Placing A Peripheral Intravenous (PIV) Catheter

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Peripheral intravenous (IV) access is utilized for volume resuscitation, medication administration, blood product transfusion, nutrition, lab draws, and many other reasons. It’s a skill which anesthesiologists perfect through experience but often poses a challenge to new trainees. Let’s discuss the basic set up and some tips.

Preparation
  • IV fluid bag with flushed (“primed”) tubing
  • Alcohol pads
  • TB syringe with 1% lidocaine
  • Skin tape and Tegaderm
  • 4 x 4″ gauze pads and/or a disposable chuck (nurses love it when you don’t make a mess)
  • Tourniquet
  • IV needles (typically I start with an 18 and 20 gauge over-the-needle catheter)
Location

For most operative cases (especially if an arm remains untucked), hand, forearm, or antecubital IVs are the easiest. If a vein isn’t obvious, some common places to “blindly” look for veins are on the dorsal aspect of the hand between the 4th and 5th digits and along the radial aspect of the hand (“intern vein”, beware of the radial artery/nerve!) Often times veins are easier to palpate than to see, so be mindful of this. Also, study the distribution of your own veins – while veins are far more variable in location than arteries, use any help you can get (including ultrasound) if need be! Your goal is to find a vein with a straight segment which can accommodate your IV catheter while praying that you don’t hit a valve. If you blow a vein proximally (antecubital fossa), you’ll potentially lose many good distal sites (hand, forearm), so start distal!

Technique

iv-placement

After placing the tourniquet and cleaning your venous target with alcohol, place a small subcutaneous wheal of lidocaine with the TB syringe at the same point you’ll enter with the IV needle. Be careful not to hit the vein or make such a large wheal that it distorts your entry point. Ensure the patient is still comfortable, and then gently apply traction along the skin to prevent the vein from rolling as you insert the catheter. Begin IV placement at roughly 15- 30 degrees carefully advancing the needle. As soon as you’re below the skin, stay superficial as you hunt for your vein. Carefully advance the needle… pull back some if you need to (just don’t exit the skin)… and adjust your angle. At this point, you should still be holding the IV needle and catheter as a single unit. Once you have blood return in the flash chamber, completely drop your angle and advance the needle another 1-2 mm to ensure the catheter has followed the needle into the vein. Do NOT move the needle at this point – if you advance it, you’ll go through the vein… if you withdraw it, the catheter will be sitting outside the vein. I’ve found holding the needle fixed with one hand and using the other hand to slide the catheter off is a safer technique for beginners. Do not forget to release the tourniquet! 

Place the Tegaderm on top of where the IV enters the skin, connect the IV tubing to the catheter hub, and see if you have flow in the drip chamber. Sometimes this requires flushing the line to remove entrained air. If successful, tape the tubing along the extremity in a manner to prevent kinking, tugging, or accidental dislodgment while moving the patient. I usually loop the tube to minimize the amount of slack. Make sure the IV site is clean, dispose any used supplies appropriately, and you’re good to go! 🙂

The single most important trick to improving your IV skills is experience. Keep practicing and don’t overthink it!

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