What is the proper procedure for starting an intravenous (IV) line?

How to Start an IV Line

Use maximum sterile barrier precautions, select an upper extremity site in adults, apply alcoholic chlorhexidine (≥2% CHG) to the insertion site, and secure with a transparent dressing—ultrasound guidance should be used when available to reduce complications. 1, 2

Pre-Procedure Preparation

Hand Hygiene and Sterile Technique

• Perform hand hygiene using either alcohol-based waterless product or soap and water before catheter insertion or manipulation 1, 3
• Prepare all necessary equipment in advance and create a sterile field to minimize the time the system is open 1, 3
• For central lines specifically, implement maximum sterile barrier precautions including mask, cap, sterile gown, sterile gloves, and large sterile drape covering the patient 3

Patient Preparation

• Apply anesthetic cream (containing lidocaine and prilocaine) 1 hour prior to venous access, particularly in pediatric patients 2
• Ensure adequate hydration status—oral hydration is generally sufficient, but IV hydration may be necessary for debilitated or fasting patients 2
• Have the patient void before the procedure to improve comfort 2

Site Selection

Peripheral IV Access

• In adults, use an upper-extremity site rather than a lower-extremity site for catheter insertion 2
• Replace any catheter inserted in a lower extremity site to an upper extremity site as soon as possible 2
• In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used 2

Central Venous Access

• Use a subclavian site rather than jugular or femoral site in adult patients to minimize infection risk for non-tunneled CVC placement 2
• Avoid the femoral vein for central venous access in adult patients 2, 3
• Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease to prevent subclavian vein stenosis 2, 3

Catheter Selection

• Select catheters based on the intended purpose and duration of use, known infectious and non-infectious complications (e.g., phlebitis and infiltration) 2
• Avoid steel needles for administration of fluids and medications that might cause tissue necrosis if extravasation occurs 2
• Use a midline catheter or PICC instead of a short peripheral catheter when the duration of IV therapy will likely exceed 6 days 2
• Use a CVC with the minimum number of ports or lumens essential for the management of the patient 2

Insertion Technique

Skin Preparation

• Apply alcoholic chlorhexidine solution (minimum 2% CHG) to the insertion site and allow it to dry completely before puncturing the skin 1, 3
• Clean injection ports with 70% alcohol or an iodophor before accessing the system 2

Ultrasound Guidance

• Use ultrasound guidance for catheter insertion when available to reduce the number of cannulation attempts and mechanical complications 2, 1, 3
• Ultrasound guidance should only be used by those fully trained in its technique 2

Insertion Process

• Use Luer-lock connections rather than slip connections to prevent accidental disconnection 1
• For pediatric patients, insertion of a secure peripheral intravenous catheter is advantageous as it reduces the risk of tracer extravasation 2
• Radiopharmaceuticals requiring slow injection (such as [123I]mIBG) should be injected over 1 to 2 minutes to avoid hypertension, nausea, or pallor 2

Post-Insertion Care

Securing the Catheter

• Apply a sterile, transparent dressing over the insertion site to secure the catheter 1, 3
• Replace transparent dressings no more than once weekly unless soiled or loose 3

Monitoring

• Evaluate the catheter insertion site daily by palpation through the dressing to discern tenderness and by inspection if a transparent dressing is in use 2
• Gauze and opaque dressings should not be removed if the patient has no clinical signs of infection 2
• Monitor the IV site regularly for any signs of disconnection or infiltration 1
• The insertion site should be monitored, especially in young children who cannot convey discomfort 2

Removal Criteria

• Remove peripheral venous catheters if the patient develops signs of phlebitis (warmth, tenderness, erythema or palpable venous cord), infection, or a malfunctioning catheter 2
• Promptly remove any intravascular catheter that is no longer essential 2

Maintenance and Equipment Management

Administration Sets

• Replace administration sets that are continuously used, including secondary sets and add-on devices, no more frequently than at 96-hour intervals, but at least every 7 days 2, 3
• Replace tubing used to administer blood, blood products, or fat emulsions within 24 hours of initiating the infusion 2
• Replace tubing used to administer propofol infusions every 6 or 12 hours, when the vial is changed, per the manufacturer's recommendation 2

Needleless Connectors

• Change needleless components at least as frequently as the administration set, with no benefit to changing more frequently than every 72 hours 2
• Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices 2

Flushing

• Perform routine flushing with saline after completion of any infusion or blood sampling 1, 3

Critical Pitfalls to Avoid

• Do not use any container of parenteral fluid that has visible turbidity, leaks, cracks, or particulate matter or if the manufacturer's expiration date has passed 2
• Do not combine the leftover content of single-use vials for later use 2
• Do not administer dextrose-containing solutions or parenteral nutrition fluids through pressure monitoring circuits 2
• Cap all stopcocks when not in use 2
• When adherence to aseptic technique cannot be ensured (i.e., catheters inserted during a medical emergency), replace the catheter as soon as possible 2

Special Considerations

Intraosseous Access

• In an emergency, intraosseous (IO) administration is an acceptable alternative when IV access cannot be promptly obtained 2
• Adenosine may be given intraosseously if IV access has not been achieved 2

High-Risk Patients

• For patients with pulmonary arteriovenous malformations (PAVMs), take additional precautions as IV contrast material administration adds a small risk of air embolism 1
• Consider daily chlorhexidine bathing for ICU patients over two months of age to reduce infection risk 3