Procedure

Peripheral IV Access

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Peripheral IV Access, Peripheral Catheterization, Peripheral Venous Catheterization, Peripheral Intravenous Catheter, Peripheral Vascular Catheter

  • See Also
  1. Intravenous Access
  2. Central IV Access
  3. Intraosseous Access
  4. Ultrasound-Guided Internal Jugular Vein Catheterization
  5. Ultrasound-Guided Antecubital Line
  6. Difficult Intravenous Access in Children
  • Types
  • Needles
  1. Over the Needle Catheter (Preferred)
    1. Age < 1 year: 22, 24 gauges
    2. Age 1-8 years: 18, 20, 22 gauges
    3. Age >8 years: 16, 18, 20 gauges
    4. Large Bore: 14-16 gauge
  2. Butterfly Needle
    1. Newborn: 23-25 gauges
    2. Age <8 years: 23, 21, 20 gauges
    3. Age >8 years: 21, 20, 18 gauges
  • Types
  • Sites
  1. Upper Extremity: Antecubital
    1. Cephalic Vein (lateral Forearm)
    2. Median cubital vein
    3. Basilic Vein (medial Forearm)
  2. Lower Extremity
    1. Great Saphenous Vein
      1. Descends through medial leg and ankle
      2. Lies anterior to medial malleolus
      3. Extends over dorsum into dorsal venous arch
    2. Median Marginal Vein
  3. Scalp
    1. Small superficial veins
    2. Not recommended in Resuscitation
  • Technique
  1. Consider Local Anesthesia at catheter insertion site
    1. See Difficult Intravenous Access in Children
    2. Subcutaneous 1% Lidocaine 5 minutes before
    3. Topical Lidocaine (ELA-Max, LMX) occluded 30 min. before
    4. J-Tip (transdermal Lidocaine device)
    5. Luhmann (2004) Pediatrics 113:e217-20 [PubMed]
  2. Consider limb warming prior to IV cannula insertion
    1. Mitt for hand and Forearm warmed to 125 F (52 C)
    2. Increases success rate and decreases insertion time
    3. Lenhardt (2002) BMJ 325:409-10 [PubMed]
  3. Immobilize the extremity
  4. Locate and stretch the vein
    1. Soft roll of gauze to hyperextend the elbow
    2. Flex the wrist to extend the dorsal hand veins
    3. Extend the ankle to extend the dorsal foot veins
  5. Consider Ultrasound guidance for difficult IV starts
    1. Ultrasound is helpful for difficult IVs, but interferes with placement of easy IV starts
    2. McCarthy (2016) Ann Emerg Med 68(1): 10-8 +PMID: 26475248 [PubMed]
  6. Apply a Tourniquet to proximal vein
    1. Consider Blood Pressure cuff (inflated to 150 mmHg on arm)
      1. Very effective at maintaining non-compressible veins for peripheral vein cannulation
      2. Kule (2014) J Emerg Med S0736-4679(13) [PubMed]
  7. Antiseptic to cannulation site
  8. Flush the needle catheter with sterile saline
  9. Enter Skin
    1. Puncture distal to the site
    2. Enter at 45 degrees with bevel down
    3. Pull the skin to the side while entering skin
    4. Avoid entering the vein with needle
  10. Cannulate vein
    1. Slowly advance catheter/needle until free Blood Flow
    2. Advance catheter/needle a few millimeters
    3. Advance the remainder of the catheter of needle
  11. Remove the needle and confirm backflow
  12. Remove the Tourniquet
  13. Secure intravenous catheter
    1. Consider Skin Glue (Tissue Adhesive, Dermabond)
      1. One drop over skin entry and one drop under plastic hub
      2. Decreases dislodgment risk
      3. Budgen (2016) Ann Emerg Med 68(2):196-201 +PMID: 26747220 [PubMed]
    2. Cover with Transparent Film Dressing (e.g. Tegaderm)
  1. See Intraosseous Access
  2. See Ultrasound-Guided Internal Jugular Vein Catheterization
  3. See Ultrasound-Guided Antecubital Line
  4. External Jugular Vein Catheterization
  5. Tourniquet Infusion Technique
    1. Obtain distal IV Access (e.g. 22 gauge) in a small hand vein or similar
    2. Apply Tourniquet above the elbow
    3. Infuse 100 cc Normal Saline into the hand vein to result in arm vessel engorgement
    4. Place standard size (e.g. 18 gauge) IV into one of the proximal engorged Forearm or antecubital veins
  6. Central Vein Placement of peripheral IV
    1. Identify a central vein for access (e.g. internal Jugular Vein) via Ultrasound
    2. Use a long peripheral catheter (48 mm is ideal if available, or use the angiocatheter in the Central Line kit)
    3. Sterilize the region
    4. Cannulate the vessel at a shallow angle with peripheral catheter under Ultrasound guidance
    5. Remove peripheral catheter within 72 hours
  • References
  1. Strayer in Herbert (2018) EM:Rap 18(8): 16-7
  2. Quinn (2014) Emerg Med J 31(7): 593 [PubMed]
  3. Maayedi (2009) J Emerg Med 37(4): 419 [PubMed]