Pain can be caused by the following:

Pain can be prevented by using methods to relax and relieve anxiety, for example massage, distraction or the use of local anaesthetic creams or injections. The practitioner should avoid the use of bruised, recently used or sensitive areas. If the patient complains of pain, depending on the site (e.g. nerve or artery), it may be necessary to remove the device immediately. Reassure the patient and explain, especially in the case of nerve pain, that it may last for a few hours; provide the patient with an information leaflet (containing instructions on what to do if the pain gets worse or there is no improvement) and document the incident (Dougherty [124]).

Haematoma is leakage of blood into the tissues and is indicated by rapid swelling during the insertion procedure or after removal (McCall and Tankersley [303], Perucca [369]). It can be caused by:

Prevention includes good vein and device selection and using a careful technique. Practitioners should always be aware of when patients have fragile veins or are on anticoagulant therapy, and inexperienced individuals should not attempt cannulation in these individuals (Perucca [369]). A tourniquet should not be applied to a limb where recent venepuncture has occurred and the tourniquet should not be left in place for any longer than necessary.

On removal of the cannula, adequate pressure should be applied to the site. Alcohol pads inhibit clotting and should not be used (Perucca [369]). In the event of a haematoma occurring, the needle should be removed immediately and pressure applied to the site for a few minutes (Garza and Becan‐McBride [170], McCall and Tankersley [303]). Elevate the extremity if appropriate, reassure the patient and explain the reason for the bruise. Apply a pressure dressing if required and an ice pack if the bruising is extensive (Moini [320]). Hirudoid or arnica ointment can help to reduce bruising and discomfort. Arnica is made of dried roots or flower of the arnica plant, which stimulates activity of the white blood cells, which in turn process congested blood and reduce the bruise (Goedemans et al. [172]). Hirudoid is a substance similar to heparin and acts by dissolving blood clots and improving blood supply to the skin (EMC [140]). They are both applied directly to the affected arm (BNF [42]). The incident should be documented and the patient given an information sheet with advice about when and whom to contact if the haematoma gets worse or they develop any numbness in the limb (Dougherty [124], Moini [320], Morris [325], Perucca [369]).

Inadvertent arterial puncture is characterized by pain and bright red blood caused by accidental puncture of an artery (Dougherty [124], McCall and Tankersley [303], Moini [320]). It can be prevented by adequate assessment and recognition of arteries prior to performing the procedure. It is rare when proper procedures are followed and can be associated with deep or blind probing (McCall and Tankersley [303]). However, should it occur, the device should be removed immediately and pressure applied to the puncture site for up to 5 minutes or until the bleeding has stopped (McCall and Tankersley [303], Moini [320]). Reassure the patient but do not reapply the tourniquet to the affected limb. If an inadvertent arterial puncture goes undetected, accumulation of blood can result in compression injury and damage nearby nerves. The incident must be documented and the patient given an information sheet with advice about when and whom to contact if they develop numbness or tingling in the limb (Dougherty [124]).

If a nerve is accidentally hit on insertion of the needle into the vein, this will result in pain – described as severe shooting pain (Masoorli [299], Yuan and Cohen [480]), painful burning sensation (Moini [320]) or a sharp electric tingling sensation that radiates down the nerve (McCall and Tankersley [303]). It can occur due to poor vein selection, inserting the needle too deeply or quickly, or blind probing, and can lead to injury and possibly permanent damage (McCall and Tankersley [303]). Prevention may be achieved by ensuring that the location of superficial nerves is known; for example, a common place to hit a nerve is the cephalic vein but this can be avoided by placing three fingers at the wrist and inserting the needle above them (the nerve runs deeper at that point and therefore the practitioner will be less likely to touch it) (Boeson et al. [45], Masoorli [300]). In the event of touching a nerve, release the tourniquet and remove the needle immediately (Garza and Becan‐McBride [170]). Reassure the patient and explain that the pain may last for a few hours or days and that the area may feel numb. Explain that if the pain continues beyond a few days or gets worse, medical advice should be sought. Give the patient an information sheet with advice about when and whom to contact and document the incident (Dougherty [124], Garza and Becan‐McBride [170]).

Phlebitis is inflammation of the intima of a vein (Perucca [369], Washington and Barrett [463]). It is characterized by pain and tenderness along the cannulated vein, erythema, warmth, and streak formation with or without a palpable cord (a palpable thickening of the vein that occurs in relation to phlebitis) (Mermel et al. [309]).

There are three main types of phlebitis:

Phlebitis causes significant pain, PIVC failure and therapy interruption, and it requires the insertion of a new PIVC with associated increased equipment costs and staff time (Ray‐Barruel et al. [380], [379]). It compromises future venous access, and untreated bacterial phlebitis may lead to bloodstream infection; therefore, early detection of complications and removal of the PIVC is crucial (Alexandrou et al. [6], Ray‐Barruel et al. [380]). Influencing factors that increase the risk of phlebitis include being female, dwell time, large‐gauge cannulas, higher number of doses of irritating medications such as antibiotics; factors that reduce risk include choice of vein (forearm), smaller‐gauge cannulas and use of specialized vascular access teams (Alexandrou et al. [6], Carr et al. [64], Da Silva et al. [98], Johnson et al. [233], Mestre et al. [310], Wallis et al. [461], Washington and Barrett [463]). Prevention is key and includes appropriate device and vein selection, dilution of drugs, and pharmacological methods, for example application of glyceryl trinitrate patches (Alexandrou et al. [6], Dougherty [124]). Treatment includes discontinuing the infusion at the first signs of phlebitis (grade 1) (see Figure 17.8). Warm or cold compresses can be applied to the affected site. The patient should be referred to a doctor if the phlebitis rating is over 3. If bacterial phlebitis is suspected then the insertion site should be cultured and the cannula tip sent to microbiology (Dougherty [124], Morris [325]).

See Chapter c15: Medicines optimization: ensuring quality and safety.