Peripheral IV Insertion

Peripheral IV access is time-critical when fluids, blood or drugs cannot wait. Limit each clinician to two attempts, then hand off.

A peripheral IV (PIV) is a short catheter in a superficial vein of the arm or hand. It carries fluids, medications and blood products. For most prehospital and ED patients, it's the default route. When you can't get one in quickly, intraosseous (IO) access is the usual backup.

How It Works

• Catheter over needle: The needle goes into the vein. You thread the plastic catheter off it, then pull the needle out. Only the catheter stays behind.
• Flash confirms entry only: Blood in the flashback chamber means the needle tip is in the vein. It says nothing about the catheter tip, which may still be outside.
• Flush confirms placement: A patent catheter flushes clean, with no resistance, swelling or pain.
• Gauge and length set flow: Bigger and shorter means faster. Narrow or long catheters slow the flow, and so do needleless connectors.

Where It Fits

• Plan A: Standard PIV at a forearm or antecubital site.
• Plan B: Ultrasound-guided PIV or external jugular (EJ) cannulation, per training and protocol, after repeated failure.
• Plan C: IO access for emergencies or when a PIV is impractical, per protocol. In adult cardiac arrest, the 2025 AHA Guidelines for CPR and ECC (Part 9) say IV access first (COR 1, LOE A). IO is reasonable when IV access fails or isn't feasible (COR 2a, LOE A). In infants and children in arrest, IV or IO gets picked by what's on hand, who can do it well and what can happen fastest (Part 8, COR 1, LOE C-EO). For newborns, IO can help if IV access, including the umbilical vein, fails or isn't feasible (Part 5, COR 2a, LOE C-LD).

Indications

• Fluid resuscitation or maintenance infusion
• Medications that are ordered or preferred by the IV route
• Blood products or contrast that need a patent line of adequate gauge
• Procedural or monitored transport where a reliable line is needed

Absolute Contraindications

Nothing rules it out when IV access is clinically needed. Never cannulate an arm with an AV fistula or graft, since dialysis depends on it.

Relative Contraindications & Cautions

• Mastectomy or axillary node dissection on the same side, or lymphedema (per agency policy)
• Paralyzed or paretic limb, with reduced sensation or movement
• Infected, cellulitic or burned skin at the site
• Injury or fracture proximal to the site, or a known thrombosed vein
• Lower-extremity sites in adults when an upper-extremity site is available

Consider an Alternative

• Repeated failure: ultrasound-guided PIV or EJ, per protocol (see Step-by-Step Procedure)
• Emergency with no PIV: intraosseous access, per protocol

Abort / Stop Criteria

• Two failed attempts by the same clinician: stop, reassess, and hand off
• Swelling, resistance on flush, or a bright pulsatile return: stop and remove

Team Roles During the Procedure

• Operator: Selects the site, inserts the catheter and confirms placement
• Assistant: Positions the arm, applies traction and keeps the patient still
• Medication clinician: Flushes the line and checks the infusion
• Monitor / recorder: Documents time, site, gauge, attempts and complications

Predicting Difficult Access

• No visible or palpable vein at the usual sites
• Prior difficult access, or two or more failed attempts
• Obesity, IV drug use, or chronic kidney disease with scarred or thrombosed veins
• Young children, older adults with fragile veins, or a patient who cannot hold still

Site & Device Check

• Check both arms for an AV fistula or graft, mastectomy, lymphedema, paralysis and injury
• Confirm the infusion order: fluid, volume, rate and any drug that needs a specific route
• Confirm the catheter gauge matches the purpose (see Equipment & Preparation)

Forearm

1. Position the arm: Support it, extend the wrist slightly and keep the palm up.
2. Find a straight segment: Palpate the cephalic or basilic vein for a bouncy, straight segment.
3. Anchor the vein: Apply traction on the skin distal to the site.

Antecubital Fossa

1. Extend the elbow: Keep the arm straight to limit movement and reduce infiltration.
2. Choose the median cubital vein: Usually the largest and easiest to reach here.
3. Locate the artery: The brachial artery lies medial to the biceps tendon. Never aim at a pulsating vessel.

Dorsal Hand

1. Support the hand: Rest it on a towel with the fingers slightly flexed.
2. Choose a vein away from the knuckles: Avoid veins that cross a joint.
3. Secure with care: Tape so the knuckles remain free to move.

Equipment

• IV catheter: Gauge and length matched to the patient and the infusion
• Tourniquet: Single-use preferred
• Antiseptic: 70% alcohol, tincture of iodine, an iodophor or chlorhexidine gluconate, per the CDC 2011 guideline; use the agency-stocked product
• Gloves: Clean (non-sterile) examination gloves for peripheral insertion
• Flush: Prefilled normal saline syringe
• Extension set or saline lock: With a needleless connector
• Dressing and securement: Transparent dressing, tape or securement device
• Sharps container: Within reach
• Backup: A second catheter, and IO access equipment per protocol

Sizing

Patient Positioning & Preparation

• Position: Support the arm and extend it, palm up
• Fill the veins: Let the arm hang briefly, and ask the patient to open and close the fist
• Warm the site: A warm compress can help veins that won't fill
• Select before prepping: Palpate and choose the vein before the tourniquet and antiseptic

Treat these as typical references. Check local protocol and current drug labeling before you use them. Doses vary by protocol; follow local protocols and medical direction.

Phentolamine for Vasopressor Extravasation

• Treatment (adult): 5–10 mg in 10 mL saline, injected into the area of extravasation within 12 hours (label)
• Labeled use: Norepinephrine extravasation only. Other vasopressors per pharmacy and protocol. Infiltrate it locally into the extravasation area, never IV.
• Prevention: Add 10 mg to each liter of norepinephrine solution. That does not change the pressor effect (label)
• Pediatric: The label has no extravasation dose for kids. Get pharmacy and medical direction.
• Cautions: Contraindicated with myocardial infarction, angina, coronary disease or hypersensitivity. The label also reports hypotension, tachycardia, arrhythmia, myocardial infarction and cerebrovascular events (label).
• Supply: Phentolamine shortages have pushed some settings to terbutaline as the alternative, per local protocol.

The label source is phentolamine mesylate for injection (DailyMed). For norepinephrine itself, see its medication page.

IV Drip Rate Calculation (AEMT)

Drops per minute = mL per hour × drop factor ÷ 60.

Phase 1: Prepare

1. Hand hygiene, then gather supplies: Clean hands with an alcohol-based rub or soap and water, then don clean gloves. Confirm the gauge, flush and dressing. Prime the tubing if it will carry fluid.
2. Position the patient: Support and extend the arm, palm up. Ask the patient to stay still.
3. Apply the tourniquet: Place it proximal to the intended site, snug enough to distend veins without stopping arterial flow.

Phase 2: Perform

4. Select and feel the vein: Choose a straight, bouncy segment. A visible vein can be shallow and fragile.
5. Clean the site: Use the agency-stocked antiseptic (see Equipment), then let it dry completely. Do not re-palpate after cleaning.
6. Anchor and insert: Use the non-dominant hand to apply distal traction. Hold the catheter bevel up at a shallow angle and enter the skin smoothly.

7. Advance the catheter: After flash, lower the angle and advance the needle 1–2 mm. Then advance the catheter off the needle with the index finger while holding the hub still.
8. Release and withdraw: Release the tourniquet, apply gentle pressure proximal to the tip, and withdraw the needle into the sharps container.

Phase 3: Confirm & Secure

9. Connect and flush: Attach the extension set or saline lock. Flush gently and watch for swelling, pain or resistance.
10. Secure: Apply a transparent dressing and tape. Label the date, time, gauge and your initials.
11. Document: Record the site, gauge, number of attempts, confirmation method and any complication.

Alternative Technique: Ultrasound-Guided PIV

A 2026 meta-analysis of randomized trials in emergency departments found that ultrasound guidance raised first-attempt success in difficult access (RR 1.80; 95% CI 1.18–2.73). Use it only with local ultrasound training and credentialing.

1. Scan first: Use the short axis to find a patent vein and judge its depth and size.
2. Keep the needle tip in view: Advance under real-time view until the tip enters the vein.
3. Advance the catheter: Then confirm with a flush and check for swelling, as in the standard technique.

Alternative Technique: External Jugular (EJ) Cannulation

1. Position: Lay the patient supine with a slight Trendelenburg tilt and the head turned away from the site.
2. Identify the vein: Clean the site and find the EJ over the sternocleidomastoid. Use ultrasound if it is not visible or palpable.
3. Insert: Enter at a shallow angle (about 10°) above the vein. After flash, advance the needle 1–2 mm, then advance the catheter and remove the needle.
4. Confirm: Aspirate blood and flush. Watch the site as fluid runs. Swelling means the catheter is outside the vein.

Alternative Technique: Gravity Infusion Set-Up (AEMT)

1. Verify the order: Check fluid, volume, rate and expiration against the order.
2. Select the set: Use a macrodrip set for routine fluids and a microdrip set (60 gtt/mL) for low, precise rates, per protocol.
3. Prime: Fill the drip chamber partway, open the clamp to clear air from the tubing, then close it.
4. Set the rate: Use the formula in Medications & Settings. Count drops for a full minute and adjust the clamp.

Primary Confirmation

Flush it. Free flow with no resistance and no swelling confirms the catheter is in the vein. Flashback alone doesn't.

Secondary Confirmation

• No swelling, pain or coolness along the vein or at the site
• Fluid runs at the ordered rate under gravity or the pump
• Dressing is dry, intact and labeled

Ongoing Monitoring

• Check the site at each vital sign set and during every move, per agency policy
• Check the infusion rate, bag level and pump alarms
• Ask about pain or burning at the site

Pediatrics

• Scalp veins are acceptable in neonates and young infants. Upper and lower extremities are acceptable in children, per the CDC 2011 guideline
• Chlorhexidine: CDC 2011 makes no recommendation on its safety or efficacy in infants under 2 months. Follow the neonatal skin-antisepsis policy
• Use the smallest catheter that meets the need. Many children use 22–24G (agency policy)
• When time allows, put on a topical anesthetic (EMLA or LMX) for non-emergent access
• Get an assistant to immobilize the limb. A transillumination light can help you see veins
• Size catheters and fluids by weight and protocol: equipment sizing, vascular access in children

Older Adults

• Fragile, rolling veins: use a smaller gauge and less tourniquet pressure
• Thin skin: secure carefully and avoid stripping tape
• A forearm site often holds better than the hand

Obesity

• Veins may sit deep and be hard to feel. Go to ultrasound early
• You may need a longer catheter. Antecubital and upper-arm sites are often more successful

Dialysis Patients

• Never cannulate the AV fistula or graft arm, and keep BP readings and tourniquets off it
• Use the other arm when you can. Coordinate with the dialysis unit

IV Drug Use

• Scarred or thrombosed veins are common, and sites are limited
• Ultrasound is often needed. Consider IO or central access early when clinically indicated

Immediate Aftercare

• Check the site and the flow rate after insertion and after every move
• Label the catheter with date, time, gauge and initials

Ongoing Maintenance

• Replacement: CDC 2011 says there is no need to replace more often than every 72–96 hours. The adult interval beyond that is unresolved. Catheters placed in an emergency or prehospital setting without assured aseptic technique should be replaced as soon as possible, within 48 hours (CDC 2011, Category IB). A Cochrane review found no clear difference in catheter-related bloodstream infection between removing catheters only when clinically indicated and routinely re-siting them.
• Flush: Flush per facility policy, and before and after each use.
• Dressing: Change when soiled, damp or loose, or per policy
• Unused lines: Pull them. Each one adds infection and phlebitis risk

Transport Considerations

• Secure the catheter and tubing before moving the patient
• Reassess the site after every move, and when the patient is repositioned
• Use the flush and the monitors to confirm function in noise or vibration
• Plan for dislodgement en route. Carry a backup catheter

Pearls

• Feel first: A bouncy vein you can palpate holds a catheter better than a visible one that rolls.
• Traction is the skill: Pull the skin distal to the site. That anchors the vein so it can't roll away.
• Lower the angle after flash: That's what keeps the catheter from going through the vein.
• Start distal: A failed distal site still leaves proximal options. The reverse doesn't work.
• Flush and look: Free flow with no swelling is what confirms placement.

Common Pitfalls

• Treating a flash as success → flush and check for swelling
• Re-palpating after antisepsis → re-prep if you must touch the site
• Re-advancing the needle → remove the whole unit and start over
• Missing a fistula arm → check both arms before the tourniquet
• Leaving an unused line → remove it when the infusion ends

Skill Maintenance

• Practice on task trainers at an interval set by your agency
• Use a checklist for preparation, confirmation and documentation
• Debrief after each live attempt: site, gauge, attempts and outcome
• Review your agency's infiltration grading and extravasation antidotes at least yearly