Peripheral intravenous (PIV) insertion in the non-affected limb of stroke patients with motor or sensory deficits is preferable to insertion in the affected limb due to higher risks of complications like infiltration, deep vein thrombosis, and infection in the affected limb. Placement in the affected limb requires close monitoring for complications if medically necessary. Long-term PIV placement increases risks of thrombophlebitis. More data is needed comparing complication rates of PIV placement in affected versus non-affected limbs through a clinical study.

1. Peripheral Intravenous Placement
Complications in the Stroke Patient
Stephanie Bax, Kristen Newlon, and Caitlin Mitchell

2. PICO Question
In stroke patients with an affected limb, how does peripheral intravenous (PIV) insertion in
the non-affected limb compared to PIV insertion in the affected limb affect PIV
complications?
 P – Problem
Stroke patients with an affected limb
 I – Intervention
PIV insertion in non-affected limb
 C - Comparison/Control
PIV in affected limb
 O – Outcome
Absence of PIV complications

3. Saint Luke’s Health System Policy and Procedure
 Intravenous Access Device Care and Maintenance, SLHS PC-028, 2014
 Level E: Peer Review without clinical studies
 A PIV is no longer than 3 inches and placed in upper and lower extremities
 Risk of thrombus if less than 1 inch above or below point of flexion
 Nurse must be attentive to pain, tenderness, redness, swelling, or infiltration
 Changing the PIV site after 48 hours is recommended but not required by CDC

4. Vascular Access: A Guide to Cannulation
 Scales, 2005
 Level D: Professional Standards
 Areas of stroke, dermatitis, edema, cellulitis, planned limb surgery should be avoided
 Avoid placement in tender, thrombosed, or hardened veins
 Certain veins are more suitable for cannulation than others
 Cannulation in the lower extremities points to increased risk of DVT
 For comfort and independence, the patient may prefer the non-dominant limb

5. Peripheral Venous Access in Adults
 Frank, 2015
 Level E: Peer Reviewed Professional
 Motor and/or sensory deficits are contraindicated for PIV placement due to the
patient’s inability to feel signs of infiltration
 Limbs with these deficits are likely to develop DVT due to the likeliness of infiltration
and other issues such as pulmonary embolism
 Temporary IV access in an affected limb can be used when medically necessary, but
requires close monitoring for infiltration

6. Epidemiology of PIV Infusion Thrombophlebitis
 Tagalakis, Kahn, Libman, and Blostein, 2002
 Level C: Systematic review with inconsistent results
 One of the most serious complications of a PIV is thrombophlebitis, which is caused
when an PIV is occluded and then becomes infected. The infection is caused by an
intravascular access, which then can lead to bacteremia.
 There is a significant increase of patients with intravenously-related bloodstream
infection that relate to peripheral vein thrombophlebitis
 The length of time that the PIV is in the vein is the most important predictor of
peripheral vein thrombophlebitis

7. Upper Extremity DVT Associated with PICC
 Hyman and Cardenas, 2002
 Level E: Multiple Case Reports
 People with cervical spinal cord injuries are at risk for DVTs due to upper extremity
paralysis
 Common signs and symptoms of DVTs are: swelling, pain, and limb limitations
 Low incidences of DVTs in upper extremities have been reported
 High risk of other complications such as pulmonary embolism are associated with
DVT’s

8. Recommendations
 With critical decision thinking and judgment of healthcare staff, PIV insertion should
be avoided in complete sensory and/motor deficit limbs
 Patient may prefer the non-dominant limb for independence and comfort
 Nurse may not need to replace PIV as often if in affected limb due to less movement
and risk of hitting the PIV
 If treatment is medically necessary, temporary PIV access in the affected limb may be
used cautiously with extensive nursing judgement for about 72-96 hrs
 Monitor for:
 Motor Deficit: pain, redness, swelling, difficulty flushing, burning with medication
administration
 Sensory Deficit: redness, swelling, difficulty flushing

9. Recommendations Continued
 In nursing practice of using PIV on affected limb:
 Frequent flushing every 2-4 hrs with 10 cc’s of normal saline
 Note signs and symptoms of infection: increased WBC, tachycardia, fever,
hypotension, etc.
 No blood pressure cuff on side with PIV
 Mobility of the affected limb with PIV
 Practice sterile technique
 Follow policy and procedure on site changes and dressing changes

10. Next Step: Gather More Data!
 Subjects: Hospitalized CVA patients with motor or sensation deficits in upper or lower
limb and with informed consent
 When in practice, observe for signs and symptoms of infiltration or DVT
 Document results of PIVs that were discontinued due to these complications
 Also document pertinent patient data:
Type of CVA, related medical history (increased risk of clotting), location of PIV
(affected vs non-affected limb and anatomical site), duration of PIV insertion, and
symptoms causing reason for removal
 Time frame of one year to gather data
 Use clinical tools to to interpret results and provide more conclusive recommendations

11. References
Frank, R. L. (2015). Peripheral venous access in adults. Up to Date. Retrived from
http://uptodate.com/contents/preipherial-venous-acess-in-adults?topicKey=EM%2F…
Hyman, G., & Cardenas, D. (n.d.). Upper-extremity deep vein thrombosis associated with peripherally
inserted central catheters in acute spinal cord injury: A report of 2 cases. Archives of Physical Medicine
and Rehabilitation, 1313-1316.
Scales, K. (2005). Vascular access: a guide to peripheral venous cannulation. Nursing standard, 49 (49),
48-52.
Saint Luke’s Health System. (2014). Intravenous access device care and maintenance. SLHS policy &
procedure, PC-028, 1-9.
Tagalakis, V., Kahn, S. R., Libman, M., & Blostein, M. (2002). The epidemiology of peripheral vein infusion
thrombophlebitis: A critical review. American Journal of Medicine., 113, 146-151.

12. Questions?