What is the proper technique for performing intravenous (IV) insertion access?

Proper Technique for Intravenous Insertion Access

The proper technique for intravenous insertion access requires strict adherence to aseptic technique, appropriate site selection, proper skin preparation with chlorhexidine-alcohol solution, and careful cannulation technique to minimize complications and ensure successful placement. 1

Preparation

• Perform hand hygiene either by washing with antiseptic-containing soap and water or using waterless alcohol-based gels or foams before and after any vascular access procedure 1
• Select the appropriate catheter size - use the smallest practical size cannula for the intended purpose to minimize vessel trauma 1
• Gather all necessary equipment including sterile gloves, antiseptic solution, dressing supplies, and needle with safety device 1
• Assess and select an appropriate insertion site, avoiding the wrist and cubital fossa when possible due to higher risk of catheter colonization and infection 2
• For peripheral access, forearm veins are preferred over hand veins when available 1
• Apply tourniquet to the access arm to enhance vein visibility 1

Skin Preparation

• Disinfect clean skin with an appropriate antiseptic before catheter insertion 1
• 2% chlorhexidine solution in 70% isopropyl alcohol is the preferred antiseptic for skin preparation 1, 3
• Apply antiseptic in a circular rubbing motion and allow it to completely air dry (at least 30 seconds for alcohol-based solutions) 1, 4
• If using povidone iodine, allow 2-3 minutes for full bacteriostatic action before proceeding 4
• Do not touch the prepared site after antiseptic application unless using sterile technique 1

Insertion Technique

• Put on clean gloves for peripheral IV insertion or sterile gloves for central venous access 1
• Pull the skin taut in the opposite direction of needle insertion to stabilize the vein and compress peripheral nerve endings 4
• Hold the catheter with the bevel facing upward at approximately a 25-30 degree angle 1, 4
• Insert the needle through the skin and into the vein until blood flashback is observed 1
• Once blood flashback is seen, lower the angle of the catheter almost parallel to the skin and advance the catheter slightly to ensure the tip is within the vessel 1, 4
• Stabilize the needle/stylet while advancing the catheter forward into the vein 4
• Remove the tourniquet once the catheter is successfully placed 1
• Apply pressure to the vein above the catheter tip while removing the stylet/needle to prevent bleeding 4
• Immediately activate any safety mechanism on the needle and dispose of it properly 1

Post-Insertion Care

• Assess for adequate blood flow by alternately aspirating and flushing the catheter with a syringe 1
• Carefully assess for signs of infiltration (pain, swelling, or discoloration) 1
• Secure the catheter with sterile transparent semi-permeable dressing or sterile gauze with tape 1
• Label the dressing with date, time, and operator initials 1
• Flush the catheter with appropriate solution (saline) after insertion and after each use 1
• Document the procedure including catheter size, insertion site, number of attempts, and any complications 1

Common Pitfalls and How to Avoid Them

• Using too steep an insertion angle may cause the needle to puncture through the posterior wall of the vein 1, 4
• Failure to stabilize the vein can lead to "rolling veins" and unsuccessful cannulation 4
• Improper skin preparation increases infection risk - always allow antiseptic to fully dry 1
• Applying pressure to the puncture site before the needle is completely removed can damage the vein 1
• Avoid insertion at areas of flexion (wrist, cubital fossa) as these have higher rates of complications 2
• Do not palpate the insertion site after antiseptic application unless using sterile technique 1
• Avoid repeated attempts in the same area, which can cause vascular damage and increase infection risk 1

Special Considerations

• For difficult access, consider using visualization technologies such as ultrasound, transillumination, or infrared devices 1, 5
• For patients requiring long-term access, consider midline catheters or central venous access devices rather than repeated peripheral cannulation 1
• Peripheral catheters do not need to be routinely replaced at 72-96 hours; they can remain in place until clinically indicated 1
• Assess the catheter site daily for signs of infection or infiltration 1