What are the alternatives for IV access in a patient with infiltrated intravenous (IV) lines who is not a candidate for a Peripherally Inserted Central Catheter (PICC) line?

Alternatives for IV Access in Patients with Infiltrated IVs Who Cannot Get a PICC Line

For patients with infiltrated IVs who cannot get a PICC line, ultrasound-guided peripheral IV catheters and midline catheters are the preferred alternatives for short to intermediate-term access (up to 14 days), while tunneled central venous catheters or implanted ports should be considered for longer durations. 1

Algorithm for Selecting Alternative IV Access

Short-Term Access (≤5 days)

• First choice: Ultrasound-guided peripheral IV catheters
  • Success rates of 87-99% reported in difficult access patients 2, 3
  • Can prevent central line placement in up to 85% of difficult access cases 4
  • Appropriate placement sites include forearm veins and, in emergencies only, external jugular vein (for ≤96 hours) 1

Intermediate-Term Access (6-14 days)

• First choice: Midline catheters
  • Recommended by the American College of Physicians for peripherally compatible infusates 5
  • More durable than peripheral IVs with lower complication rates than PICCs 5
  • Suitable for frequent phlebotomy and difficult venous access 1

Long-Term Access (≥15 days)

• For 15-30 days: Non-tunneled central venous catheters (if skilled operators available) 1
• For ≥31 days: Tunneled central venous catheters or implanted ports 1
  • Tunneled catheters are appropriate for difficult venous access if duration ≥31 days
  • Implanted ports are appropriate for difficult access if duration ≥31 days

Special Considerations

For Patients with Chronic Kidney Disease

• For CKD stage 3b or greater (eGFR <45 mL/min):
  • Avoid PICCs and midline catheters to preserve veins for potential hemodialysis access 1, 5
  • Place peripheral IVs in dorsum of hand (not forearm) for short-term access 1
  • Consider tunneled small-bore central catheters (4-French single-lumen or 5-French double-lumen) inserted in jugular vein for longer durations 1
  • Consult nephrology before any central access placement 1

For Infusion of Irritants/Vesicants

• Midline catheters and peripheral IVs are inappropriate for irritants or vesicants 1, 5
• Central venous access is required (non-tunneled CVC, tunneled catheter, or port) 1

Complications and Monitoring

Ultrasound-Guided Peripheral IVs

• Failure rates: 12-47% within 24-96 hours 4, 6
• Common complications: infiltration (most common), inadvertent removal (2.7%), phlebitis/cellulitis (0.7%) 2, 6
• Monitor for signs of infiltration and replace based on clinical indications rather than arbitrary time limits 1

Midline Catheters

• Regular monitoring for infiltration, phlebitis, occlusion, and infection is essential 5
• Not suitable for chemotherapy administration 5

Practical Tips for Success

• Train nurses and providers in ultrasound-guided techniques to improve success rates 3
• For blood transfusions, 16-20 gauge peripheral IVs are appropriate and preferable to central access 1
• Replace peripheral IVs based on clinical signs and symptoms rather than predetermined schedules 1
• Consider external jugular vein placement (by trained providers) when arm veins are unavailable for short-term access 1

By following this evidence-based approach to vascular access selection, clinicians can minimize unnecessary central line placements while ensuring appropriate access for patients with difficult veins.