Introduction

Peripheral intravenous catheters (PIVCs) are the most commonly used invasive device in hospitalised paediatric patients. They are primarily used for therapeutic purposes such as administration of medications, fluids, and blood products.

Aim

The aim of this guideline is to provide evidence-based recommendations for the management of peripheral intravenous catheters (PIVCs), including midlines and extended dwell PIVCs. For information related to PIVC insertion, please refer to RCH Clinical Practice Guideline: Intravenous access - peripheral.

Types of PIVCs

A peripheral intravenous catheter (PIVC) is a thin plastic tube inserted into a vein using a needle. PIVCs allow for the administration of medications, fluids and/or blood products. Some PIVCs have a longer catheter length, which are usually inserted under ultrasound guidance. A longer PIVC is referred to as an extended dwell PIVC. 

Image 1: a peripheral intravenous catheter (PIVC); Illustration by The Royal Children's Hospital, Melbourne 

A midline is a type of peripheral intravenous catheter which is usually between 5-10cm long and inserted into the brachial or basilic veins in the upper arm. These devices are inserted by specially trained practitioners. A midline is to be managed in the same way as a PIVC as the tip of the device remains in the peripheral vasculature. 

Image 2: a midline catheter *coming soon* 

Definition of terms 

• • Aseptic technique aims to prevent pathogenic microorganisms from being introduced to susceptible sites by hands, surfaces and equipment. It is a set of practices designed to reduce contamination and protect the patient from infection during invasive procedures such as midline/PIVC insertion and maintenance. See procedure here.
  • Key Parts are parts of the device/s that must remain aseptic throughout the clinical procedures. Examples of key parts include, the catheter hub, needleless connector, syringe hub and drawing up needle.
  • Key Sites are the area on the patient such as a wound or intravenous insertion site that must be protected from microorganisms
  • Scrub the hub ensure the needleless connector is ‘scrubbed’ vigorously with 2% chlorhexidine and 70% alcohol swab for 15 seconds and allow for it to completely air dry.
  • Hand Hygiene is performed to protect the patient from organisms which may enter their key sites or key parts during a procedure. See procedure here.
  
  

Assessment

Midline/PIVC site assessment aims to:

1. Ensure early recognition of complications such as extravasation, phlebitis, occlusion and device associated pressure injuries.
2. Ensure the dressing, catheter and attachments are intact and secure to prevent dislodgement.
3. Maintain visibility of the insertion site. 

How to perform midline/PIVC site assessment

Midline/PIVC assessment is to include the ‘Touch, Look, Compare’ technique (TLC). Whenever possible, cluster site assessment with other care.

• Touch to assess the site is soft, warm, dry and non-tender.
• Look to ensure the site is dry and without redness. Ensure tapes are not too tight, there are no kinks in the catheter and the insertion site is visible.
• Compare the site with the other limb or side of the body. The site should be the same size, without swelling.

Indications for midline/PIVC removal:

With each assessment, also assess clinical indication for ongoing access. If the patient no longer requires IV access, remove the device as soon as clinically appropriate to avoid complications.

Caregiver and patient education:

Education should be provided on the signs of injuries and the process of contacting nursing staff.

Frequency of midline/PIVC assessment:

Documentation

• Midline/PIVC site assessment and complications are to be documented in the LDA flowsheet row.
• The volume of fluid infused, and the infusion rate is documented in the fluid balance flowsheet.
• Documentation occurs with each assessment.
  

Management of Midline/PIVC associated complications 

*High risk medications 

Please see Peripheral Extravasation Injuries CPG for list of high risk medications.

Management of Midline/PIVC 

Anytime a Midline/PIVC is accessed please ensure the following occurs:

• Scrub the hub, needless connector is ‘scrubbed’ vigorously with 2% chlorhexidine and 70% alcohol swab for 15 seconds and allow for it to completely air dry.
• Aseptic technique is utilised, see Aseptic technique procedure.

Infusion Pump Pressure

Pressure limit defaults for intravascular infusion pumps are programmed by Biomedical Engineering, based on the manufacturer’s recommendations.

Upper limit infusion pump pressure can be manually increased with clinical discretion to accommodate:

• Increased viscosity of the fluid being administered

• High rate of the fluid being administered

• Reduced diameter of the intravascular catheter

• Increased length of the intravascular catheter

• Increased level of patient activity 

If pump pressure exceeds the recommended limits, check the patency of the midline/PIVC.

Special consideration: Patients admitted to the Neonatal Unit should have line pressure documented within the Peripheral IV Cannula Lines, Drains, and Airway (LDA) tab.  

Flushing and locking midlines/PIVCs

To keep vein open (TKVO)* is a continuous infusion of fluid administered in-between medication(s). The infusion rate of TKVO usually ranges from 1mL-10mL per hour. TKVO rates vary depending on the patients age, weight and underlying condition.

Intermittent locking* refers to the administration of a small volume (usually between 2-10mL) of 0.9% normal saline in-between infusions and then disconnecting the infusion set from the midline/PIVC. The volume of the lock should take into consideration the volume of the midline/PIVC, and any add on devices. The lock is to be administered using a pulsatile (push-pause) technique and if a clamp is present, it is to be closed under positive pressure (i.e., whilst the lock is being administered).

*There is limited evidence available to guide practice on the advantage of TKVO versus intermittent locking in patients who are not receiving continuous medication or fluid. Intermittent locking may be the preferred method for patients who are able to ambulate whilst receiving intermittent intravenous treatment.  

If the midline/PIVC is to be accessed intermittently for the administration of medications or fluids, it is to be flushed prior to infusion or at least once a shift

In most cases, 0.9% sodium chloride for injection is to be used to flush the midline/PIVC. This must be prescribed as a medication

Use 10mL syringe for flushing to avoid excessive pressure and catheter rupture. If resistance is felt during flushing and force is applied this may result in an infiltration or extravasation injury

Use aseptic non touch techniques including cleaning the access port (scrub the hub) vigorously for at least 15 seconds and allowing to dry prior to accessing the system

When flushing or locking the midline/PIVC use a pulsatile flushing technique (push pause motion)

Flush catheters:

• Before and after each infusion
• Immediately after placement
• Prior to and after fluid infusion (as an empty fluid container lacks infusion pressure and will allow blood reflux into the catheter lumen from normal venous pressure) or injection.
• Prior to and after blood drawing

Lock catheters:

• At the completion of an intermittent infusion;
• Close clamp or ensure 3-way tap is clamped.
  
  

Midline/PIVC dressings

Midline/PIVC dressings promote catheter security and prevent infection as they provide a barrier to the external environment.  PIVC dressings are to be kept secure, clean, dry, intact and easily visible. The integrity of the dressing and all PIVC components are to be assessed when preforming TLC.

There is no evidence available to suggest that routine PIVC dressing changes are beneficial. Dressing changes are to occur when either the insertion site or dressing are no longer secure, clean, dry and intact.

If the midline/PIVC requires a dressing change, consider the risk of the procedure and determine if a standard or surgical aseptic technique should be used.

Midline/PIVC removal

Midline/PIVC removal is to occur as soon as the device is no longer required.

Using a standard aseptic technique, gently remove the old dressing and then pull the catheter our of the skin whilst applying pressure (with gauze) to the insertion site until haemostasis is achieved. 

Document removal in the medical record.

Companion Documents

RCH Clinical Practice Guidelines

• Intravenous access - Peripheral
• Peripheral extravasation injuries: Initial management and washout procedure
  

RCH Nursing Guidelines

• Pressure Injury Prevention and Management

RCH Policies and Procedures

• Central Venous Access Device
• Medication Management
• Procedural Pain Management
• Blood Transfusion - Fresh Blood Products
• Aseptic Technique
  

Evidence Table

Updated evidence table coming soon.

The evidence table can be found here. 

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Eloise Borello, CNC Vascular Assess Specialist Team approved by the Nursing Clinical Effectiveness Committee. Updated March 2025.