Peripheral IV Access

Aka: Peripheral IV Access, Peripheral Catheterization, Peripheral Venous Catheterization, Peripheral Intravenous Catheter, Peripheral Vascular Catheter

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II. Types: Needles

  1. Over the Needle Catheter (Preferred)
    1. Age < 1 year: 22, 24 gauges
    2. Age 1-8 years: 18, 20, 22 gauges
    3. Age >8 years: 16, 18, 20 gauges
    4. Large Bore: 14-16 gauge
  2. Butterfly Needle
    1. Newborn: 23-25 gauges
    2. Age <8 years: 23, 21, 20 gauges
    3. Age >8 years: 21, 20, 18 gauges

III. Types: Sites

  1. Upper Extremity: Antecubital
    1. Non-Ultrasound access
      1. Cephalic Vein (lateral Forearm)
      2. Median cubital vein
      3. Basilic Vein (medial Forearm)
  2. Lower Extremity
    1. Great Saphenous Vein
      1. Descends through medial leg and ankle
      2. Lies anterior to medial malleolus
      3. Extends over dorsum into dorsal venous arch
    2. Median Marginal Vein
  3. Scalp
    1. Small superficial veins
    2. Not recommended in Resuscitation

IV. Technique: Non-Ultrasound

  1. Consider Local Anesthesia at catheter insertion site
    1. See Difficult Intravenous Access in Children
    2. Subcutaneous 1% Lidocaine 5 minutes before
    3. Topical Lidocaine (ELA-Max, LMX) occluded 30 min. before
    4. J-Tip (transdermal Lidocaine device)
    5. Luhmann (2004) Pediatrics 113:e217-20 [PubMed]
  2. Consider limb warming prior to IV cannula insertion
    1. Mitt for hand and Forearm warmed to 125 F (52 C)
    2. Increases success rate and decreases insertion time
    3. Lenhardt (2002) BMJ 325:409-10 [PubMed]
  3. Immobilize the extremity
  4. Locate and stretch the vein
    1. Soft roll of gauze to hyperextend the elbow
    2. Flex the wrist to extend the dorsal hand veins
    3. Extend the ankle to extend the dorsal foot veins
  5. Apply a Tourniquet to proximal vein
    1. Consider Blood Pressure cuff (inflated to 150 mmHg on arm)
      1. Very effective at maintaining non-compressible veins for peripheral vein cannulation
      2. Kule (2014) J Emerg Med S0736-4679(13) [PubMed]
  6. Antiseptic to cannulation site
  7. Flush the needle catheter with sterile saline
  8. Enter Skin
    1. Puncture distal to the site
    2. Enter at 45 degrees with bevel down
    3. Pull the skin to the side while entering skin
    4. Avoid entering the vein with needle
  9. Cannulate vein
    1. Slowly advance catheter/needle until free Blood Flow
    2. Advance catheter/needle a few millimeters
    3. Advance the remainder of the catheter of needle
  10. Remove the needle and confirm backflow
  11. Remove the Tourniquet
  12. Secure intravenous catheter
    1. Consider Skin Glue (Tissue Adhesive, Dermabond)
      1. One drop over skin entry and one drop under plastic hub
      2. Decreases dislodgment risk
      3. Budgen (2016) Ann Emerg Med 68(2):196-201 +PMID: 26747220 [PubMed]
    2. Cover with Transparent Film Dressing (e.g. Tegaderm)

V. Technique: Ultrasound Guidance

  1. See Ultrasound-Guided Antecubital Line
  2. Sites
    1. Basilic Vein (often preferred)
      1. Externally rotate arm for best access
      2. Often superficial, but has variable course and size
    2. Cephalic Vein
      1. Superficial vein and easily compressed by Ultrasound probe (challenging cannulation)
      2. May be preferred in obese patients in whom vein is slightly deeper
    3. Brachial Vein
      1. Risk of brachial artery cannulation, Hematoma
      2. Risk of DVT
  3. Preparation
    1. Obtain long peripheral IV catheter (2.5 inch, double the typical IV catheter length)
    2. Position the patient's arm in abduction, external rotation and supination (ideal for basilic vein access)
    3. Prepare the skin (Chlorhexidine scrub)
    4. Use a sterile Ultrasound probe cover and single use Ultrasound gel on the skin
    5. Use a high frequency linear Ultrasound probe
    6. Sit down comfortably for the procedure
  4. Approach
    1. Identify target vein in transverse position on Ultrasound
      1. Apply pressure to the Ultrasound probe to confirm vein targets are compressible (contrast to artery)
      2. Cephalic veins will appear as the ears of a mickey mouse symbol (with the brachial artery as a head)
      3. Note the depth of the vessel
    2. Rotate the Ultrasound probe to longitudinal, in-line orientation with target vein
      1. Stabilize the Ultrasound probe, held with non-dominant thumb and index
      2. Rest the remaining fingers and palm of the non-dominant hand against the patient
      3. Avoid using an assistant to hold the Ultrasound probe
    3. Direct the needle at a 30-45 degree angle, in-line with the probe into the vessel
      1. Ideally, enter the skin at a shallow angle (but with enough angle to reach the target vessel)
    4. Observe the needle tip advancing and entering the vein
      1. Only shift gaze to the catheter blood flash after visualizing the needle enter on Ultrasound
    5. Once the needle is in the vein
      1. Reduce the needle angle to skin to 30 degrees
      2. Advance the needle 1-2 cm further under direct visualization
        1. Prevents the catheter from kinking at the entry point
      3. Thread the catheter into the vein
        1. If catheter is kinked at the entry, cannula may be "floated" further into the vein with small saline flush
    6. Confirm venous placement
      1. Attach a saline flush syringe
      2. Aspirate blood into the catheter
      3. Flush the catheter with saline
  5. Efficacy
    1. Ultrasound guided peripheral IV has reduced the need for Central Line by >80%
      1. Pare (2019) Am J Emerg Med 37(2):317-20 +PMID: 30471933 [PubMed]
      2. Shokoohi (2013) Ann Emerg Med 61(2): 198-203 +PMID:23141920 [PubMed]
    2. Ultrasound is helpful for difficult IVs, but interferes with placement of easy IV starts
      1. McCarthy (2016) Ann Emerg Med 68(1): 10-8 +PMID: 26475248 [PubMed]

VI. Technique: Difficult IV Access

  1. See Intraosseous Access
  2. See Ultrasound-Guided Internal Jugular Vein Catheterization
  3. See Ultrasound-Guided Antecubital Line
  4. External Jugular Vein Catheterization
  5. Tourniquet Infusion Technique
    1. Obtain distal IV Access (e.g. 22 gauge) in a small hand vein or similar
    2. Apply Tourniquet above the elbow
    3. Infuse 100 cc Normal Saline into the hand vein to result in arm vessel engorgement
    4. Place standard size (e.g. 18 gauge) IV into one of the proximal engorged Forearm or antecubital veins
  6. Central Vein Placement of peripheral IV
    1. Identify a central vein for access (e.g. internal Jugular Vein) via Ultrasound
    2. Use a long peripheral catheter (48 mm is ideal if available, or use the angiocatheter in the Central Line kit)
    3. Sterilize the region
    4. Cannulate the vessel at a shallow angle with peripheral catheter under Ultrasound guidance
    5. Remove peripheral catheter within 72 hours

VII. References

  1. Strayer in Herbert (2018) EM:Rap 18(8): 16-7
  2. Quinn (2014) Emerg Med J 31(7): 593 [PubMed]
  3. Maayedi (2009) J Emerg Med 37(4): 419 [PubMed]

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