What is the optimal site for intravenous (IV) placement for medication administration?

Optimal IV Placement for Medication Administration

For general medication administration, large veins in the forearm are the preferred site for peripheral IV placement, avoiding areas of flexion such as joints, the antecubital fossa, inner wrist, and dorsum of the hand. 1

Site Selection Algorithm

For Standard Peripheral IV Access

Primary recommendation: Target large forearm veins 1

• These provide optimal flow and stability for most medications
• Avoid the antecubital fossa (elbow crease) and dorsum of the hand, particularly for vesicant drugs 1
• Do not cannulate over joints or the inner wrist 1
• Avoid lower extremities entirely 1

Use flexible cannulae rather than steel "butterfly" needles for any vesicant drug infusion, as needles can easily displace or puncture the venous wall 1

Special Patient Populations

For patients with advanced CKD (stage 3b or greater, eGFR <45 mL/min):

• Place peripheral IVs in the dorsum of the hand only (avoiding forearm veins) for short-term access ≤5 days 1
• This preserves arm veins for potential future hemodialysis access 1
• For longer durations or non-peripherally compatible drugs, use tunneled small-bore central catheters in the jugular vein 1

Avoid cannulation in limbs with lymphedema except in acute emergencies due to increased infection risk 1

Device Selection Based on Duration and Drug Type

Short-term access (≤2 weeks):

• Standard peripheral IV catheters in forearm veins for peripherally compatible medications 1
• Peripheral insertion is inappropriate for fluids with osmolality >500 mOsm/L, pH <5 or >9, or access needed >2 weeks 1

Medium-term access (1-4 weeks):

• Midline catheters (10-20 cm) inserted into upper arm veins under ultrasound guidance 1
• These should NOT be used for infusions requiring central venous administration 1

Long-term access or vesicant drugs:

• Central venous access devices are required for irritant or vesicant medications 1
• For infection prevention, subclavian site is preferred over jugular or femoral in adults 1

Critical Pitfalls to Avoid

Two-thirds of PIVCs worldwide are placed in non-recommended sites (hand, wrist, antecubital veins), contributing to high failure rates 2

Never use steel butterfly needles for vesicant drug infusion - they easily displace and cause extravasation 1

In patients with difficult venous access requiring >6 days of therapy, ultrasound-guided peripheral IV or midline placement is appropriate rather than repeated standard attempts 1

Verification and Maintenance

• Always check for blood return before drug administration 1
• Flush with 10-20 mL normal saline between different drug infusions 1
• Monitor insertion site continuously during infusion for swelling, pain, or redness 1
• Document insertion date, time, and perform daily site assessments (currently lacking in 36% of cases worldwide) 2