Peripheral IV placement is one of the most common medical procedures and is a foundational skill among healthcare professionals.

Ultrasound-guidance is an important technique that improves the success rate of establishing a peripheral IV in adults, particularly in cases where IV access is difficult.

Indications for IV Access:

• Administration of fluids, medications, or nutrition, which cannot be delivered effectively and/or efficiently via other routes.
• Transfusion of blood products.
• Direct access to the bloodstream is needed.

Contraindications:

• A less invasive route is available and appropriate.
• Do not insert a catheter at any site with evidence of infection, burns or open wounds.
• Avoid a specific extremity in the following cases:
  • Limb with massive edema.
  • Arteriovenous fistula.
  • History of ipsilateral mastectomy or lymph node dissection.
  • Procedure planned for limb.

• Avoid specific veins if there is evidence of the following:
  • Sclerosis.
  • Phlebitis.
  • Thrombosis.
  • Site of recent catheterization.

Catheter Selection:

• Catheter gauge size:
  • Smaller gauges (G) (20-24 G) for administration of medications, antibiotics and moderate fluid volumes.
  • Larger bore catheters (14-18 G) for rapid administration of large fluid volumes (e.g., hemorrhage, trauma).
• Catheter length:
  • Standard IV catheter (3.2cm) for veins < 1cm deep.
  • Double length catheter for veins up to 2cm deep.

Site Selection:

• Adults:
  • Start with distal veins of the upper extremities (ideally non-dominant hand or forearm), moving to more proximal sites if necessary.
  • Possible sites include:
    • Dorsum of hand – Dorsal metacarpal veins.
    • Radial forearm – Cephalic vein.
    • Volar forearm – Median antebrachial veins.
    • Proximal arm (ultrasound-guidance recommended) – Basilic, cephalic, brachial veins.
  • Alternative options if the upper extremities are not feasible:
    • Anterior to medial malleolus – Greater saphenous vein.
    • Dorsum of foot – Dorsal metatarsal veins.
    • Neck – external jugular vein.
• Pediatrics:
  • Upper or lower extremity, or scalp (neonates, infants).
  • Target larger veins and avoid placement of catheters over joints, except in trauma resuscitation/emergent cases where antecubital. fossa veins (e.g. median cubital vein) are often used.

Preparatory Steps:

• Universal precautions and aseptic technique adherence. Use clean gloves.
• Body hair around the site can be clipped if indicated but should not be shaved.

• Consider providing analgesia:
  • Topical (EMLA, LMX, Tetracaine, or Vapocoolant sprays) – may take 30-60 minutes for full effect.
  • Subcutaneous injection (lidocaine).

Traditional Technique

• Place tourniquet (5-10cm proximal to insertion site) and locate target vein by inspection and palpation.
• Additional vein dilation techniques:
  • Bring extremity below heart level.
  • Tap/stroke vein.
  • Instruct patient to clench and relax their fist.
  • Apply warm compress or bathe site in warm water.
    *Transillumination devices may help to locate veins.
• Clean insertion site with antiseptic (70% alcohol, tincture of iodine, or alcoholic chlorhexidine gluconate solution) and allow time to dry.
• Inspect the catheter.
• Consider injecting local anesthetic.
• Apply gentle traction to the vein and insert needle slowly at a 10-30^o Look for a flash of blood in flashback chamber to confirm that the needle is in the vein.
• Lower the angle of the needle and advance it 1-2mm further. Slide the catheter over the needle and into the vein.
  *Inability to advance the catheter suggests it has punctured the vein’s posterior wall, that the catheter is not yet in the vein, or that it is blocked by a valve or bend in the vessel.

• Remove the tourniquet, retract the needle and attach extension tubing.
• Flush the catheter with normal saline.
• Secure catheter with sterile transparent semipermeable adhesive dressing and tape. Loop the tubing. Ensure area is dry prior to applying the dressing and replace any dressing that becomes soiled. Consider a splint if the site is over a joint.
• If there is concern that the catheter has been placed extravenously or into an artery by accident, remove the catheter and apply pressure (2-3 minutes).

Ultrasound-Guidance:

Training and familiarity with US is important prior to using this tool for IV insertion.

• Consider after failed cannulation attempts with the traditional technique or in patients with a known history of difficult IV access.
• Use a high frequency linear transducer. Clean the probe or use a sterile probe cover, along with sterile gel.
• Longer IV catheters are preferred when using ultrasound-guidance.
• Apply a tourniquet and clean the area to be scanned.
• Veins can be identified by their compressibility, lack of pulsatility, and thin walls.
• All potential arm veins should be evaluated to select for the most appropriate cannulation site. Prioritize distal extremity sites when possible. Aim for the largest veins that are approximately 0.3-1.5cm deep.

• Transverse/Short Axis Approach (probe is perpendicular to vein):
  • Note the depth of the target vein and corresponding catheter length needed.
  • Clean the insertion site with antiseptic.
• Keep the vein in the middle of the screen and align the needle with the middle probe marker. The distance from the probe to the needle should be approximately equal to the depth of the target vein. Insert the needle at a 45^o .
• Advance the needle until the tip is visible (bright dot), then walk the needle in while tracking the tip by moving the probe accordingly.
• Observe vessel puncture and look for the flash of blood then decrease the angle of the needle and advance it 1-2mm further, ensuring the tip remains in the center of the vein. Advance the catheter over the needle into the vein.
• Remove the needle and tourniquet, secure the catheter and perform a saline flush (infuse 5-10mL of normal saline and look for microbubbles in vessel).
• Longitudinal/Long Axis Approach (probe is parallel to vein):
  • Advanced technique that allows visualization of the entire needle throughout cannulation.
• Use the transverse view initially to locate the target vein.
• Clean the insertion site with antiseptic.
• Keep the vein in view and insert the needle distal to but aligned with the center of the long axis of the probe at a 30^o angle in the same plane. Ensure the needle remains in view at all times.
• Once the needle is within the vein, advance the catheter over the needle, and secure and test catheter in same manner as the transverse approach.
• US can be further used to confirm adequate catheter placement, and to assess fluid pockets indicative of extravasation and other potential complications.

Alternative Options

• If gaining peripheral IV access is challenging in emergent/necessary settings, the following options could be considered:
  • Intraosseous catheters.
  • Support of US guidance (see “Ultrasound-Guidance” section above).
  • Central venous catheters.

Potential Complications:

It is important to remove the catheter if there are signs of infection or phlebitis, or issues with the catheter itself.

• Potential complications include, but are not limited to:
  • Hematoma.
  • Bruising.
  • Extravasation of IV fluids – look for swelling, pain, slow infusion rate.
  • Inflammation.
  • Infection.
  • Infiltration.
  • Nerve irritation.
  • Arterial puncture.
  • Phlebitis with prolonged use.
  • Thrombophlebitis – more relevant to lower extremity IVs.
  • Embolism.
  • Thrombosis.
  • Blood stream infections (BSI) – rare.

Monitoring:

• Placement, patency, function of the catheter, as well as signs of infection and complications should be assessed at regular intervals.
• Maintain suspicion for clot formation within the catheter and do not forcefully flush in these situations.

Catheter Replacement:

• Adults – not necessary to replace earlier than every 72-96 hours.
• Pediatrics – replace when clinically indicated.

Not Recommended:

>

• Topical antibiotic ointments/creams are not recommended over insertion sites due to risk of fungal infections and antimicrobial resistance.
• Routine administration of systemic antibiotic prophylaxis and/or anticoagulants to prevent catheter-related infections is not recommended.

Considerations:

• Catheter and catheter sites should not be submerged in water. Catheter and connecting device must be covered when showering.
• Patients should follow up with their provider if they notice changes or discomfort associated with their catheter site.

1. Peripheral venous access in adults.
   Frank RL.  Accessed April 5^th, 2021
   In: Post TW, ed. . Waltham, MA:

   [UpToDate; 2021.]

    

   
   

2.  Guidelines for the prevention of intravascular catheter-related infections, 2011. Centers for Disease Control and Prevention. 

   O’Grady NP, Alexander M, Burns LA, et al.Published 2011. Updated October 2017. Accessed March 1^st, 2021.

   [Centers for Disease Control and Prevention]

    

   
   

3. Ultrasound for peripheral and arterial access. Best Practice & Research Clinical Anaesthesiology.

   Oliver LA, Olivre JA, Ohanyan S, Park W, Benelyahoo A, Vadivelu N.  2019;33(4):523-537. doi:10.1016/j.bpa.2019.10.002

   [PubMed.gov]

   
   

4. Videos in clinical medicine: Ultrasound-guided peripheral IV placement. 

   Joing S, Strote S, Caroon L, et al. . 2012;366(25), e38. 

   [ The New England Journal of Medicine]

   
   

5. Comparison of ultrasound guidance with palpation and direct visualisation for peripheral vein cannulation in adult patients: a systematic review and meta-analysis. 

   van Loon FHJ, Buise MP, Claassen JJF, Dierick-van Daele ATM, Bouwman ARA. Br J Anaesth. 2018;121(2):358-366. doi:10.1016/j.bja.2018.04.047

   [British Journal of Anaesthesia]

   
   

6.  Clinical procedures tutorial: IV insertion. In: Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 20^th ed. Sadikot S. Chapter CP11:2018. Accessed April 3^rd, 2021.

   McGraw-Hill Education

   
   

1. VIDEO: Ultrasound-Guided IV Insertion
   (3-part video by 5 Min Sono, <5-minutes each)

   [BC Pocus]

    

   
   

2. VIDEO:

   Ultrasound-guided IV
   (6-minute video by 5 Min Sono)

   [BC Emergency Medicine Network]