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The upper extremity has two primary venous systems; the cephalic vein on the radial side of the forearm and the basilic vein originating on the ulnar side of the forearm. The two systems communicate at the wrist and antecubital fossa. Venous anatomy can vary considerably between patients and each individual must be examined prior to the procedure. Care should be avoided of the arterial anatomy in the area by palpating prior to cannulation.
The lower extremity's venous system consists of the greater and lesser saphenous vein. The greater originates from the median side of the dorsal median arch passing just anterior to the medial malleolus following the medial border of the tibia to the knee. The lesser originates on the lateral dorsal foot and passes posterior to the lateral malleolus and then through the gastrocnemius muscle.
Difficulty in obtaining venous access may occur from provider or patient factors. The most common provider factor is lack of experience with the procedure. Patient factors include young age, obesity, malnutrition and absence of visible or palpable peripheral veins on exam.
Venipuncture can be both physically and emotionally painful for pediatric patients and anxious adults. Anesthesia has been shown to attenuate both metabolic and hormonal response to pain. Anesthesia by topical means has been shown to be both efficacious and effective. In addition, it has the advantage of avoiding tissue distortion seen with infiltrated anesthetics.
Using a insulin syringe with 1% lidocaine, needle free CO2 injection devices or other lidocaine injections are also potential methods for decreasing the pain associated with venipuncture.
Liposomal lidocaine (ELA-max)
Self-heating lidocaine and tetracaine patch (Synera)
Several techniques can be used to improve vein dilation and cannulation success
Although PIVs are rarely complicated by infection, cleaning of the site prior to needle introduction is key to preventing this complication. Chlorhexidine-based solutions have been shown superior to both aqueous and alcohol-based providone-iodine preparations.
Previously a "heparin lock" was the common practice for keeping PIVs patent. However, further research has shown that periodic flushing with normal saline works as well as heparin solutions and avoids complications from the use of heparin.