HWN Suggests

Inserting peripheral intravenous cannulae – tips and tricks

‘I can’t find a vein’

This is probably the most common problem in IV cannulation, particularly in patients who have had multiple venous punctures, such as renal patients and intravenous drug abusers (IVDAs). There are two ways to solve this problem.

Look for alternative sites... Long saphenous vein at the ankle. This vein is found just anterior to the medial malleolus. It may be difficult to palpate, but can be located using a ‘tap test’ – transmission of a finger tap can be felt 2 cm proximally if there is a column of blood present. This site is particularly useful in children and is almost always present if the site has not been used before

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 Mythbuster: Administration of Vasopressors Through Peripheral Intravenous Access

In critically ill patients, with hemodynamic instability, vasopressor infusion through a proximal PIV (antecubital fossa or external jugular vein), for <4hours of duration is unlikely to result in tissue injury and will reduce the time it takes to achieve hemodynamic stability.

Articles of Interest

Life in the Fastlane

veins are filled by use of a tourniquet and the vein immobilised by finger traction on the adjacent skin. Cannula is held at ~20° to the skin and the vein punctured.

Circulation - Peripheral cannulation

Dorsal hand and cubital fossa veins considered as first alternatives.

Intravenous access - Peripheral

Dorsum of the non-dominant hand is preferred - the vein running between the 4th and 5th metacarpals is most frequently used. In addition to the usual sites in adults, commonly used sites in children include the volar aspect of the forearm, dorsum of the foot and the great saphenous vein at the ankle.

Not a Stab in the Dark - Mastering the Ultrasound Guided Peripheral IV

Always use long IV (1.88 inches) catheters or it will pull out of the vessel.

Pediatric IV Cannulation Tips and Tricks

Decide on the necessity and urgency – ask yourself if the IV needs to be placed now or can you delay while the child drinks or sucks on a popsicle and settles down.

Pediatric Peripheral IV Access

Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric peripheral IV placement.

SGEM#204: Hold the Line – IVs Aren't Always Required

Emergency department patients often have peripheral IV cannula (PIVC) placed at triage for initial blood draws or “just in case” they are used during the emergency department stay or hospitalization. It is one of the most commonly performed procedures in the emergency department. PIVC placement can lead to discomfort, infection, and use of time and other emergency department resources (Rickard et al and Stuart et al). Some studies report that up to half of these are never used.

Should We Use Skin Glue to Secure Peripheral IVs?

While application of skin glue to the peripheral IV insertion site is a simple intervention which may decreased peripheral IV failure rate, further high-quality evidence is needed before this is practice is widely adopted.

Unlocking Common ED Procedures: Approach to the Patient with Difficult Vascular Access

Prior to attempting PIV insertion, see if your ancillary staff had tried a smaller gauge needle. Gentle fluid hydration and many medications can be administered through a 22-gauge catheter, so a patient with multiple failed attempts at cannulation with an 18 or 20-gauge needle can often be rescued by switching to a smaller bore catheter.

Resources

International Emergency Medicine Education Project

Palpation is more important than visualization. Secure vein proximally and distally from the insertion site if dealing with a ‘roller’ vessel.

Peripheral IV – Treatment

Ultrasound-guidance is an important technique that improves the success rate of establishing a peripheral IV in adults, particularly in cases where IV access is difficult.

SAEM

POCUS images...