Peripheral IV Insertion

• Tourniquet placement: 4-6 inches above intended site
• Maximum attempts: 2 per provider (then escalate)
• Dwell time: Replace per institutional policy (typically 72-96 hours)
• Flow rates: Larger gauge = faster flow (18G can deliver ~100 mL/min)
• Flush: Normal saline before and after use

Preferred Sites (in order)

• Forearm: Cephalic and basilic veins — most stable, less movement, lower infiltration risk
• Dorsum of hand: Good visibility, but more painful and prone to infiltration
• Antecubital fossa (AC): Large veins (median cubital, cephalic, basilic) — ideal for large-bore access but limits arm movement
• Upper arm: Basilic or brachial veins — deeper, may need ultrasound

Sites to Avoid

• Affected extremity: Mastectomy side, AV fistula/graft, lymphedema, paralysis/paresis
• Areas of infection: Cellulitis, burns, skin breakdown
• Injured extremity: Fractures, trauma proximal to site
• Lower extremities: Higher infection and DVT risk (use only if no other option)
• Joint areas: Wrist, elbow flexion points (impairs movement, infiltration risk)

Essential Equipment

• IV catheter: Appropriate gauge for patient and indication
• Tourniquet: Single-use preferred
• Antiseptic: Chlorhexidine (preferred) or alcohol swab
• Gloves: Non-sterile examination gloves
• Transparent dressing: Tegaderm or equivalent
• Extension set or saline lock: With needleless connector
• Flush syringe: Pre-filled normal saline
• Tape: For securing
• Sharps container: Immediately accessible
• Gauze: 2x2 or 4x4

Patient Preparation

• Explain procedure: Reduces anxiety, increases cooperation
• Position: Arm supported, extended, palm up
• Select site: Palpate and visualize before applying tourniquet
• Vein enhancement: Warm compress, have patient open/close fist, gravity (arm dependent)

Step 1: Prepare Equipment

Gather all supplies. Prepare flush syringe and extension set. Prime tubing if connecting to IV fluids. Ensure sharps container is within reach.

Step 2: Position Patient & Select Site

Position arm comfortably with support. Apply tourniquet 4-6 inches above intended site. Identify vein by palpation — feel for bouncy, resilient vessel. Select straightest segment possible.

Step 3: Prepare Site

Don gloves. Clean site with chlorhexidine using back-and-forth friction for 30 seconds. Allow to dry completely (critical for antiseptic effect). Do not re-palpate after cleaning.

Step 4: Anchor the Vein

Use non-dominant hand to apply traction on skin distal to insertion site. This stabilizes the vein and prevents it from rolling. Maintain traction throughout insertion.

Step 5: Insert Catheter

Hold catheter with bevel up at 10-30° angle. Warn patient of stick. Puncture skin smoothly — watch for flash of blood in chamber. Once flash obtained, lower angle and advance 1-2mm to ensure catheter (not just needle) is in vein.

Step 6: Advance Catheter

While holding needle hub steady, advance the catheter over the needle into the vein using your index finger. The catheter should slide smoothly. Never re-advance the needle once it's been withdrawn.

Step 7: Remove Needle & Secure

Release tourniquet. Apply pressure proximal to catheter tip to prevent blood loss. Withdraw needle completely and immediately dispose in sharps container. Connect extension set or saline lock.

Step 8: Confirm & Flush

Flush with normal saline. Observe for swelling, pain, or resistance. Good IV should flush easily without signs of infiltration. Secure with transparent dressing and tape. Document time, site, gauge, and number of attempts.

Insertion Technique

• Feel, don't just look: The best veins are palpable (bouncy, resilient) — visible veins may be superficial and fragile
• Traction is everything: Proper skin traction prevents vein rolling and makes insertion much easier
• Go slow after flash: The rush to advance often leads to through-and-through puncture
• Float the catheter: For difficult veins, flush while advancing to "float" catheter into position

Difficult Access Strategies

• Warm compress: Apply for 2-3 minutes to vasodilate
• Gravity: Let arm hang dependent for 1-2 minutes
• Multiple tourniquets: Double tourniquet technique for very difficult access
• Blood pressure cuff: Inflate to just below diastolic for enhanced filling
• Ultrasound: Consider early for known difficult access, obesity, or IVDU

Common Complications

• Infiltration: Fluid leaking into surrounding tissue — swelling, coolness, pain at site. Remove IV immediately.
• Hematoma: Blood collection under skin from through-and-through puncture or inadequate pressure. Apply pressure for 2-3 minutes.
• Phlebitis: Vein inflammation — redness, warmth, pain along vein course. Remove IV, apply warm compress.
• Infection: Redness, purulence, fever. Remove IV, culture tip if indicated, consider antibiotics.
• Air embolism: Rare with peripheral IVs. Ensure lines are primed and connections secure.

Troubleshooting

• No flash: May be too deep or too shallow. Withdraw to just under skin and redirect.
• Flash but catheter won't advance: Catheter tip may not be in vein, or hit a valve. Try floating with flush or withdraw and start fresh.
• Blood return but won't flush: Catheter may be against wall. Pull back slightly, reposition arm.
• Positional IV: Works only in certain positions — often too short or against valve. May need replacement.

Pediatrics

• Use smaller gauges (22-24G typically)
• Scalp veins in infants are acceptable
• Consider EMLA/LMX cream for non-emergent access
• Have assistance for immobilization
• Transillumination device can help visualize veins

Elderly

• Fragile, rolling veins — use smaller gauge, less tourniquet tension
• Thin skin — secure carefully to prevent tears
• May need shallower angle of insertion
• Forearm often better than hand (more tissue support)

Obese Patients

• Veins may be deep and difficult to palpate
• Consider ultrasound guidance early
• Longer catheters may be needed (1.75" vs standard 1.25")
• Antecubital and upper arm sites often more successful

IV Drug Users

• Scarred, thrombosed veins from repeated use
• May have limited access sites
• Ultrasound often essential
• Consider alternative access early (IO, central line)

• Assess regularly: Check site every shift for signs of complications
• Flush protocol: Flush before and after each use, and every 8-12 hours if not in use
• Dressing changes: Change if soiled, damp, or loose — otherwise per facility policy
• Dwell time: Replace per institutional policy (CDC no longer mandates routine replacement at 72-96 hours for properly functioning IVs)
• Documentation: Date, time, site, gauge, and any complications

1. American Academy of Orthopaedic Surgeons. (2021). Nancy Caroline's emergency care in the streets (8th ed.). Jones & Bartlett Learning.