.
    Saphenous vein - Both the medial and lateral saphenous veins can be used in dogs. The medial saphenous can work great for cats but the lateral is often too small. Be vigilant to monitor for urine and fecal contamination on those saphenous catheters.
  3. Clip the IV catheter site. Careful of clipper burn. Make sure to hold the clipper blade as flat to the skin as possible to decrease the chance of clipper burn. Clipper burn will increase inflammation leading to possible bacterial infections and increase the chance your patient will want to lick and chew at the catheter site. Note: Make sure you clip well below your intended catheter insertion point.
  4. Scrub the insertion site. There are many different antimicrobial cleansers to cleanse the skin. The most common types that we use are Chlorhexidine/alcohol and Betadine/alcohol. Whichever you choose make sure to do a succession of 3 scrubs.  How the scrub is stored can also have an effect on bacterial contamination.  Jars full of wet gauze (even if it is gauze soaked in scrub or alcohol) can harbor resistant bacteria that will transfer to your IV catheter site.  It is best to wet your gauze with scrub and alcohol just prior to using it on your patient.
    • Chlorhexidine Scrub - It is both bactericidal (kills bacteria) and bacteriostatic (inhibits more bacteria from growing). It is minimally affected by the presence of organic debris on the skin surface. It can potentially cause mucosal irritation in cats if they groom a prepped area. Chlorhex is NOT deactivated by alcohol (a common misconception).  
    • Betadine Scrub - Similar to Chlohex in its bactericidal effect however lacks any residual effect (it is NOT bacteriostatic). It is deactivated by any organic debris on the skin. Can be irritating to the skin surface. Betadine is NOT deactivated by alcohol (a common misconception).
    • Alcohol - Rapid onset bactericidal, but not bacteriostatic. Its use is recommended to increase the bactericidal activity of Chlorhexidine and Betadine scrub solutions.
  5. Catheter insertion: After all the trouble we have gone through clipping and cleaning there a few things we often do that will completely undo our aseptic technique.  Be careful of the following pitfalls:
    • Feeling for the vein with our finger over the insertion point. If you have to feel, feel way above your insertion point. Better yet, feel before you start your surgical scrub.
    • Dragging the catheter through hair. Wherever you decide to make your insertion point, make sure there is a healthy inch below that point that has been clipped and prepped accordingly.  It is ingrained in technicians to place the catheter as low as possible on the leg in case we need to attempt another placement. But watch for two things when placing an IV catheter very low on the cephalic vein. If placed too low it can cause a lot of movement in the catheter whenever the carpus or the tarsus is bent. This can lead to catheters inching out. The other problem is mega-paw. Cats especially are prone to mega-paw with very low placed cephalic catheters due to the way they sit with their front feet tucked under. The tape directly over their carpus gets really tight when the paw is tucked under.
    • Placing a finger directly over insertion point after catheter is placed. I see this all of the time. Techs will do this when pulling the stylet out of the IVC in order to stop blood from gushing out while they plug in the male adaptor plug. YIKES! All of the scrubbing for nothing! Here is a little secret…. you (or your assistant) can put a finger over the vein approximately where the end of your catheter is.  You won’t contaminate the insertion site and it works.. Not a drop of blood will come out of the catheter if done right!
    • Applying tape over bloody skin/hair. Dried blood makes a delicious medium for all sorts of bacteria to grow. A simple wipe with a chlorhex solution soaked gauze works wonders.
  6. Taping: There are many ways that an IV catheter can be taped. My only recommendation is that each practice decide which way they are going to tape and stick to it. This makes it easy for the next person to take down the tape and inspect the insertion site if needed, or to loosen tape due to mega-paw. Speaking of mega-paw, always be careful not put tape on too tight. Tight tape can not only cause painful mega-paw it can potentially occlude the catheter causing the fluids to go SQ.  Also watch out for those patients that are really dehydrated (5% or more) Often the tape you put on so carefully can become really tight as you patient rehydrates.
  7. IV Catheter Maintenance: Peripheral catheters can be left in for approximately 3-7 days depending on the catheter type. (There are certain IV catheters that are much easier on the vein and can be left in longer then the typical 3 days.)  At least once daily the site should be visually and manually inspected for signs of purulent/serous discharge, pain/resistance on injection, swelling above or below the catheter, and ropiness of a vessel that can signify thrombophlebitis. Also, if the patient develops a fever of unknown origin the catheter should be closely inspected and possibly pulled.  And last by not least; patients that have been good then suddenly decide to lick or chew at their catheter could have an underlying problem with that catheter. Always inspect the catheter carefully for leaking/infection etc before just putting an e-collar on them.

By taking the right approach to cleanliness and IV catheter management you can increase the life of the IV catheter and the comfort of the patient.

What protocols do you implement in your hospital to avoid infections and other problems with IV catheters?

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Betty Snitzer's picture

When placing the catheter, after it has been inserted, we place a small amount of BNP without Dex ointment at the insertion site before taping. This adds another barrier against bacterial infection at the site of insertion.

Liz Hughston's picture

I remember reading a study a few years ago that showed that BNP actually INCREASED the incidence of bacterial infection at IVC sites. Maybe in JVECCS?

Lani O'Brien's picture

Our hospital uses band-aids over the insertion site. Works really well to keep a clean, dry barrier over it.

Annie  Reedy's picture

That's clever. We are worried about getting the non-sterile tape so close to the insertion site, so we may try this. Thanks!

Dawn Slye's picture

our hospital uses the small round band-aids and they work well :)

Ana Jordache's picture

I understand the importance of a sterile field for IV catheter placement, but I do think people are slightly "over- dramatic" Our clinic just uses a small amount of alcohol after shaving (more so to "highlight" the vein) I have never seen an IV catheter infection. Have you?

Megan Brashear's picture

Couple responses: Liz and Betty, I can't remember where I read it, but yes, the oil based ointments can actually hold bacteria against the insertion site and cause more problems. It may have been JVECCS, I will dig deeper and see if I can find it.

Ana, I have seen IV catheter site infections. The population of patients that we treat in the ICU is going to be different than in more practices, they tend to have more challenged immune systems and those IV catheters are staying in for days at a time. I don't know what kind of patient population you are working with, but that will have bearing on the infection rate. I have seen red and inflamed insertion sites, phlebitis, and some patients will spike a fever for unknown reason. We look to the IV catheter and in many cases the fever will disappear when the catheter is removed and replaced. Infections are not common, but still evident and in my opinion is worth a little extra work to keep the site clean and my patient safe.

Jayme Gavisk's picture

Very good article. The band-aid idea is also helpful, especially in my situation (day clinic doing only short hospitalization, spays/neuters, etc). I have only had occasion to place a medial saphenous cath on a cat once and it was laterally recumbent. I have no idea how this would work with a normally ambulating cat. o.O (Also found it amusing that autocorrect wanted to make saphenous = sousaphone).

Gretchen Brittain's picture

I really like the bandaid idea. Also, i will remember to hold off at end of catheter while male adapter being secured rather than the insertion site. Thank You!

Sarah  Sigillito's picture

About protecting the insertion it wrong to use your first piece of tape to both secure the hub and cover the insertion point? It seems that by the end of taping in the video of IVC placement that by the end of taping, the insertion point is just barely covered but still covered. Would a small square of tegaderm be a feasible seal? I think it might, but I wonder if its not economically practical.

About wrapping...At my hospital we all tape in our own technique, most use an anchor piece, but we are required to use stirrups, cast padding and vet wrap all the way from the toe up to elbow. I'm not a fan of the bulk of the wrap as i feel pts are actually more likely to try to pull out the IVC when their leg feels cumbersome from so much bandaging. I also feel that it limits our ability to check the integrity of the catheter. Any thoughts on the use of stirrups and full wrap technique?

Megan Brashear's picture

Sarah, yes, the first piece of tape should secure the hub and cover the insertion point. I like to wrap tape at least an inch proximal to the catheter as well so there is more tape to the skin, better sealing of the insertion point, and distributing the tape maybe results in less mega-paw? Maybe... As far as wrapping the entire leg, we do not do that because it makes finding IVC problems more difficult. If the catheter is leaking, the site inflamed, the vein ropey, etc all of those issues become extremely difficult to see/feel if the leg is wrapped. It does somewhat depend on patient population, if most of your patients are in an out in a day you're probably okay, but for our longer term patients I like to see more of what's going on with that leg.

Amy Schneider's picture

Our office also likes to create a "tunnel" by inserting scissors or another instrument under the tape along the outside of the limb. This loosens the tape and makes the removal much easier.

Carmen Castro's picture

I had a question, I have heard that to help maintain an IV catheter you should re-tape the catheter (every 24 hrs) Is there any literature supporting this?


Megan Brashear's picture

Hi Carmen, to my knowledge there isn't any literature supporting removing the tape and retaping every 24 hours. What we do is inspect IV catheters every 4 hours and if a patient is suddenly acting different towards the catheter, and retape in siutations of swelling or tape contamination with water, drool, urine, feces, or blood. If the tape is clean, the IV catheter flushes well with no pain or swelling and the animal is comfortable, you can introduce a problem or bug by removing and replacing tape - not to mention risk losing the catheter if the patient is less than cooperative. If it ain't broke don't fix it, but if it is gross get that tape out of there.

Tinille McKenzie-Wyatt's picture

Thanks for this article. One question- I had read and always heard that the residual effects of chlorhexidine are negated when paired with alcohol (so we use saline). Can you share where the info came about alcohol NOT deactivating the chlorhexidine?

Ladan Mohammad-Zadeh's picture

Hi Tinille! Thank you for your comment. After reading your comment, I had to think about this question myself! I took a very unofficial poll of our doctors (including surgeons) to see what they could recollect. Most agreed with you that they do remember some reason not to use alcohol with chlorhexidine. The surgeons cited exactly your point that when chlorhexidine is used sequentially with alcohol, the alcohol may wipe away the chlorhexidine and make its residual bacteriocidal/static activity lower. So I hit the literature on this one to find the answer. I found there are a surprising number of products containing both chlorexidine 2% and 70% isopropyl alcohol. The most popular brands include ChloraPrep, Chlorascrub, Chlorex 2% and CHG-Prep. They come in bottled solutions, ready to use swab sticks, skin applicators and pads. So it appears that they can be applied together. There are a few recent studies that examined use of a combination product (specifically ChloraPrep) compared to traditional povidone-iodine (without alcohol). The most cited article is this one from the New England Journal of Medicine, N Engl J Med 2010;362:18-26. They demonstrated chlorhexidine 2% in 70% alcohol was superior to povidone-iodine in preventing surgical site infections in clean contaminated wounds. So that answers the question of "can chlorhexidine and alcohol be used together". I think the question is what is the effect when these products are used sequentially. Remember these combination products are being applied at once and left on the skin. Meredith's article suggests that we are swabbing with chlorhexidine scrub and alternating with alcohol. And if the alcohol removes the chlorhexidine does that negate the residual effect of the chlorhexidine? In my literature search I did not see a study that evaluated the use of chlorhexidine and alcohol in this sequential manner. So I am not sure what the effect would be. It seems reasonable that if you are planning on applying chlorhexidine and alcohol in an alternating manner and the alcohol is the LAST treatment applied before IV catheter placement, then perhaps the residual bacteriocidal effects of chlorhexidine would be negated. However, long lasting skin sterility is not necessary for IV catheter placement, only immediate sterility, which is achieved with the technique described above. In surgery, our surgeons use chlorhexidine scrub alternating with chlorhexidine solution OR povidone-iodine and alcohol. Sorry for the very lengthy response. This question certain got my brain cells going! These chlorhexidine/alcohol combination products have peaked my interest. If I find any additional information, I'll be sure to post again. Many thanks, Ladan

Kimberly  Harper's picture

At my hospital we store our gauze in metal tins that have been autoclaved (gauze too) and pre-wet them with scrub / alcohol so they are ready to go in case of an emergency. Do you have literature available for how this leads to more IVC infections? My doctors are interested in changing how we prep / store IVC supplies.

David Banuelos-Contreras's picture

When placing a catheter we usually put some ointment along the catheter to avoid bacteria or infection where the catheter is placed, we also use buddy tabs to make it easier to remove a catheter, aside from that we avoid making the tape tight around them.