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).

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 having the patient dangle their hands, apply two tourniquets to the upper arm, 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. 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).
6. 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.
7. A working 20 gauge PIV is better than a blown 18 G PIV. Don’t get too ambitious. Consider using a 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! 🙂