by Keith A. Raymond
Peripheral Intravenous (IV) cannulation is a nursing skill. Few countries throughout the world require physicians to perform this procedure on a regular basis. Mastery of technique, understanding nuances and anatomy, and daily performance are required to maintain this skill. Therefore, if a nurse reports that he is unable to obtain IV access, and it is required urgently, establishing an IV access or intraosseous (IO) line should be considered to avoid delay.
IV lines can safely remain in place safely for up to 72 hours. In some cases, this is up to 7 days.
“There is no body cavity that cannot be reached with a number fourteen needle and a good strong arm.”
― Samuel Shem, The House of God
IV Line Access and Procedure
Success rates in multiple attempts for admitted patients at a children’s hospital range from 23% for physicians, 44% for nurses to 98% for IV nurse clinicians. The average time required for peripheral IV cannulation is reported at 2.5 to 13 minutes, with difficult IV access requiring as much as 30 minutes. Therefore, we will focus here on peripheral IV cannulation and line access for the easiest and most commonly used sites in emergencies, as we must provide high volumes and medications to the patient quickly.
Intravenous access is used when therapies cannot be used or are less effective by alternative routes. In critical situations, medication bioavailability, hydration, and blood products can be given and provide rapid onset of action. Peripheral access is typically safer, easier to obtain, and less painful than central access. Finally, two large bore intravenous catheters in place can provide the same or more fluids during resuscitation as a central line.
- Patients with anatomic disparities that could lead to fluid or medication extravasation locally or proximally.
- Massive edema in extremities, burns, cellulitis, or injuries at or proximal to proposed insertion sites.
- Any site where there is a concern for vascular flow.
Equipment and Patient Preparation
- skin disinfectant (Povidine and Alcohol Swabs),
- 16-18 gauge IV catheter (smaller catheters may be used for pediatric patients, but larger is better in critical cases),
- 3-way stopcock,
- isotonic crystalloid solution,
- intravenous tubing,
- an elastic tourniquet or blood pressure (BP) cuff.
- Topical anesthetic, eg. EMLA ( 2.5% lidocaine and prilocaine),
- transilluminator light,
- ultrasound with a vascular probe.
- Obtain informed consent or implied, following procedure discussion,
risks, and benefits.
- If possible, have the patients wash their forearms, including the antecubital space, three times with soap and water, then pat dry.
- Select the site starting distally, preferred Cephalic vein in the forearm, then Medial Brachial Vein in Antecubital Sulcus.
- Always apply universal precautions (gloves as a minimum) to the procedural list. Both visualize and palpate the vein to be cannulated.
- There is a slight give to the vessel compared to surrounding tissue.
- Disinfect overlying skin, and provide topical anesthetic to site as desired.
- Transillumination and/or ultrasound may be used to provide additional guidance, but prevent contamination of the clean prepped site to be accessed.
- Apply the tourniquet or BP cuff (inflate above diastolic reading) proximal to the intravenous site.
- Using ‘no-touch’ technique, insert the IV catheter distal to and along the line of the vein at a 10 to 15-degree angle to the skin.
- Advance the needle and the catheter slowly; in most cases, a ‘flash’ of blood will enter the catheter (but not always).
- SLOWLY advance the needle an additional 1 to 2 millimeters, then slide the cannula into the vein, while securing the needle in place.
- Remove the needle while pressing on the overlying skin over the cannula proximal to the insertion site to stem the blood flow.
- Attach the 3-way stopcock, then flush the stopcock and cannula of blood with 5 ml of saline to prevent clotting, and assess the flow of fluid through the catheter. Watch for skin bulge suggesting extravasation of fluid.
- Secure the catheter with tape and release the tourniquet or BP cuff.
- Attach intravenous tubing to 3 way stopcock, attached to the fluid of choice and initiate flow, watching again for fluid extravasation. Medications may be administered through another port of the stopcock or added to the IV solution as desired.
- Make sure that you removed the tourniqet before you give drug or fluid infusion.
- If fluid extravasation occurs at any time, remove the catheter, and repeat the procedure at the more proximal site (never distal to the previous attempt).
Post Procedure Care
- All medications administered should be followed by a 20 ml saline flush.
- A three-way stopcock should remain attached to the IV line if it is not in active use.
- Clean surrounding skin of blood and other contaminants following insertion.
- All IV catheters should be removed within 7 days or as soon as no longer necessary.
- Be vigilant during infusions for tissue swelling or catheter displacement.
Hints and Pitfalls
- Palpation is more important than visualization.
- Secure vein proximally and distally from the insertion site if dealing with a ‘roller’ vessel.
- Use an arm board in pediatric patients, to prevent catheter displacement from movement.
- Do not use flashlights for transillumination as they can burn skin, use transilluminator only. Lowering the room light during transillumination maximizes visualization.
- Following two failed attempts, seek assistance and/or switch to an Intraosseous line.
- Thrombosis and Hemorrhage
- Air embolism
- Extravasation of Drugs
- Vasculitis and Contusions
Refernces and Further Reading
- Clinical Practice Guidelines for Intravenous Access-Peripheral The Royal Children’s Hospital Melbourne, Australia. http://www.rch.org.au/clinicalguide/guideline_index/Intravenous_access_Peripheral
- Katsogridakis, Y.L., Seshadri, R., Sullivan, C., & Waltzman, M.L. (2008). Veinlite transillumination in the pediatric emergency department: a therapeutic interventional trial. Pediatric Emergency Care, 24(2), 83-88
- Leidel, B.A., Kirchhoff, C., Bogner, V., Stegmaier, J., Mutschler, W., Kanz, KG., & Braunstein, V. (2009). Is the intraosseous route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Safety in Surgery, 3(1), 24-31. doi: 10.1186/1754-9493-3-24