Intravenous Cannulation

  • Author: Gil Z Shlamovitz, MD, FACEP; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: May 06, 2015
 

Overview

Background

Intravenous (IV) cannulation is a technique in which a cannula is placed inside a vein to provide venous access. Venous access allows sampling of blood as well as administration of fluids, medications, parenteral nutrition, chemotherapy, and blood products.[1]

Veins have a three-layered wall composed of an internal endothelium surrounded by a thin layer of muscle fibers that is surrounded by a layer of connective tissue. Venous valves encourage unidirectional flow of blood and prevent pooling of blood in the dependent portions of the extremities; they also can impede the passage of a catheter through and into a vein. Venous valves are more numerous just distal to the points were tributaries join larger veins and in the lower extremities.[2]

This topic describes placement of an over-the-needle IV catheter, in which the catheter is mounted on the needle (see the first image below). Such devices are available in various gauges (16-24 gauge), lengths (25-44 mm), compositions, and designs (see the second image below).

Over-the-needle IV catheter. Over-the-needle IV catheter.
Various sizes of over-the-needle IV catheters. Various sizes of over-the-needle IV catheters.

In general, it is advisable to select the smallest gauge of catheter that can still be effectively used to deliver the prescribed therapy; this will minimize the risk of damage to the vessel intima and ensure adequate blood flow around the catheter, which reduces the risk of phlebitis.[3] However, if the situation is an emergency situation or if the patient is expected to require large volumes infused over a short period of time, the largest-gauge and shortest catheter that is likely to fit the chosen vein should be used.

Veins with high internal pressure become engorged and are easier to access. The use of venous tourniquets, dependent positioning, “pumping” via muscle contraction, and the local application of heat or nitroglycerin ointment can contribute to venous engorgement.[2]

The superficial veins of the upper extremities are preferred to those of the lower extremities for peripheral venous access because cannulation of upper-extremity veins interferes less with patient mobility and poses a lower risk for phlebitis.[4] It is easier to insert a venous catheter where two tributaries merge into a Y-shaped form. It is recommended to choose a straight portion of a vein to minimize the chance of hitting valves.

This chapter describes the placement of an IV catheter in an upper extremity. A similar technique can be used for placement of IV catheters in different anatomic sites.

Indications

Indications for IV cannulation include the following:

  • Repeated blood sampling
  • IV fluid administration
  • IV medications administration
  • IV chemotherapy administration
  • IV nutritional support
  • IV blood or blood products administration
  • IV administration of radiologic contrast agents for computed tomography (CT), magnetic resonance imaging (MRI), or nuclear imaging

Contraindications

No absolute contraindications to IV cannulation exist.

Peripheral venous access in an injured, infected, or burned extremity should be avoided if possible.

Some vesicant and irritant solutions (pH < 5, pH >9, or osmolarity >600 mOsm/L) can cause blistering and tissue necrosis if they leak into the tissue, including sclerosing solutions, some chemotherapeutic agents, and vasopressors. These solutions are more safely infused into a central vein. They should only be given through a peripheral vein in emergency situations or when a central venous access is not readily available.

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Periprocedural Care

Equipment

Equipment used for IV cannulation includes the following (see the images below):

  • Nonsterile gloves
  • Tourniquet
  • Antiseptic solution (2% chlorhexidine in 70% isopropyl alcohol)
  • Local anesthetic solution
  • 1-mL syringe with a 30-gauge needle
  • 2 × 2 gauze
  • Venous access device
  • Vacuum collection tubes and adaptor
  • Saline or heparin lock
  • Saline or heparin solution
  • Transparent dressing
  • Paper tape
    Partial selection of equipment required for IV can Partial selection of equipment required for IV cannulation.
    Partial selection of equipment required for IV can Partial selection of equipment required for IV cannulation.
    Vacuum collection tubes and adaptor for IV cannula Vacuum collection tubes and adaptor for IV cannulation.

Patient preparation

Anesthesia

Both intradermal injection of a topical anesthetic agent just prior to IV insertion[5] and topical application of a local anesthetic cream[6] about 30 minutes prior to IV insertion have shown significant reduction of pain associated with the procedure. Both should be used unless the situation is an emergency.[7]

Positioning

Make sure that there is adequate light and that the room is warm enough to encourage vasodilation. Adjust the height or position of the bed or chair to make sure you are comfortable and to prevent unnecessary bending. Make sure the patient is in a comfortable position, and place a pillow or a rolled towel under the patient’s extended arm.

The patient’s skin should be washed with soap and water if it is visibly dirty.

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Technique

Approach considerations

Use properly fitted nonsterile gloves and eye protection device to prevent exposure via accidental blood splashes.

The technique of IV cannulation is outlined in the following section, as well as in the video below.

IV cannulation. Video courtesy of Gil Z Shlamovitz, MD.

Insertion of intravenous catheter

Place a venous tourniquet over the patient’s nondominant arm, and select a site for IV catheter insertion. The veins of choice for catheterization include the cephalic or basilic veins, followed by the dorsal hand venous network (see the images below).[8]

Insertion sites for IV cannulation. Insertion sites for IV cannulation.
Insertion site for IV cannulation. Insertion site for IV cannulation.

For prolonged courses of therapy, it is recommended, though not always practical, to start distally and move proximally as distal catheters are replaced.

If difficulty is encountered in finding an appropriate vein, one of the following techniques may be used:

  • Inspection of the opposite extremity
  • Opening and closing the fist
  • Using gravity (holding the arm down)
  • Gentle tapping or stroking of the site
  • Applying heat (warm towel/pack) or a nitroglycerin ointment

Application of a tourniquet to the proximal arm with infusion of 60 mL of normal saline solution via a small intravenous catheter that is inserted distally may cause enough venous engorgement to allow placement of a more proximal large-bore IV catheter.[9]

Ultrasound guidance has been shown to facilitate peripheral venous placement in emergency department (ED) patients with difficult IV access and should be used when appropriate veins are not readily visualized or palpable.[10] Risk factors for difficult venous access in the ED include diabetes, sickle cell disease, and history of IV drug abuse.[11]

The author recommends the use of ultrasound guidance in patients who have difficult venous access or those in whom venous cannulation by standard methods has failed.[12] Ultrasound-guided peripheral IV access has been associated with reductions in central venous catheter placement, particularly in noncritically ill patients.[13]

Transillumination is another technique that can be used in patients with difficult IV access.[14]

Apply an antiseptic solution such as 2% chlorhexidine solution or 70% alcohol with friction for 30-60 seconds (see the image below). Allow to air-dry for up to 1 minute to ensure disinfection of the site and to prevent stinging as the needle pierces the skin. Once the skin is cleaned, do not touch or repalpate it.

Application of antiseptic solution for IV cannulat Application of antiseptic solution for IV cannulation.

While the skin is allowed to dry, flush the saline or heparin lock with the appropriate solution. The syringe may be left attached to the tubing (see the image below).

Flushing of tubing with normal saline for IV cannu Flushing of tubing with normal saline for IV cannulation.

Unless the situation is an emergency, if the patient is interested in local anesthesia, infiltrate 0.5-1 mL of a local anesthetic using a 25- or 30-gauge needle to raise a wheal at the site of catheter insertion (see the image below).

Subcutaneous injection of local anesthetic for IV Subcutaneous injection of local anesthetic for IV cannulation.

Stabilize the vein using your nondominant hand (thumb) to apply traction to the skin distal to the chosen site of insertion (see the image below). This will prevent superficial veins from rolling away from the needle. Stabilization should be maintained throughout the procedure.

Applying traction with nondominant thumb to stabil Applying traction with nondominant thumb to stabilize vein for IV cannulation.

Hold the venous access device in your dominant hand bevel up to ensure smoother catheterization because the sharpest part of the needle will penetrate the skin first. Release the needle from the catheter and replace it, ensuring that the catheter was not damaged or fragmented. This will ensure smooth advancement once the venous access device is inside the vein.

The angle of the needle entry into the skin will vary according to the device used and the depth of the vein (see the image below). Small superficial veins are best accessed by using a small catheter (22-24 gauge) placed at a 10º-25º angle. Deeper veins should be accessed with a larger catheter at a 30º-45º angle.

Angle of insertion with bevel up for IV cannulatio Angle of insertion with bevel up for IV cannulation.

Upon entry into the vein, the practitioner might feel a “giving way” sensation. Blood should appears in the chamber of the venous access device (ie, flashback). (See the image below.) The angle of the venous access device should be reduced to prevent puncturing the posterior wall of the vein. It should be advanced gently and smoothly an additional 2-3 mm into the vein.

Flashback of blood into venous access device for I Flashback of blood into venous access device for IV cannulation.

If no blood is observed in the flashback chamber, the device should be withdrawn to just beneath the skin level, and another attempt to recatheterize the vein should take place. Flashback may stop if the device punctured the posterior wall of the vein or if the patient is extremely hypotensive. If swelling develops, withdraw the device, release the tourniquet, and apply direct pressure for 5 minutes for a hematoma.

If venous catheterization is unsuccessful, the needle should never be reintroduced into the catheter. This could result in catheter fragmentation and embolism.

After the venous access device’s hub is dropped to the skin, maintain skin traction with your nondominant hand. Hold the needle grip of the venous access device in place between your dominant thumb and middle finger, while using your dominant index finger to slide the hub of the catheter over the needle and into the vein (see the image below).

Sliding hub of catheter over needle and into vein Sliding hub of catheter over needle and into vein for IV cannulation.

Use your nondominant middle finger to apply pressure over the catheter to prevent blood spill and hold the hub in place using your nondominant index and thumb fingers. Then use your dominant hand to withdraw the needle (see the image below). Secure the needle in either its safety cover and/or a dedicated biohazard sharps container.

Using nondominant hand to secure venous access dev Using nondominant hand to secure venous access device in vein while using dominant hand to remove and secure needle for IV cannulation.

If blood sampling is needed, attach an adaptor or a syringe to the hub and obtain the required samples (see the image below).

Using blood sampling adapter for IV cannulation. Using blood sampling adapter for IV cannulation.

Release the tourniquet. While applying pressure to the catheter to prevent blood spillage and while continuously stabilizing the hub and wings to the skin as described before, disconnect the blood sampling adaptor or syringe, and securely attach the preflushed saline or heparin lock to the hub of the venous access device. Secure the venous access device to the skin using the transparent dressing and tape (see the image below).

Securing saline lock with transparent dressing for Securing saline lock with transparent dressing for IV cannulation.

Using the saline or heparin flush syringe, withdraw a small amount of blood to verify that the catheter is still inside the vein. Immediately flush the tubing with the remainder solution. Slide the plastic tubing lock, and continue to lock the tubing (if such a lock is available). (See the image below.)

Flushing and locking venous access device for IV c Flushing and locking venous access device for IV cannulation.

Finish securing the tubing to the skin using tape. Place a label indicating date, time, and other facility-specific required information over the transparent dressing (see the image below).

Labeling for IV cannulation. Labeling for IV cannulation.

Removal of intravenous catheter

Removal of peripheral IV catheters can be performed as clinically indicated; the catheters should not be routinely replaced on a fixed schedule.[15, 16]

Stop infusion solution and disconnect the tubing, leaving just the saline/heparin lock tubing connected to the venous access device. Release the adhesive tape and transparent dressing from the skin. Withdraw the catheter outside of the vein (see the image below), and apply direct pressure with gauze for at least 5 minutes.

Removal of IV catheter. Removal of IV catheter.

Inspect the catheter for fragmentation. Document in the patient’s chart the date, time, and reason for catheter removal and the integrity of the catheter as inspected. Place a 2 × 2 gauze pad or a cotton ball with a paper tape over the IV insertion site. Instruct the patient to continue manual pressure for 10 more minutes in order to minimize hematoma formation.

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Complications

Periprocedural and postprocedural complications may include the following:

  • Pain
  • Failure to access the vein
  • Blood stops flowing into the flashback chamber
  • Difficulty advancing the catheter over the needle and into the vein
  • Difficulty flushing after the catheter was placed in a vein
  • Arterial puncture
  • Peripheral nerve palsy
  • Skin and soft tissue necrosis

For pain, an anesthetic cream 30 minutes prior to insertion attempt and/or subcutaneous infiltration of an anesthetic solution should be used prior to peripheral IV insertion whenever possible.

Collapse of the vein, inadequate skin traction, incorrect positioning, and incorrect angle of penetration can all lead to a failed attempt at accessing the vein. In this case, either attempt insertion at a different site or, if it is believed the selected vein should be accessible, withdraw the venous access device to just beneath the skin and reattempt to insert.

If blood stops flowing into the flashback chamber, the cause might be vein collapse, venospasm, needle hub position against a venous valve, or penetration of the posterior wall of the vein. Observation of a developing hematoma necessitates removal of the catheter. In this case, release and then reapply the venous tourniquet, and attempt to gently stroke the vein to engorge it with blood and release venospasm. Finally, attempt to withdraw the needle a few millimeters to move it away from a valve.

Failure to release the catheter from the needle before insertion, encountering a venous valve, removing the needle too far with the catheter being too soft to advance into the vein, poor skin traction, or venous collapse can all lead to difficulty in advancing the catheter over the needle and into the vein. In this case, release the tourniquet and then reapply it to help engorge the vein. Connect a syringe with normal saline (0.9%) solution to the hub, then attempt to “float” the device in place by simultaneously flushing the catheter and advancing it.

Difficulty flushing after the catheter was placed in a vein can be caused by the catheter tip position against a venous wall or a valve, blood clot, or piercing of the venous wall. Observation of a hematoma necessitates removal of the catheter. In this case, withdraw the catheter slightly to release it from a wall/valve and attempt to flush it back in.

In the case of arterial puncture, palpate the vein carefully before attempting to insert a venous access device to ensure that there is no palpable pulse in the vessel. If an accidental arterial puncture occurred, as evidenced by arterial pulsation of blood out of the catheter, remove the catheter and apply direct pressure using gauze for at least 10 minutes.

Thrombophlebitis can be caused by thrombus formation with subsequent inflammation, infection, or both. Pain in the IV site along the path of the catheter, skin erythema and/or induration, swelling, drainage from the skin puncture site, or presence of a palpable venous cord are the signs of thrombophlebitis.

Remove the catheter and treat with appropriate antibiotics if you suspect an infectious etiology. Regularly and at least daily inspect the site of insertion for signs of infections. Some sources recommend the routine replacement of peripherally inserted IV catheters every 3-4 days, whereas others suggest that proper antiseptic technique and at least daily monitoring of the insertion sites may allow for safe less frequent replacement as long as no signs of phlebitis are present.[17, 16]

Accidental puncture of the median nerve is rare but possible, in that this nerve is located just posterior to the basilic vein in the antecubital fossa. Other peripheral nerves might be accidently punctured, causing pain and (rarely) paralysis when other veins are selected.

Continuous infusion of solutions into a venous access device that extravasated into the surrounding tissue might result in a compartment syndrome. Make sure to monitor the site while the transfusion is taking place, and use extra caution in patients who are unable to communicate pain or discomfort. Some infusion pumps are preset to stop the infusion and sound an audible alert with any increase in resistance to flow.

Some vesicant and irritant solutions may cause severe soft tissue damage if they extravasate outside of the vein and into the surrounding tissue.

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Contributor Information and Disclosures
Author

Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

Acknowledgements

The author thanks Mark Scalzi, RN, BSN, for his help with producing the multimedia content associated with this article.

Medscape Drugs & Diseases also thanks Gil Z Shlamovitz, MD, FACEP, Associate Professor of Clinical Emergency Medicine, University of Southern California, and Chief Medical Information Officer, Keck Medicine of USC, Los Angeles, CA, for assistance with the video contribution to this article.

References
  1. Scales K. Intravenous therapy: a guide to good practice. Br J Nurs. 2008 Oct 23-Nov 12. 17(19):S4-S12. [Medline].

  2. Feldman R. Venipuncture and Peripheral Intravenous Access. Reichman and Simon. Emergency Medicine Procedures. New York: Mcgraw Hill; 2004. 297-313.

  3. Dougherty L. Peripheral cannulation. Nurs Stand. 2008 Sep 3-9. 22(52):49-56; quiz 58. [Medline].

  4. Roseman JM. Deep, percutaneous antecubital venipuncture: an alternative to surgical cutdown. Am J Surg. 1983 Aug. 146(2):285. [Medline].

  5. Burke SD, Vercler SJ, Bye RO, Desmond PC, Rees YW. Local anesthesia before IV catheterization. Am J Nurs. 2011 Feb. 111(2):40-5; quiz 46-7. [Medline].

  6. Valdovinos NC, Reddin C, Bernard C, Shafer B, Tanabe P. The use of topical anesthesia during intravenous catheter insertion in adults: a comparison of pain scores using LMX-4 versus placebo. J Emerg Nurs. 2009 Jul. 35(4):299-304. [Medline].

  7. McNaughton C, Zhou C, Robert L, Storrow A, Kennedy R. A randomized, crossover comparison of injected buffered lidocaine, lidocaine cream, and no analgesia for peripheral intravenous cannula insertion. Ann Emerg Med. 2009 Aug. 54(2):214-20. [Medline].

  8. Ortega R, Sekhar P, Song M, Hansen CJ, Peterson L. Videos in clinical medicine. Peripheral intravenous cannulation. N Engl J Med. 2008 Nov 20. 359(21):e26. [Medline].

  9. Stein JI. A new technique for obtaining large-bore peripheral intravenous access. Anesthesiology. 2005 Sep. 103(3):670. [Medline].

  10. Panebianco NL, Fredette JM, Szyld D, Sagalyn EB, Pines JM, Dean AJ. What you see (sonographically) is what you get: vein and patient characteristics associated with successful ultrasound-guided peripheral intravenous placement in patients with difficult access. Acad Emerg Med. 2009 Dec. 16(12):1298-303. [Medline].

  11. Fields JM, Piela NE, Au AK, Ku BS. Risk factors associated with difficult venous access in adult ED patients. Am J Emerg Med. 2014 Oct. 32(10):1179-82. [Medline].

  12. Egan G, Healy D, O'Neill H, Clarke-Moloney M, Grace PA, Walsh SR. Ultrasound guidance for difficult peripheral venous access: systematic review and meta-analysis. Emerg Med J. 2012 Aug 14. [Medline].

  13. Shokoohi H, Boniface K, McCarthy M, Khedir Al-tiae T, Sattarian M, Ding R, et al. Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients. Ann Emerg Med. 2013 Feb. 61(2):198-203. [Medline].

  14. Atalay H, Erbay H, Tomatir E, Serin S, Oner O. The use of transillumination for peripheral venous access in paediatric anaesthesia. Eur J Anaesthesiol. 2005 Apr. 22(4):317-8. [Medline].

  15. Rickard CM, Webster J, Wallis MC, Marsh N, McGrail MR, French V, et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet. 2012 Sep 22. 380(9847):1066-74. [Medline].

  16. Webster J, Osborne S, Rickard CM, New K. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev. 2013 Apr 30. 4:CD007798. [Medline].

  17. Aziz AM. Improving peripheral IV cannula care: implementing high-impact interventions. Br J Nurs. 2009 Nov 12-25. 18(20):1242-6. [Medline].

 
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Partial selection of equipment required for IV cannulation.
Partial selection of equipment required for IV cannulation.
Various sizes of over-the-needle IV catheters.
Over-the-needle IV catheter.
Vacuum collection tubes and adaptor for IV cannulation.
Vein palpation for IV cannulation.
Insertion sites for IV cannulation.
Insertion site for IV cannulation.
Application of antiseptic solution for IV cannulation.
Flushing of tubing with normal saline for IV cannulation.
Subcutaneous injection of local anesthetic for IV cannulation.
Applying traction with nondominant thumb to stabilize vein for IV cannulation.
Angle of insertion with bevel up for IV cannulation.
Flashback of blood into venous access device for IV cannulation.
Sliding hub of catheter over needle and into vein for IV cannulation.
Using nondominant hand to secure venous access device in vein while using dominant hand to remove and secure needle for IV cannulation.
Using blood sampling adapter for IV cannulation.
Securing saline lock with transparent dressing for IV cannulation.
Flushing and locking venous access device for IV cannulation.
In same patient, flushing and locking venous access device for IV cannulation.
Again in same patient, flushing and locking venous access device for IV cannulation.
Labeling for IV cannulation.
Removal of IV catheter.
IV cannulation. Video courtesy of Gil Z Shlamovitz, MD.
 
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