What are the recommended peripheral intravenous (IV) maintenance and flush orders for an adult patient with a peripheral IV catheter receiving intermittent medications such as metoclopramide piggyback?

Peripheral IV Maintenance and Flush Orders

For adult patients with peripheral IV catheters receiving intermittent medications, flush with normal saline after each medication administration, inspect the site at every shift change, and replace the catheter only when clinically indicated (signs of phlebitis, infiltration, malfunction) rather than on a routine 72-96 hour schedule.

Flushing Protocol

• Flush peripheral IV catheters with normal saline after each intermittent medication administration to maintain patency and prevent occlusion. 1

• For ambulatory patients receiving intermittent IV therapy every 24 hours, flush once every 24 hours rather than more frequently—studies show that flushing every 24 hours results in lower complication rates (39.4%) compared to flushing 2-3 times daily (75%). 2

• Clean injection ports with 70% alcohol or iodophor before accessing the system to minimize contamination risk. 1

• Cap all stopcocks when not in use to prevent infection. 1

Site Assessment and Monitoring

• Evaluate the catheter insertion site daily by palpation through the dressing to detect tenderness, and by visual inspection if using a transparent dressing. 1

• Do not remove gauze or opaque dressings unless the patient has clinical signs of infection or local tenderness. 1

• Inspect the IV site at each shift change and remove the catheter immediately if signs of inflammation, infiltration, occlusion, infection, or blockage are present. 3

Catheter Replacement Strategy

• Replace peripheral venous catheters only when clinically indicated rather than routinely every 72-96 hours—there is moderate-certainty evidence showing no difference in catheter-related bloodstream infection (CRBSI) or thrombophlebitis rates between clinically indicated replacement and routine replacement. 3

• Remove the catheter immediately if the patient develops signs of phlebitis including warmth, tenderness, erythema, or palpable venous cord. 1

• Remove the catheter if it becomes infiltrated or malfunctions (unable to flush or draw blood). 1, 3

• If venous access sites are limited and no evidence of phlebitis or infection is present, peripheral catheters can remain in place longer than 96 hours with close monitoring. 1

• In pediatric patients, leave peripheral catheters in place until IV therapy is completed unless complications develop. 1

Catheter Selection and Site

• Use upper-extremity sites in adults rather than lower-extremity sites; if a catheter was placed in a lower extremity during an emergency, replace it to an upper-extremity site as soon as possible. 1

• Consider a midline catheter or PICC when IV therapy duration will likely exceed 6 days, as these do not require routine replacement. 1, 4

• Avoid steel needles for medications that might cause tissue necrosis if extravasation occurs. 1

Topical Care

• Do not routinely apply prophylactic topical antimicrobial or antiseptic ointment to the peripheral IV insertion site, as this does not reduce infection and may promote fungal colonization or catheter damage. 1

Administration Set Replacement

• Replace administration sets (including secondary sets and add-on devices) no more frequently than every 72 hours unless catheter-related infection is suspected. 4

• Replace tubing used for blood products or lipid emulsions within 24 hours of initiating the infusion. 4

Common Pitfalls to Avoid

• Do not routinely replace functioning peripheral IVs every 72-96 hours—this outdated CDC recommendation has been superseded by evidence showing clinically indicated replacement is equally safe, reduces costs by approximately $7 per catheter, and spares patients unnecessary pain from re-insertion. 3

• Do not flush more frequently than necessary—excessive flushing (2-3 times daily) increases complication rates compared to once-daily flushing in ambulatory patients. 2

• Do not ignore early signs of complications—infiltration and blockage occur more frequently with clinically indicated replacement, so vigilant monitoring at each shift is essential to catch problems early. 3

• Ensure trained personnel perform insertion and maintenance of IV catheters to minimize complications. 1