How to perform an intravenous (IV) procedure on a patient?

How to Perform Intravenous (IV) Catheter Insertion

For peripheral IV access, use ultrasound guidance with real-time visualization in patients with difficult venous access, select upper extremity sites over lower extremity sites, employ strict aseptic technique with chlorhexidine skin preparation, and secure the catheter with transparent dressings while avoiding routine replacement before clinically indicated. 1, 2, 3

Pre-Procedure Preparation

Equipment and Environment Setup

• Prepare all necessary equipment in advance and create a sterile field to minimize the time the system is open 2
• Perform proper hand hygiene using either alcohol-based waterless product or soap and water before catheter insertion or manipulation 2
• Use a standardized procedure checklist that includes ultrasound guidance protocols to reduce complications 3
• Ensure familiarity with your specific ultrasound machine operation prior to initiating the procedure 3

Site Selection Strategy

• In adults, always use an upper extremity site instead of a lower extremity site for catheter insertion 1
• Select catheters based on the intended purpose, duration of use, and known complications such as phlebitis and infiltration 1
• Avoid steel needles for administration of fluids and medications that might cause tissue necrosis if extravasation occurs 1
• Use the smallest practical cannula size to minimize vein trauma 4

Duration-Based Device Selection

• For 5 or fewer days of access: use ultrasound-guided peripheral IV catheters as first-line for peripherally compatible infusates 4
• For 6-14 days: prefer ultrasound-guided peripheral IV catheters or midline catheters (10-20 cm length) over PICCs 4
• For 15-30 days: PICCs are appropriate 4
• For 31 days or more: tunneled catheters or implanted ports become appropriate options 4

Insertion Technique

Ultrasound-Guided Approach (Preferred Method)

• Use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for all vascular access procedures, regardless of provider experience level 3
• Use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures 3
• Evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation 3
• Avoid using static ultrasound alone to mark the needle insertion site—always use real-time guidance 3

Skin Preparation

• Apply alcoholic chlorhexidine solution (minimum 2% CHG) to the insertion site and allow it to dry completely before puncturing the skin 1, 2
• The drying time is critical to avoid blood contamination and maximize antiseptic effectiveness 1

Cannulation Procedure (For Peripheral Access)

• Use either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access 3
• Insert the needle at approximately a 25° angle when cannulating 1
• When blood flash is observed, flatten the angle of the needle parallel to the skin and advance slowly 1
• Visualize the needle tip and guidewire in the target vein prior to vessel dilatation 3
• To increase success rates, utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available 3

Securing the Catheter

• Use Luer-lock connections rather than slip connections to prevent accidental disconnection 2
• Apply a sterile, transparent dressing over the insertion site to secure the catheter 2
• Use caution when taping needles and avoid lifting up on the needle after it is in the vein, as improper taping can cause infiltration 1

Post-Insertion Care and Maintenance

Immediate Assessment

• Assess for adequate blood flow by alternately aspirating and flushing the needle with a syringe 1
• Assess carefully for signs of infiltration: pain, swelling, or discoloration 1
• Monitor the IV site regularly for any signs of disconnection or infiltration 2

Routine Maintenance

• Perform routine flushing with saline after completion of any infusion or blood sampling 1, 2
• Replace administration sets, including secondary sets and add-on devices, no more frequently than at 72-hour intervals unless catheter-related infection is suspected 1
• Do not routinely change peripheral cannulae at 72-96 hours—only replace when clinically indicated 4
• Clean injection ports with 70% alcohol or an iodophor before accessing the system 1
• Cap all stopcocks when not in use 1

Special Population Considerations

Patients with Chronic Kidney Disease

• For patients with stage 3b CKD or greater (eGFR <45 mL/min), avoid placing any devices in arm veins to preserve vessels for future hemodialysis access 1, 4
• When venous access for 5 or fewer days is necessary, place peripheral IVs in the dorsum of the hand (avoiding forearm veins) for peripherally compatible infusates 1
• For longer durations or non-peripherally compatible drugs, use tunneled small-bore central catheters (4-French single-lumen or 5-French double-lumen) inserted in the jugular vein 1

Patients with Difficult Venous Access

• Use real-time ultrasound guidance for peripheral IV placement in patients with difficult peripheral venous access to reduce total procedure time, needle insertion attempts, and needle redirections 3
• Ultrasound-guided PIV insertion is an effective alternative to central venous catheter insertion in patients with difficult venous access 3
• For patients requiring frequent phlebotomy or with difficult access, consider midline catheters or PICCs based on duration of therapy 1, 4

Patients with Lymphedema

• Avoid insertion in limbs with lymphedema except in acute situations due to increased infection risk 4

Common Pitfalls and Complications

Infiltration Management

• If infiltration occurs, monitor closely and respond quickly to minimize damage to the access 1
• If infiltration occurs after heparin administration, take care to properly clot the needle tract and not the fistula 1
• Immediate application of ice can help decrease pain, size of infiltration, and bleeding time 1
• If the site is infiltrated, rest it for at least one treatment; if not possible, the next cannulation should be above the site of infiltration 1

Needle Removal Technique

• Apply gauze dressing over the needle site but do not apply pressure until the needle has been completely removed 1
• Remove the needle at approximately the same angle as it was inserted to prevent dragging across the patient's skin 1
• Using too steep an angle during needle removal may cause the needle's cutting edge to puncture the vein wall 1

Air Embolism Prevention

• Use Luer-lock connections and ensure all components of the system are compatible to minimize leaks and breaks 1, 2
• Minimize contamination risk by wiping the access port with appropriate antiseptic and accessing the port only with sterile devices 1

Training and Competency Requirements

• Designate trained personnel for the insertion and maintenance of intravascular catheters 1
• Novice providers should complete systematic training that includes simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting independent insertion 3
• Trainees should demonstrate minimal competence before placing catheters independently, with proctored assessment being most important 3
• Periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency 3