Hand Vein Peripheral Intravenous Cannulation

Reliable peripheral intravenous (PIV) access is essential to patient safety in the event of massive resuscitation in the operating room, so anesthesiologists tend to place cannulas in the hands as they are less likely to kink and permit more proximal placement of additional PIVs. If you blow an IV in the hand, you can just move up the arm and try again. If you blow an IV in the antecubital fossa, you might affect venous return for other veins distal to that point (forearm, wrist, hand).

My hand veins

Here are some tips for cannulating hand/wrist veins… many of which can be applied to other PIV locations.

  1. Let the patient run their hands under warm water for 30 seconds.
  2. While their hands are dangling (ie, blood in pooling in the hand), apply two tourniquets to the forearm, or even better, apply a tourniquet with a noninvasive blood pressure cuff on that arm in continuous inflation (venous stasis mode).
  3. Immediately apply alcohol prep all over the patient’s hands before looking for veins. This aids in local venodilation.
  4. “Tap” veins in common areas (the “intern vein” across the lateral wrist, the wrist dorsum, etc.) This supposedly causes local trauma and the release of nitric oxide – a potent dilator.
  5. Consider shaving hairy patients (especially if they have darker skin tones).
  6. If you can’t see or feel the vein, don’t attempt to stick it. There are other extremities, so look elsewhere. Less failed attempts = happier patient. That being said, under extenuating circumstances I’ve placed blind IVs by aiming between the ring/pinky fingers and the middle/ring fingers (see the corresponding veins in the image above).
  7. Use your non-dominant thumb to pull the skin distally thereby anchoring the vein while inserting the PIV with your dominant hand (see my post on IV placement technique). Once blood is seen in the flash chamber, advance the entire PIV several millimeters and thread the catheter off the needle.
  8. A working 20 gauge PIV is better than a blown 18 G PIV. Don’t get too ambitious. Consider using the smaller IV to hydrate the patient (many have been NPO for 12+ hours) before searching for additional sites.

Let me know if you have questions or other tips! 🙂

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6 Comments
  1. Cagla says

    Saving this article forever! I had the hardest time “feeling” for deeper veins as a medical assistant and now that I’m in med school, I will need to practice a ton at it. Thanks for the tips 🙂

    1. Rishi says

      Thanks so much, Cagla! Best wishes to you! 🙂

  2. Rebecca says

    Hey doc!I have a question on CCBs. Why is Nifedipine being a prototype DHP avoided in patients suffering from Myocardial Infarction?

    1. Rishi says

      In STEMI patients, nifedipine (immediate release) is specifically contraindicated because there’s a concern for hypotension, tachycardia, and overall reflexive sympathetic activation.

      1. Rebecca says

        Thanks doc! 😊

  3. Adnane Lahlou says

    Thanks for the tips mate….. As i’m in my fourth/fifth month in pediatric anesthesia/ intensive care…. The ones I find problems with are the toddlers/newborns…. Very challenging especially when the baby is dehydrated, I had a discussion with a friend on whether the new devices showing the veins (forgot the name) were efficient in such cases without a proper answer