Multiple factors determine the route and site for vascular access, and knowing the basic anatomy, techniques, indications, and contraindications is essential.
Infusion rate is key in the resuscitation of those with severe hypovolemia or hemorrhage.1 Flow rates increase with larger catheter radius, use of more pressure (gravity, manual push-pull devices, pressure bag application, or commercial rapid infusing devices), decreasing viscosity (coadministration of crystalloid with viscous blood products), or decreasing catheter length (peripheral angiocatheter vs. triple-lumen catheter). Maximal flow rates occur from shorter and wide catheters, although both may be hard to achieve.
PERIPHERAL VENOUS ACCESS AND ANATOMY
The most commonly accessed veins for peripheral catheterization of the upper extremity are in the dorsal hand and the antecubital fossa (Figure 31-1).
Venous anatomy of the upper extremity.
Peripheral catheterization of the superficial veins of the lower extremity is possible, sometimes overlooked, and occasionally more difficult. Avoid IV access of the lower extremity in adults, especially diabetics, due to an increased risk of infection and phlebitis. See discussion below of venous cutdown of the saphenous vein at the medial malleolus.
TECHNIQUE FOR PERIPHERAL VENOUS ACCESS
Gather all equipment before beginning the procedure (Table 31-1). Observe universal precautions. The procedure for peripheral IV line insertion is in Table 31-2.
TABLE 31-1Materials for Peripheral IV Line Placement |Favorite Table|Download (.pdf) TABLE 31-1 Materials for Peripheral IV Line Placement
Personal protective equipment (gloves, face shield)
Alcohol swabs or povidone-iodine
Appropriate-sized venous catheter
IV solution and tubing (if indicated)
Sterile transparent dressing
TABLE 31-2Peripheral IV Line Insertion |Favorite Table|Download (.pdf) TABLE 31-2 Peripheral IV Line Insertion
|Step ||Comment |
|1. Apply tourniquet. ||Apply tourniquet tightly enough to facilitate adequate venous filling and distention without causing patient discomfort or ischemia. |
|2. Locate vein. || |
Inspect and palpate the vein.
Warm the skin, tap the vein, or apply topical nitroglycerin ointment to ease identification.
|3. Clean area with either an alcohol swab or povidone-iodine solution. ||— |
|4. Apply gentle traction with the nondominant hand to anchor the vein. ||— |
|5. Insert catheter needle into skin and vessel at a 15- to 30-degree angle with dominant hand. || |
Peripheral veins are easiest to access at the apex of the “Y” formed by merging veins or where veins are straight for several centimeters.
Use a more obtuse (60-degree) angle for deeper veins.
|6. Observe for blood flash in catheter hub. ||This indicates successful vessel penetration. |
|7. Gently advance catheter into vessel lumen until the hub is flush against the skin. |
See Figure 31-2.
If you meet resistance, withdraw the catheter slightly, as it may have penetrated the posterior vessel ...