Peripheral IV Access - PIV - Curbside
Peripheral IV Access - PIV
Editors: Dan Imler, MD
Inclusion Criteria  (Any one criteria present)
  • Clinical need for peripheral IV access
Exclusion Criteria
  • Insertion site appear actively infected or has overlying hematoma or infiltration
  • Phlebitis or sclerosed veins
  • Burns or trauma proximal to insertion site
  • Arteriovenous fistula in extremity
  • Surgical procedure affecting extremity
Consider intraosseous line, ultrasound guided PIV or central line placement

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Total Notes: 7

1 Venous Access

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.

  1. Predicting peripheral venous access difficulty in the emergency department using body mass index and a clinical evaluation of venous accessibility.
    Sebbane M, Claret PG, Lefebvre S, Mercier G, Rubenovitch J, Jreige R, Eledjam JJ, de La Coussaye JE
    J Emerg Med. 2013 Feb;44(2):299-305.
  2. Is peripheral line placement more difficult in obese than in lean patients?
    Juvin P, Blarel A, Bruno F, Desmonts JM
    Anesth Analg. 2003;96(4):1218
  3. Variables influencing intravenous catheter insertion difficulty and failure: an analysis of 339 intravenous catheter insertions.
    Jacobson AF, Winslow EH
    Heart Lung. 2005 Sep;34(5):345-59.
  4. Infusion phlebitis in post-operative patients: when and why.
    Monreal M, Oller B, Rodriguez N, Vega J, Torres T, Valero P, Mach G, Ruiz AE, Roca J
    Haemostasis. 1999;29(5):247.
  5. Peripheral venous catheter-related inflammation. A randomized prospective trial.
    Haddad FG, Waked CH, Zein EF
    J Med Liban. 2006;54(3):139.

2 Site selection

  • In general, the most distal site possible should be selected first thus saving the more central sites for subsequent cannulation.
  • Upper extremity locations are more durable and experience lesser complications (thrombosis, embolization) - although lower in children and infants
  • The intended use of the cannula should be taken into account including comfort
  • Recently attempted sites should be avoided as they likely have extravagated fluids or developing hematomas.
  • The larger the peripheral vein, the higher the likelihood of successful cannulation
  • Veins of the upper extremity are at decreased risk of thrombosis and thrombophlebitis
  • Avoiding sites over joints is preferable as the catheters commonly become kinked or dislodged
  • Avoid dominate extremities if possible
  • Avoid firm veins as they may be sclerosed and difficult to access
  • Scalp veins are rarely a primary choice for anatomical placement

  1. An epidemiologic study of the risks associated with peripheral intravenous catheters.
    Tager IB, Ginsberg MB, Ellis SE, Walsh NE, Dupont I, Simchen E, Faich GA
    Am J Epidemiol. 1983;118(6):839.
  2. Vascular access: a guide to peripheral venous cannulation.
    Scales K
    Nurs Stand. 2005;19(49):48.

3 Anesthetics

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.

  1. Biologic markers of pain in the vulnerable infant.
    Goldman RD, Koren G
    Clin Perinatol. 2002;29(3):415.
  2. Eutectic mixture of local anesthetics reduces pain during intravenous catheter insertion in the pediatric patient.
    Cordoni A, Cordoni LE
    Clin J Pain. 2001;17(2):115.

4 Efficacy of topical anesthetics

Vasocoolent spray

  • Vasocoolent sprays have been shown superior to placebo in trials looking at their anesthetic potential. Spraying time appears to be the key factor in the amount of anesthesia provided (as well as patient specific patterns)


  • ELMA should only be placed on intact skin as it can be absorbed systemically through wounded tissue. It also carries the risk of methemoglobinemia in patients with underlying risk factors. The key to efficacy in use of EMLA appears to be length of time the medication is left on intact skin. Anesthesia measured by needle insertion was 3 mm one hour and 5 mm after 1.5 to 2 hours.

Liposomal lidocaine (ELA-max)

  • Liposomal lidocaine has shown efficacy vs. placebo and in some cases vs. EMLA (although there are contradicting studies). It does have a faster onset of action than EMLA.

Self-heating lidocaine and tetracaine patch (Synera)

  • Similar to EMLA and Liposomal lidocaine, the self-heating patch has shown improvement over placebo. It has the shortest onset of action of the three.

  1. Vapocoolant spray is equally effective as EMLA cream in reducing immunization pain in school-aged children.
    Cohen Reis E, Holubkov R
    Pediatrics. 1997;100(6):E5.
  2. Topical vapocoolant quickly and effectively reduces vaccine-associated pain: results of a randomized, single-blinded, placebo-controlled study.
    Mawhorter S, Daugherty L, Ford A, Hughes R, Metzger D, Easley K
    J Travel Med. 2004;11(5):267.
  3. Ethyl chloride as a cryoanalgesic in pediatrics for venipuncture.
    Soueid A, Richard B
    Pediatr Emerg Care. 2007;23(6):380.
  4. The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial.
    Farion KJ, Splinter KL, Newhook K, Gaboury I, Splinter WM
    CMAJ. 2008;179(1):31.
  5. Efficacy of ethyl chloride as a local anesthetic for venipuncture and intravenous cannula insertion in a pediatric emergency department.
    Ramsook C, Kozinetz CA, Moro-Sutherland D
    Pediatr Emerg Care. 2001;17(5):341.
  6. Pharmacologic approaches for reducing venous access pain in children.
    Zempsky WT
    Pediatrics. 2008;122 Suppl 3:S140.
  7. Topical skin anesthesia for venous, subcutaneous drug reservoir and lumbar punctures in children.
    Halperin DL, Koren G, Attias D, Pellegrini E, Greenberg ML, Wyss M
    Pediatrics. 1989;84(2):281.
  8. Eutectic mixture of local anesthetics reduces pain during intravenous catheter insertion in the pediatric patient.
    Cordoni A, Cordoni LE
    Clin J Pain. 2001;17(2):115.
  9. Depth and duration of skin analgesia to needle insertion after topical application of EMLA cream.
    Bjerring P, Arendt-Nielsen L
    Br J Anaesth. 1990;64(2):173.
  10. A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children.
    Eichenfield LF, Funk A, Fallon-Friedlander S, Cunningham BB
    Pediatrics. 2002;109(6):1093.
  11. Topical anesthetics for intravenous insertion in children: a randomized equivalency study.
    Kleiber C, Sorenson M, Whiteside K, Gronstal BA, Tannous R
    Pediatrics. 2002;110(4):758.
  12. A randomized, double-blind comparison study of EMLA and ELA-Max for topical anesthesia in children undergoing intravenous insertion.
    Koh JL, Harrison D, Myers R, Dembinski R, Turner H, McGraw T
    Paediatr Anaesth. 2004;14(12):977.

5 Vein dilation

Several techniques can be used to improve vein dilation and cannulation success

  • Elevate skin temperature to 39 to 42 C at the site
  • Place anticipated site below the level of the heart using gravity to reduce venous return
  • Tap or gently stroke vein in a proximal to distal direction
  • Instruct the patient to alternately clench and relax their fist (if using an upper extremity site)
  • Use a rubber tourniquet 5 - 10 cm from the site for proximal compression
  • Nitroglycerin ointment at the site

  1. Venodilatation techniques to enhance venepuncture and intravenous cannulation.
    Roberge RJ
    J Emerg Med. 2004;27(1):69.
  2. Local warming and insertion of peripheral venous cannulas: single blinded prospective randomised controlled trial and single blinded randomised crossover trial.
    Lenhardt R, Seybold T, Kimberger O, Stoiser B, Sessler DI
    BMJ. 2002;325(7361):409.
  3. Local warming does help when inserting cannulas.
    Beer J
    BMJ. 2002;325(7371):1038.
  4. Tips for improving your venipuncture techniques.
    Millam DA
    Nursing. 1987;17(6):46.
  5. Methods of obtaining peripheral venous access in difficult situations.
    Mbamalu D, Banerjee A
    Postgrad Med J. 1999;75(886):459.
  6. Evaluation of venous distension device: potential aid for intravenous cannulation.
    Hedges JR, Weinshenker E, Dirksing R
    Ann Emerg Med. 1986;15(5):540.
  7. Making sense of the technique of venepuncture.
    Campbell J
    Nurs Times. 1995;91(31):29.
  8. Facilitated intravenous access through local application of nitroglycerin ointment.
    Roberge RJ, Kelly M, Evans TC, Hobbs E, Sayre M, Cottington E
    Ann Emerg Med. 1987;16(5):546.

6 Aseptic site preperation

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.

  1. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters.
    Maki DG, Ringer M, Alvarado CJ
    Lancet. 1991;338(8763):339.
  2. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis.
    Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S
    Ann Intern Med. 2002;136(11):792.
  3. Chlorhexidine-based antiseptic solution vs alcohol-based povidone-iodine for central venous catheter care.
    Mimoz O, Villeminey S, Ragot S, Dahyot-Fizelier C, Laksiri L, Petitpas F, Debaene B
    Arch Intern Med. 2007;167(19):2066.

7 Flushing PIV

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.

  1. A meta-analysis of effects of heparin flush and saline flush: quality and cost implications.
    Goode CJ, Titler M, Rakel B, Ones DS, Kleiber C, Small S, Triolo PK
    Nurs Res. 1991;40(6):324.
  2. Benefit of heparin in peripheral venous and arterial catheters: systematic review and meta-analysis of randomised controlled trials.
    Randolph AG, Cook DJ, Gonzales CA, Andrew M
    BMJ. 1998;316(7136):969.
  3. Peripheral venous catheters: a review of current practices.
    Fernandez RS, Griffiths RD, Murie P
    J Infus Nurs. 2003;26(6):388.