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“The Science Behind the Art” 
Volume 11 - No.1, 2023 

Anesthesia eJournal - Online 
ISSN 2333-2611

Page 1

A Review Evaluating Intravascular Access for High Volume Resuscitation: 
Can You Keep Up?
Puneet Mishra, MD • puneet.mishra@vumc.org
Jonathan P. Wanderer, MD • jon.wanderer@vumc.org
David A. Edwards, MD • david.a.edwards@vumc.org
Susan S. Eagle, MD • susan.eagle@vumc.org
Stephen P. Bruehl, PhD • stephen.bruehl@vumc.org
Matthew W. Semler, MD • matthew.w.semler@vumc.org
Kelly L. Mishra, MD • kelly.mishra@vumc.org

Acknowledgments: 
Caroline Walker (MSN) assisted with infographic editing.
Cassandra Palmer (BS) assisted with infographic editing.

Disclosures:
No financial support or funding was provided for this work

Declaration of Conflicting Interests:
No conflicts of interest to declare.

Affiliation:
Vanderbilt University Medical Center 

KEYWORDS: Vascular Access Devices, Resuscitation, Central Venous Catheterization, Peripheral Venous Catheterization, 
Hypovolemia

Abstract
Anesthetists and anesthesiologists are frequently in the position of administering high-volume resuscitation in the 
setting of hemorrhage, hypovolemia, or vasodilatory shock.  The ability to rapidly infuse intravenous (IV) fluid solutions 
differs vastly for different types and sizes of IV access. In patients who may require rapid large volume resuscitation, it 
is critical to understand the capacity of existing IV devices.  Selecting the most appropriate IV access for patients can 
be paramount in preventing hypotension, end organ dysfunction, and even death. This article objectively reviews and 
compares the flow rates of commonly used central and peripheral intravenous devices to demonstrate the influence of 
catheter length and radius. 

AEJ
Volume 11- No. 1, 2023



Glossary of Terms:
IV = intravenous 
mL/min = milliliters/minute 

Q = flow rate
n = viscosity
r = radius 
l = length of tubing
PIVs = Peripheral Intravenous Catheters PICCs = 
Peripherally Inserted Central Catheters CVCs = Central 
Venous Catheters
RICs = Rapid Infusion Catheters
IO = Intraosseous
MAC = Arrow® Multi-lumen Access Catheter Fr = French
LAD = luer activating devices
SLIC = Single Lumen Infusion Catheter

INTRODUCTION
Choosing the most appropriate vascular access in patients with 
hypovolemic or vasodilatory shock is a critical decision for a 
perioperative or critical care clinician.  While this is seemingly 
simple, a clinician must weigh the adequacy of existing 
intravenous (IV) access versus the time needed to place additional 
large-bore peripheral or central catheters.  This is particularly 
critical in the time sensitive setting of acute hypovolemic shock 
due to severe hemorrhage in the perioperative and obstetrical 
arenas, where acute bleeding at rates over 500ml/min can occur.1 
Different forms of IV access have drastic differences in their 
ability to facilitate rapid fluid resuscitation ranging from 
maximum flow rates of 9.6 milliliters/minute (ml/min) to over 
500ml/min. This manuscript collates information on several of 
the most common IV devices and presents it in tabulated and 
graphical format for easy reference. This information is meant to 
provide clinical decision support to the perioperative and critical 
care clinician.  
DISCUSSION
Intravenous flow rates

The fundamental principles of Poiseuille’s Law (Q = πPr4/8nl) is 
critical in understanding the relationship among catheter length, 
radius, and flow rates for laminar flow. Poiseuille’s Law states that 
flow rate (Q) is proportional to the pressure gradient along the IV 
tubing and inversely proportional to the viscosity (n) of the fluid 
as well as the length of the tubing (l ). Increased fluid viscosity 
and increased length of tubing result in decreased flow rate when 
pressure is held constant. Very importantly, Q is proportional to 
the IV catheter radius (r) to the fourth power.  Therefore, 
increasing the radius of an IV catheter drastically increases and 
has the largest impact on the flow rate. The impact of changes in 
r and l on Q, account for the wide range of flow rates across IV 
devices.  This concept is paramount for understanding why some 
forms of central access may be superior while other are inferior 

to peripheral access when rapid, high-volume resuscitation is 
warranted.  The infographic in Figure 1 compares the flow rates 
of these IV catheters. 
Although the radius and length of IV catheters are of critical 
importance, there are numerous other factors that can affect flow 
rates. These include viscosity of the fluid administered, the radius 
of delivery tubing, the height of the fluid above the patient, the 
addition of a pressure bag, the presence of a fluid warmer, and in 
line devices such as luer-activating devices (LADs) with one-way 
valves that can limit flow. For example, LADs can reduce the flow 
rates through a 16g PIV by 19-38%.2 Placing a PA Catheter or 
Arrow® Single Lumen Infusion Catheter (SLIC) through the 
introducer port on an Arrow® Multi-lumen Access Catheter 
or an Arrow® 8.5 Fr introducer will also reduce the flow rate. 
This explains why there are certain clinical scenarios where the 
maximum flow rate may be less than the manufacturer published 
rates.3,4 However, the general principles of Poiseuille’s law still 
apply, and the comparison between the different devices remains 
constant.
Types of intravenous access
Choosing the most appropriate IV access requires consideration 
of many factors, such as the specific indication for placement, 
the length of time the access will be required, how quickly access 
is needed, medications infused, ease of placement, risks, and the 
possible need for rapid large volume resuscitation.  There are 
numerous types of IV catheters encountered in the inpatient 
setting: peripheral intravenous catheters (PIVs), peripherally 
inserted central catheters (PICCs), non-tunneled central 
venous catheters (CVCs), tunneled CVCs, peripheral rapid 
infusion catheters (RICs), hemodialysis CVCs, implanted ports, 
and intraosseous (IO) catheters. This review summarizes the 
salient points regarding rapid volume resuscitation for the most 
encountered IV catheters in the hospital setting.
Central Venous Catheters (CVCs) exist in many forms and 
the decision of which type to place is multifactorial. Not all 
CVCs allow for the high flow rates required for rapid volume 
resuscitation. For example, a triple lumen catheter is relatively 
long in length and provides significantly lower flow rates than 
most PIVs (Figure 1, Table 1).  In fact, the 18g port of a triple 
lumen catheter infuses at a max rate of 26 milliliters/minute (mL/
min) which is less than a 20-gauge PIV with a max flow rate of 
65 mL/min.  Therefore, if selecting a CVC, an Arrow® Multi-
lumen Access Catheter, Arrow® 8.5 Introducer, or Arrow® double 
lumen central line would be more appropriate for rapid volume 
administration since each port can allow for flow over 100mL/
min.  The Arrow® Multi-lumen Access Catheter and Arrow® 8.5 
Introducer are capable of infusion rates over 500 mL/min and can 
be used with rapid infuser devices. 
A large bore CVC is advantageous in the setting of hemorrhage, 
and clinicians should weigh potential risks. These risks include 
time needed for placement, vascular injury, and central line 
associated blood stream infections. The risks should be balanced 
against the need for rapid infusion and administration of drugs 
such as vasopressors that can be caustic when infused peripherally.
Peripherally Inserted Central Catheters (PICCs) provide more 
durable and dependable IV access for patients with limited 

Texas Christian University 
“The Science Behind the Art” 
Volume 11 - No.1, 2023 

Anesthesia eJournal - Online 
ISSN 2333-2611

Page 2



peripheral access and those needing long-term infusions. PICC 
lines are both small in diameter and long in length (three times 
longer than the next longest catheter); therefore, flow rate is slow 
at ~10 mL/min (Figure 1).  PICC lines have very limited utility 
in patients needing high-volume resuscitation. 
Rapid Infusion Catheters (RICs) are large bore, short, 
peripherally inserted catheters that allow for high flow rates. 
Most placed in the operating room environment, RICs are 
typically inserted in the antecubital vein, using the Seldinger 
technique. The large diameter (7 Fr and 8.5 Fr) and short length 
allow for rapid volume resuscitation up to 572 mL/min (Figure 
1, Table 1). Even though RICs are superior to PIVs for large 
volume resuscitation, it is important to note that RICs require 
extra vigilance because high-volume peripheral infiltration and 
extravasation can occur rapidly and compromise vascular flow in 
the affected limb leading to compartment syndrome.5,6

Peripheral Intravenous Catheters (PIVs) are the most common 
IV access, primarily because the superficial nature of peripheral 
veins often allows for simpler and less traumatic access. There are 
several PIV catheter lengths, but flow rate primarily depends on 
the gauge. Furthermore, the relatively short catheter length of 
PIVs favors fast flow rates.  The rate of a free-flowing crystalloid 
infusion ranges from 65 mL/min in a 20-gauge PIV to 325 mL/
min in a 14-gauge PIV (Figure 1).

CONCLUSION
The purpose of this review and the included infographic and 
table is to objectively compare the flow rates of the IV catheters 
commonly used in the hospital setting.  This information can 
help clinicians make an informed decision when choosing an 
IV catheter. Figure 1 illustrates that central venous access is not 
always superior to peripheral access when it comes to maximum 
flow rates.  We argue that in the setting of acute hemorrhagic 
shock, one 16g peripheral IV is more effective than a triple 
lumen CVC. If very rapid fluid resuscitation is required, only the 
Arrow® Multi-lumen Access Catheter, Arrow® 8.5 Fr introducer, 
7.0 Fr or 8.5 Fr RIC, and 14g PIV can provide resuscitation at 
rates over 300mL/min and can be considered true large bore 
access. 16g PIVs and double lumen central lines can provide 
rates over 200mL/min and thus serve as moderate sized IV 
access. Importantly, the maximum flow rates for triple lumen 
central lines, PICCs, and 20g PIVs are well under 100mL/
min and cannot be considered adequate access if rapid volume 
resuscitation is required.  Therefore, when choosing between the 
many different types of IV access that are available, it is critical to 
understand the Poiseuille’s law principles and the integral role of 
catheter length and radius.

REFERENCES
1. Carlisle KM, Halliwell M, Read AE, Wells PNT. Estimation of total hepatic blood flow by duplex ultrasound. Gut. 1992;33:92-97.
2. Hall JM, Roberts FL. An investigation into the reduction in flow rate of intravenous fluid by antireflux valves. Anaesthesia. 

2005;60(8):797-800.
3. McPherson D, Adekanye O, Wilkes AR, Hall JE. Fluid flow through intravenous cannulae in a clinical model. Anesth Analg.

2009;108(4):1198-1202.
4. Khoyratty SI, Gajendragadkar PR, Polisetty K, Ward S, Skinner T, Gajendragadkar PR. Flow rates through intravenous access

devices: an in vitro study. J Clin Anesth. 2016;31:101-105.
5. Chou WH, Rinderknecht TN, Mohabir PK, Phillips AW. Skin Necrosis Distal to a Rapid Infusion Catheter: Understanding

Possible Complications of Large-bore Vascular Access Devices. Cureus. 2019;11(1):e3854.
6. Dychter SS, Gold DA, Carson D, Haller M. Intravenous therapy: a review of complications and economic considerations of

peripheral access. J Infus Nurs. 2012;35(2):84-91.
7. ARROW. Insert. Teleflex.
8. Pro-PICC. Insert: MedComp. Harleysville, PA.
9. Wrenn EA, Wohlers R, Montgomery M, et al. Comparison of flow dynamics of peripherally and centrally inserted intravenous

catheters using a rapid infusion system. AANA. 2017;85:256-260.

Texas Christian University 
“The Science Behind the Art” 
Volume 11 - No.1, 2023 

Anesthesia eJournal - Online 
ISSN 2333-2611

Page 3



TABLE 1. Flow Rate Comparison for IV Devices from Manufacturers

IntravenousAccessDevice
Flow 

(ml/min)
Flow 

(L/hr)
Time to 
infuse1L 
(minutes)

CENTRALVENOUSCATHETERS(CVC)

Arrow® Multi-lumenAccessCatheter(MAC)

9Frdistallumen 
12Frproximallumen

Combined

507 30.42

199 11.94

1.97

5.03
706 42.36     1.42

Arrow® 8.5FIntroducer(Cordis) 500 30  2

DoubleLumenCVC
Lumen1(14 g)

Lumen2(14 g)

Combined

127 7.62

100 6

7.87

10

227 13.62 4.41

TripleLumenCVC

Lumen1(16 g)

Lumen2(18 g)

Lumen3(18 g)

53 3.18

26 1.56

27 1.62

18.87

38.46

37.04

Combined 106 6.36 9.43

PeripherallyInsertedCentralCatheter(PICC) 9.6 0.58 100

PERIPHERALRAPIDINFUSIONCATHETERS(RIC)
8.5 Fr RIC 572 34.32 1.75

7 Fr RIC 500 30 2

PERIPHERALINTRAVENOUSCATHETERS(PIV)

14 g PIV 325 19.5 3.08
16 g PIV 215 12.9 4.65
18 g PIV 110 6.6 9.09
20 g PIV 65 3.9 15.38

Flow rates for IV devices obtained from manufacturers in mL/min, L/hr, and time to infuse one liter of saline in minutes. CVC = 
Central Venous Catheters, RIC = Rapid Infusion Catheters, PICC = Peripherally Inserted Central Catheter, PIV = Peripheral In-
travenous Catheter. Rates are based on 100 cm height gravity flow rates. Some resources may quote slight variations in flow rate, and 
this may be dependent on the testing conditions or slight variations in lengths for different brands of PIVs.

Texas Christian University 
“The Science Behind the Art” 
Volume 11 - No.1, 2023 

Anesthesia eJournal - Online 
ISSN 2333-2611

Page 4



Texas Christian University 
“The Science Behind the Art” 
Volume 11 - No.1, 2023 

Anesthesia eJournal - Online 
ISSN 2333-2611

Page 5

Peripheral IVs (PIV)Peripheral Rapid Infusion Catheters (RIC)

Central Venous Catheters (CVC)

Q = �ow rate (ml/min)
r = radius of tubing
l = length of tubing
P = pressure gradient
n = viscosity of �uid

Fr = french (3X diameter)
g = gauge (outer diameter)

��= 
πPr4
8��

8.5 Fr

10 cm

500
ml/m

in

Intro
duce

r

(Cord
is)

6.4 cm

8.5 Fr

572
ml/m

in

ml/m
in500

7 Fr
5 cm

3.2 cm

16 g

215

3.2 cm

18 g

110

2 cm

20 g

65

3 cm
14 g

325
ml/m

in

16 cm

Double Lumen

127

100

14 g

14 g

{
227

ml/m
in

20 cm

Trip
le Lumen

16 g

18 g

18 g

53
26

27{
106

ml.m
in

60 cm
PICC

9.6
ml/m

in

12 g

MAC

9 Fr

11.5 cm

ml/m
in507

199{
706

ml/m
in

Q

r
�

Poiseuille’s Law

assumptions: viscosity and pressure gradient constant at 1

Visual Comparison of Intravenous
Catheter Types and Flow Rates

18
 g

5

FIGURE 1. A Visual Comparison of Intravenous Catheter Type and Flow Rates
Rates obtained from manufacturers, found on packaging [Arrow® Multi-lumen Access Catheter (MAC)7, Arrow® 8.5 Introducer, Arrow® double lumen central line, Arrow® triple 
lumen central line, Arrow® peripherally inserted central access (PICC)8, Arrow® 7.0 french and 8.5 french rapid infusion catheter (RIC), Jelco® peripheral intravenous catheters 
(PIV)]. 9 Sizes (radius, length) are all proportional and scaled. Arrow width is proportional to flow. Rates are based on 100cm height gravity flow rates. Some resources may quote 
slight variations in flow rate, and this may be dependent on the testing conditions or slight variations in lengths for different brands of PIVs.




