Central Venous Access Device (CVAD)

Internal Jugular Central Catheter (IJ)

*Bleeding can be easily recognized and controlled* (IJ is very superficial) *Less risk of pneumothorax, but still possible* (the needle is pointed downward towards the lung, can possibly puncture) *Risk of Carotid Artery puncture* (IJ is right next to carotid artery)

Trouble Shooting Central Lines

*COMPLETE OCCLUSION* Can't Flush The Line -Do Not Force -Attempt To Aspirate -Ensure Line Is Not Kinked -Change Clave Cap: can get clots too -Reposition Patient (catheter tip might be suctioning vein wall) -Sitting -Lying -Turn Head (and cough) -Valsalva Maneuver: bearing down position (blowing through straw/lifting something/BM act pressure) -Declott -Cathflo *PARTIAL OCCLUSION* Line Flushes But *Can't Withdraw Blood* -Fibrin Sheath -Power Flush -Reposition Patient -Declott -Cathflo

Length of Time: CVC vs PICC pt 2

*CVADs* are used for long-term delivery of medications, nutrition, and fluids. -Can stay in a few months to years. Most are threaded under the skin, and the delivery tip is in a central vein *FAR* from the skin insertion site. -This helps decrease risk of infection and protects from minor bumps and tugs. Since vein is large, meds and fluids given through a central line typically do not irritate the vein lining. *Peripheral IV Catheters* are commonly used for most hospitalized pts, peripheral veins are smaller, lie close to the surface of the skin, and can easily be bumped or dislodged. Meds can also irritate the lining of a peripheral vein. -PICCs are best for short-term use.

CVC Dressing Change

*Change dressing if it becomes damp, loose, or visibly soiled* *Dressing changes are to be done according to hospital policy and protocol (usually done WEEKLY)* *Chlorhexidine is the preferred cleaning agent. Per facility policy alcohol or betadine may be used* -Chlorhexidine: scrub w/ friction up and down and side to side (clean large surface area). Let dry 1-2 minutes -Alcohol or Betadine: scrub from center out (circular motions with alcohol) *Do Not use topical antibiotic ointment or creams* -Topical antibiotic ointments/creams only work for about 24 hours, then becomes a great medium for bacterial growth *Visually inspect insertion site for swelling, erythema or drainage.* -THREE E's: *erythema, edema, exudate* *Do Not use acetone or adhesive remover to remove old dressing* *Signs of Clot:* If line has a clot, fluid can backflow and move from vasculature into tissues (third spacing) and leak out of insertion hole/site onto dressing.

Hemodialysis CVAD 2

*Dialysis Catheters:* is tunneled into the superior vena cava (HemoSplit Long-Term Dialysis Catheter; double lumen). *Arteriovenous fistulas are preferred over catheters*. *DO NOT USE UNLESS APPROVED BY PHYSICIAN!* -Nurses need further training to use/access these. DO NOT TOUCH unless trained! *Used ONLY for hemodialysis* -Pt who do not have fistula -Pt in ACUTE renal distress Molecules are too big to go through arterial line - they occlude arterial capillaries

Drawing Blood from a Central Line

*Disconnect IV Fluids* *Flush With At Least 10 mls NS* *Withdraw 5 mls Blood To Discard* *Use Syringe or Vacationer to Withdraw Desired Amount of Blood* -Use syringe if you need more pressure on sluggish lines -Waste the first 3-5 cc (RED TOP) *FIRST* *Flush with At Least 20 mls of NS* -Want to flush blood in line back into vasculature - *push/pause method* -Flush with NS x2 (like practiced in lab)? *Flush with Heparin or Connect IV Fluids* -Not actually giving pt heparin - only filling the lumen to prevent clotting -10 units (BLUE) -100 units (YELLOW): used for ports sometimes *Label Specimens "Line Draw"* -can sometimes hemolysis RBCs and produce inaccurate lab readings because the content of the RBC is now in the vial (for example, high K+ in results) -Pick one lumen specific for blood draws: if it happens to clot of, you still have access to other lumens

Femoral Central Catheter

*Easy to find and locate femoral vein* *NO risk for pneumothorax* *Preferred site for emergencies, trauma, and CPR* *Fewer complications in placement* *HIGHEST risk for infection* *Risk for DVT* (*Thrombophlebitis:* blood clots in veins) -These veins tend to clot fastest: the femoral vein runs along the inside of the legs from groin area downward. Blood flow in the normal veins, which are much larger in diameter than arteries, is much slower. Veins tend to hold blood longer and flow is never fast moving. DVT has its highest risk when a person becomes immobilized and muscles are not contracting to push blood back to the heart. This stagnant blood begins to form blots along the walls of the vein. This initial clot can gradually grow to partially or completely occlude the vein and prevent blood from returning to the heart. -DVT may occur as soon as 1 day after cannulation and is usually asymptomatic -*Embolization:* from veins is totally different than from the arteries. Embolization from veins usually occurs from the veins in the pelvis, thighs, groin or from knee level. When these clots break loose they go through the heart into the lungs blocking off blood flow and this pulmonary embolism (PE) can cause death. The warning signs of smaller clots is a sudden feeling of impending doom, SOB, or pain in your chest when you breathe in and out (*pleuritic*). *Not ideal for ambulatory pt*

Complications of Central Line Insertion

*Infections* *Vascular Complications* -Air Embolism: are creating a large hole directly into a vein -Arterial Puncture -Arteriovenous Fistula: can suck line back into the fistula -Hematoma -Blood Clot: when there is difficulty threading vein (keep trying which causes irritation and inflammation) *Miscellaneous* -Dysrhythmias: cath tip touching heart -Catheter Malposition -Nerve Injury: puncture through nerve bundle to go to vein -Pneumothorax (air), Hemothorax (blood), Hydrothorax (fluid), Hemomediastinum -Pneumo/Hemothorax: air/blood in the space between chest wall and the lung (the pleural cavity) -Hydrothorax: fluid in the pleural cavity (pleural effusion: escape of fluid into pleural cavity) -Hemomediastinum: blood in mediastinum -Bowel or Bladder Perforation (a hole made by boring or piercing)

Central Line Occlusions

*Intraluminal thrombus* - VERY COMMON This type of occlusion develops when fibrin accumulates in the lumen of the CVAD, causing sluggish flow and, possibly, complete obstruction. Insufficient flushing, frequent blood withdrawal, and reflux of blood into the catheter may all contribute to intraluminal thrombus formation. *Mural thrombus* This type of clot forms when the catheter tip irritates the vessel wall to the point of injury. Fibrin from the injured site binds to fibrin that has accumulated on the catheter surface, and this causes the CVAD to adhere to the vessel wall. *Fibrin sheath* - VERY COMMON Also known as a fibrin sleeve, this condition develops when fibrin sticks to the external surface of the catheter, forming an adhesive "sock." Infused solutions get blocked by the sheath at the catheter tip but may travel back along the sheath on the outside of the catheter, causing tissue irritation and necrosis. *Fibrin tail* Also called a fibrin flap, this type of occlusion forms when fibrin adheres to the end of the catheter. This tail often acts as a one-way valve, permitting infusion when the infused solution pushes the tail away from the catheter tip, but preventing withdrawal as the tail is sucked against the tip.

Subclavian Central Catheter

*Most comfortable for conscious patients* *Highest risk of pneumothorax* (lung goes up to clavicle - easy to be punctured) -*Pneumothorax*: a collapsed lung. Occurs when air leaks into the space between your lung and chest wall. This air pushes on the outside of your lung and makes it collapse. In most cases, only a portion of the lung collapses. -*Causes:* Usually caused by blunt or penetrating chest injury, certain medical procedures, or damage from underlying lung disease. -*Symptoms:* sudden chest pain and SOB. -*Treatment:* inserting a flexible tube or needle between the ribs to remove the excess air. However, a small pneumothorax may heal on its own. *Usually not placed in pt <2 yrs old* *Vein is NONCOMPRESSIBLE (using ultrasound) -Veins Collapse; Arteries Pulsate during cannulation

PICC Line Insertion Techniques

*Seldinger Technique* -Use introducing needle to locate and cannulate the vein -Wire is threaded through the needle -Needle is removed -Skin and vessel are dilated -Catheter is placed over the wire -Wire is removed -Catheter is secured in place *Modified Seldinger* -IV insertion -Wire....... Etc. *Ultrasound Guidance:* -Looks for veins that are deeper and thicker. Use ultrasound to find these veins on pt who are hard sticks!

Accessing a Port-a-Cath

*Sterile Technique* *Use Huber (non-coring needle)* -Needle designed with a deflected or offset 'B' bevel point. This tip has the advantage of parting rather than cutting a plug from or coring the silicone septum of a vascular access port or injection site. -Reseals port-a-cath and does not take chunks of septum when inserting. *Insert needle at a 90 degree angle* Port is sutured to muscle fascia

CVC Flushing Methods

*Use 10 ml Syringe* *Scrub hub 10-15 seconds EVERY TIME* you hook up a syringe/med and between switching *Aspirate Blood Prior To Flushing* -No blood return, DO NOT USE! *SAS or SASH Method* -PICC only SAS; CVC usually SASH *Push/Pause Technique* -Creates turbulence and clears the line of clots *Flush Every 12 Hours* -Unless you have fluid running (saline); hep-lock and meds - flush every shift w/ heparin *Positive Pressure Caps (Clave Caps)* *Apply Alcohol Cap* -Does NOT replace the need for alcohol scrub

What is a CVAD?

-Central line or CVAD is an *umbrella term* for multiple types of lines A *central line,* also known as a *central venous access device (CVAD)* is a thin, soft, flexible tube - also known as a catheter. The catheter is placed in a*vein* that leads to the heart. The other end of the CVAD catheter either EXITS *near the surface of the skin* or *sits directly underneath the skin.* The CVAD contains single or multiple *lumens*

What is the Difference?

-How the line is inserted -Where the line is inserted -Length of stay of the line

My Patient has a CVC, Now What?

1. Apply STERILE non-occlusive dressing 2. Chest X-Ray to confirm TIP placement 3. Do NOT use CVC until placement CONFIRMATION 4. Use NEW IV administration set - NEVER connect old tubing to a new CVC

Central Lines ALSO KNOWN AS (AKA)...

1. By Device i. Central Venous Access Device (CVAD) ii. Central Venous Catheter (CVC) iii. Central Line 2. By Type i. TLC (triple lumen catheter) ii. PICC 3. By Site i. Subclavia, Jugular (IJ), Femoral 4. By Brand Name (Tunneled) i. Broviac, Hickman, Groshong, Mediport

Common Types of CVADS (document)

1. Peripherally Inserted Central Catheter (PICC) 2. Tunneled Catheters (Broviac, Hickman, Leonard, Groshong) 3. Implanted Ports (Port-a-Cath)

Types of CVADS

1. Subclavian Line, Femoral Line, Internal Jugular Line -Single, Double, Triple, or Quad Lumen -Each lumen terminates a different point in the catheter. Treat each lumen as its own separate IV. 2. Peripherally Inserted Central Catheter (PICC Line): Placed in arms 3. Hemodialysis Vascular Catheters (Tunneled and Non-Tunneled) -Hemodialysis catheter only used for pt receiving treatment for renal failure. It is used for dialysis access. 4. Implanted Ports (Port-a-Caths)

Case Study Questions

11 Questions

Which type(s) of thrombolytic occlusion occurs most often in patients with central lines? A. intraluminal thrombus (inside lumen) B. mural thrombus (clot on tip of cath) C. fibrin sheath: slow onset occlusion (over about 24 hr period, gets worse until cant flush it) D. fibrin tail What would you do to address this CVAD problem?

A & C CATH-Flo Mix with 2.2 mls sterile water Use 3-way stop-cock technique -IV Therapy knows how to do this! Leave in AT LEAST 60 minutes.

Hemodialysis CVAD 1

A CVAD used temporarily for dialysis access. A common site for a hemodialysis CVAD is the *internal jugular vein* The catheter has 2 lumens that are used at the *same time.* One allows blood to flow out of the body to be cleaned, and the other allows clean blood to return to the body. *Care for CVAD used for Hemodialysis:* -Sterile dressing changed every 2 days if gauze is used, and every 7 days for transparent dressings (usually done during dialysis) -regular changing of needleless connectors and flushing of tube -entry site should not get wet

Hemodialysis (HD)

A dialysis machine and special filter called an artificial kidney (dialyzer), are used to clean the blood. A *hemodialysis access, or vascular access,* is a way to reach the blood for hemodialysis. This access allows blood to travel through soft tubes to the dialysis machine where it is cleaned as it passess through the *dialyzer.* An access is placed by a minor surgery. *Access occurs through one of the following:* i. *Fistula:* an access made by joining an artery and vein in the arm ii. *Graft:* an access made by using a piece of soft tube to join an artery and vein in the arm iii. *Catheter:* a soft tube that is placed in a large vein, usually in the neck If the access is a *fistula or graft,* the nurse will place 2 needles into the access at the beginning of each treatment. These needles are connected to soft tubes that go to the dialysis machine. The blood goes to the machine through one of the tubes, gets cleaned by the dialyzer, and returns to the patient through the other tube. If the access is a *catheter,* it can be connected directly to the dialysis tubes without the use of needles. 1. A *fistula* should be considered the FIRST choice for access because it generally lasts longer and has fewer problems such as infections and clotting. However, some pt may not be able to receive a fistula because their blood vessels are not strong enough. 2. A *graft* is considered the SECOND choice for access. 3.*Catheters* are generally used as a *temporary access, but may sometimes be permanent.*

To prevent an air embolism, what action should you take during removal of a central line? A. ask the patient to hold their breath B. ask the patient to breath in C. place the patient in an upright position D. place the patient in a reverse Trendelenburg position

A: Valsalva Maneuver -Not B: increase risk for air embolism

The site of your patient's central line is oozing blood. What is the appropriate action to take? A. apply a sterile gauze dressing under a transparent dressing B. apply a sterile gauze over a transparent dressing C. change dressing every 12 hours D. change the dressing every 72 hours

B: apply pressure dressing over transparent dressing to avoid increased risk of INFECTION -Not A: cannot see site with gauze dressing under transparent dressings; also blood soaked gauze good medium for bacterial growth

Which of the following should you do after the removal of a patient's central line? A. apply a gauze dressing and a transparent dressing B. apply an antiseptic ointment or petroleum gauze under a gauze dressing C. keep the patient flat for 3 hours D. keep the patient flat for 5 minutes

B: ointment occludes the site -Not C or D: only 30 minutes

CVC Line Options

All CVCs are available in MULTIPLE LUMEN options: -Lumen: a hollow channel within the line i. single, double, triple Triple Lumen Catheters -Usually used when giving multiple meds that are NOT compatible; TPN; blood drawing clave i. Proximal Port ii. Medial Port iii. Distal Port

Implanted Port (Port-a-Cath)

An implanted port has an entry port that is a plastic or metal drum and a catheter that extends towards the heart (catheter tip ending right outside the heart). The port is surgically placed under the skin in the upper arm or chest wall. Ports can stay in place for several years. The middle of the port has a soft, rubbery section where a needle can be inserted called a *septum.* *Care with a Port:* -A special angled needle has be to inserted through the skin to give medications or fluids. Numbing medication may be placed over the port site before the needle is inserted. -When the needle is in place, a STERILE dressing covers the port site -There are fewer activity restrictions with a port -You can swim or shower without protection when the port is disconnected from a needle and tubing.

Central Line Definition

An intravascular catheter that terminates at or close to the heart or in one of the great vessels -Superior Vena Cava (SVC) -Inferior Vena Cava (IVC) -Internal Jugular Vein -Subclavian Vein -Common Femoral Vein -Umbilical Vein (neonates)

Contraindications For Central Line Placement

Bleeding Disorders (ITP) Anticoagulation or Thrombolytic Therapy (TPA Therapy) Combative Patients -This is a sterile procedure and combative pt make it unsafe and unsanitary Distorted Local Anatomy Cellulitis, Burns, Severe Dermatitis -Sterile Procedure: do NOT want to put line through non-intact skin Vasculitis: inflamed vein

A patient had a PICC line placed 12 hours ago. She is now complaining of mild pain to the insertion site. You note redness, and mild swelling to the arm. Which statement about mechanical phlebitis is correct? A. signs and symptoms usually resolve less than 12 hours after treatment B. signs and symptoms usually resolve about 1 week after treatment begins C. mechanical phlebitis is treated by application of low-degree heat D. mechanical phlebitis is treated by application of high-degree heat

C -Not A: less than 72 hs -Not B: 1 week is too long, it is something else -Not D: high-degree heat would burn pt Serous Drainage is okay, so is white (WBCs)

Your patient states she has jaw and ear discomfort during infusions of antibiotics. Her symptoms may indicate: A. thrombotic occlusion B. mechanical phlebitis C. catheter migration D. catheter rupture How would you address this CVAD problem?

C DO NOT USE LINE Notify IV Therapy Immediately for line repositioning or replacement.

Which of the following complications is most likely to cause a central line to become sluggish? A. catheter rupture B. hematoma C. medication-precipitate occlusion D. catheter occlusion How would you address this CVAD problem?

C Medication precipitation is a slow and gradual process. First sign of possible medication-precipitation occlusion is the line will become slow and sluggish -someone is not flushing meds appropriately

Cannula vs Catheter

Cannula is a short flexible tube which is introduced into a blood vessel. Catheter is a tube which is substantially longer than intravascular cannula for peripheral access to body.

Cathflo

Cathflo is a thrombolytic agent (a drug that is able to dissolve a clot [thrombus] and reopen an artery or vein) that is a viable treatment option for CVAD occlusions as *assessed by the ability to draw blood.* It is a human recombinant tissue plasminogen activator (alteplase). -A form of tissue plasminogen activator that is made in the laboratory (enzyme). It helps dissolve blood clots and is used to treat heart attacks, strokes, and clots in the lungs. If catheter function is not restored at 120 minutes after 1 dose of Cathflo, a second dose may be instilled.

Length of Time: CVC vs PICC

Central Venous Catheter (or CVAD): *< 7 Days* -these include IJ, subclav., etc. Peripherally Inserted Central Catheter (PICC): *> 7 days to years*

Preventing CLABSI (Central Line Associated BloodStream Infection)

Central venous catheters (CVCs) *disrupt the integrity of the skin allowing bacteria and/or fungi to enter.* A CLABSI is a primary bloodstream infection (BSI) in a patient that has had a central line *within a 48 hour period.* *Prevention of infection is dependent upon:* -Effectively reducing the number of microorganisms on the skin -Limiting access of the microorganisms to the catheter site

The blood return on your patient's central line decreases when he lies down. You find no kinks in the tubing. What is the most likely cause of this problem? A. catheter rupture B. hematoma C. medication-precipitate occlusion D. catheter occlusion How would you address this CVAD problem?

D The catheter may be malpositioned against the vessel wall while the patient is lying down REPOSITION YOUR PATIENT Consider line replacement

Who Needs a CVAD?

Doctor may suggest a central venous access device (CVAD) in the medical condition requires: i. Chemotherapy medications (as part of cancer treatment) ii. Long-term medications (such as antibiotics [> 7 days]) iii. Multiple IV Antibiotic Therapy: compatibility issues (contain multiple lumens) iv. Multiple Blood/Blood Products: blood is NOT compatible with ANYTHING (needs own lumen) v. Vesicant or Irritant Drugs (Dopamine, Dilantin, Vancomycin [very acidic med]) -*Vesicant:* an agent that causes blistering -*Vesicant Extravasation:* the leakage of certain drugs called vesicants out of a vein into the tissue causing blistering and other tissue injury, if severe enough can lead to tissue necrosis. *This is why these meds are given through CVAD. Vessels and thicker and the more turbulent blood flow help prevent blistering and irritation of these agents.* -*Vesicant Medications*: Dopamine, Dilantin, Vancomycin (very acidic med), Potassium Chloride, Calcium Gluconate, lot of antineoplasic drugs (chemo drugs), dextrose >10% and 0.45% Sodium Chloride. -Potassium is a common vesicant medication. When given in a peripheral vein it causes Phlebitis. It is better to given in central line because great vessels are thicker and the turbulent blood flow. vi. Frequent Blood Transfusions vii. Frequent Blood Tests viii. Hemodialysis ix. Hemodynamic Monitoring (Monitor Right Atrial [RA] Pressures) -at atrial cable junction x. Parenteral nutrition (PN) or total parenteral nutrition (TPN): nutrition given through a vein

Today you are working in the ICU and are anticipating a new admit from the ER. The patient is a 67 year old female who is being admitted with septic shock, status post cardiac resuscitation. She is requiring IV infusions of Levophed (norepinephrine) and dopamine, and is currently receiving a 1000 ml fluid bolus. Do you anticipate this patient requiring a CVAD? Which type of CVC would be appropriate?

Femoral or Subclavian Line -Femoral more likely because of doing CPR

Reducing CLABSI

HAND HYGIENE!! Chlorhexidine Site Disinfection Optimal Catheter Site (avoid femoral site) -If pt has femoral line and starts ambulating, advocate for your pt to get the line removed Strict Sterile Technique During Placement and Dressing Changes Use BioPatch -infused with hemostatic agent and chlorhexidine -Hemostatic agent: (process called hemostasis) used as an adjunct or alternative to standard surgical techniques (electrocautery, sutures) to manage bleeding from surgical surfaces. Helps with coagulation. Use Alcohol Caps Remove Line When No Longer Necessary

Today you are working on an antepartum unit. Your patient is a 27 year old women in her 14th week of pregnancy. She has had severe emesis since her 8th week of pregnancy and has been admitted to the unit with hyperemesis gravidarum and dehydration. The physician note indicates the plan to place a CVC and initiate TPN therapy for the next several weeks. Which type of central venous access device would be the most appropriate for this patient?

PICC Line

Today you are working on the medical/surgical floor. Your patient is a 45 year old male admitted with right lower extremity osteomyelitis secondary to a diabetic calcaneal ulcer. He is being discharged today and will be receiving Vancomycin therapy for the next 6 weeks. Which CVAD would be appropriate for this patient?

PICC Line -PICC because pt doesn't have cellulitis of upper extremities -NOT PORT because pt only needs it for 6 weeks

PICC Line

PICC line is placed through a puncture into the vein, typically in the arm (in an infant, a leg vein may be used). The PICC is advanced through larger veins towards the heart. The tip sits near the entry of the heart (the superior vena cava). The line can have one or more lumens. PICC lines can be left in for months, and most people find them comfortable. *Care of a PICC Line:* -Entry site must have STERILE dressing -Dressing and needleless connector need to be changed at least every 7 days -Tubing has to be flushed regularly - sometimes daily -Entry site should NOT get wet - cover it during showering/bathing -PICC can *slip out* so you have to check it daily to make sure the tubing is secure and the length of the tubing has NOT changed

Port-a-Cath

Sits below the skin for blood draws or delivering treatments *Medi-Port* -Requires surgical placement *Commonly used in pt requiring LONG TERM therapies* -Chemotherapy -Biologic Medications: produced from living organisms or contain components of living organisms. -Pt w/ really bad veins *May be in place for MONTHS to YEARS* -Comfortable for pt

Umbilical Venous Catheter (UVC)

Used in newborns and premature infants

Tunneled Central Venous Catheters

VADs that have a portion of the catheter lying in a subcutaneous tunnel. Separating the points where the catheter enters the vein from where it exits the skin. -A small cut is made on the chest, usually near the collarbone. The tip of the catheter is advanced into a large vein leading to the heart. The other end of the catheter is threaded under the skin and brought out through a small cut on the chest. Most catheters contain a *cuff* that lies under the skin at the entry site. *Broviac - Hickman - Leonard - Groshong* -Require Surgical Placement *Typically used when peripheral veins are too small for a PICC line* *Most often used in PEDIATRIC pts* (veins too small for PICC) *May be in place for SEVERAL MONTHS to YEARS* *Exit sites are typically the chest or abdominal wall* *CARE for Tunneled Catheter:* -The *cuff* helps secure the catheter, so it rarely slips out -Sterile dressing and needleless connector changed at least every 7 days. *Once healed, catheters may not need a dressing* -Tube has to be flushed regularly; sometimes daily -entry site should not get wet

Discontinuing a Central Line

Within RN scope of practice! *Supine or Trendelenburg Position* -Prevents air embolism -have pt stay down for 30 minutes *Valsalva Maneuver During Removal* *Apply Pressure* *Apply Occlusive Barrier Ointment (Vaseline)* *Apply Sterile Dressing (24 hours)*

Phlebitis

inflammation of the walls of a vein -Erythema, Pain, Swelling *Mechanical:* Associated with catheter movement within the vein. Irritation of the vein *intima* (inner lining of vein) -Usually resolves within *72 hours.* If it doesn't resolve in 72 hours it is more likely an *infection* -*Treatment:* low-degree heat (warm, moist heat) *Pick largest vein and use smallest catheter! If the catheter is too big it rubs against the vein!* *Chemical:* Associated with peripheral IV lines (PICC). Irritation of vein intima caused by *medications* -*Prevention:* infuse meds slowly, use appropriate IV/med