54

Inserting Intravenous Catheters

CAROL GORNEY
07
BACKGROUND AND HISTORY
Te inspiration for the little plastic tubes that revolutionized medicine began dur-
ing the Puritan revolution in Britain when a group of brilliant young scientists, in-
cluding William Harvey, who described circulation; Richard Lower, an anatomist
and physiologist; and Christopher Wren, a microscopist and physiologist, began ex-
periments at Oxford. Wren used a quill and pigs bladder in 1658 to create the frst
IV device. It was used to instill fuid mixtures into dogs veins. Tese initial attempts
were fraught with complications, and IV insertion was banned by the British Royal
Society in 1668 for over 100 years. By the early 1800s, successful human-to-human
transfusions were medically documented. Te Parisian cholera epidemics of the
1800s revitalized the science of IV access and began Claude Bernards experimenta-
tion with the infusion of IV fuids into dogs in 1843. Hollow needles and syringes
were invented in the 1850s, and the cornerstones of IV access and fuid therapy as we
know them were in place.
4
INDICATIONS
IV access is indicated in the following situations
3
:
n Fluid administration is done by IV access clinical settings in which it is deemed
medically necessary, including illness, volume depletion or loss, burn, blood
loss, electrolyte disturbance, heat stroke, shock, and trauma.
n Medical emergency situations may require IV administration.
n Administration of antibiotics, chemotherapeutics, or other medically neces-
sary treatments may require IV access.
n Administration of blood products require IV access.
n Administration of diagnostic substances such as dyes or contrast may require
IV access.
n Administration of some nutritional components require IV access.
3

PROCEDURE GOALS AND OBJECTIVES
GOAL: Use standard precautions to insert a peripheral intravenous (IV) catheter
following guidelines that minimize risk or injury to the patient and increase the
likelihood of success.
OBJECTIVES: The student will be able to:
n Identify the anatomy associated with the insertion of a peripheral IV catheter.
n Identify the indications and contraindications of IV insertion catheters.
n Identify the material necessary to insert an IV catheter.
n Identify proper aftercare for an IV catheter insertion site.
n Identify common complications associated with IV catheter placement.
CHAPTER 7 Inserting Intravenous Catheters 55
Local site infection
is commonly seen in
catheters left in place
for longer than 72 to
96 hours or if aseptic
technique is not
strictly followed.
IV insertion should
be avoided in
extremities with
impaired circulation:
mastectomy, axillary
lymph node dissec-
tion, lymphedema,
clot, peripheral vas-
cular disease, venous
insufciency.
CONTRAINDICATIONS
Contraindications to IV access are as follows
3
:
n Extremities with signifcant burns, edema, or injury should not be used, to
avoid more mechanical trauma.
n Extremities with cellulitis or signifcant infection should not be used, to avoid
introducing bacteria into the blood circulation.
n Insertion should not be performed distal to prior failed IV catheter insertion
attempt.
n Insertion should be avoided distal to any area of preexisting phlebitis.
n Insertion should be avoided in extremities with impaired circulation: mastec-
tomy, axillary lymph node dissection, lymphedema, clot, peripheral vascular
disease, venous insufciency.
n Extremities with indwelling fstula should not be used.
n Care should be taken when performing IV access in a patient with a known
bleeding diathesis.
n Consideration should be given to placing a peripherally inserted central cath-
eter if the medication being infused is too caustic, is hypertonic, or is to be
given for longer than 6 days.
POTENTIAL COMPLICATIONS
TECHNIQUE
n If no fash of blood is obtained, the catheter is probably not in the vein and
should not be threaded.
n If a fash is obtained but catheter cannot be threaded, a vessel valve may be
occluding the catheter and should not be forced; remove it and apply pressure.
n If the catheter is threaded but fuid does not fow freely, it is likely the catheter
is kinked or has clotted; remove it and apply pressure.
LOCAL
Te following apply at the site of IV insertion
1
:
n Failure to properly cannulate a vein may result in fuid or medication being
infused in the surrounding tissue outside of the vessel, causing pain, tissue irri-
tation, and swelling of the area. Certain medications are caustic to adipose tis-
sue and can cause necrosis of the tissue.
n Minor bleeding can occur at the site.
n Trombophlebitis can occur as a result of the mechanical trauma to the vein
when the catheter is inserted and an indwelling foreign body is present in
the vein. Tis can be minimized by avoiding trauma at the time of insertion,
securely taping the cannula in place, and avoiding placing the catheter near
a joint line, where frequent movement may cause more mechanical injury.
Reducing the risk for thrombophlebitis reduces the risk for infection and
patient discomfort.
n Local site infection or cellulitis is commonly seen in catheters lef in place for
longer than 72 to 96 hours or if aseptic technique is not strictly adhered to at
the time of insertion.
56 CHAPTER 7 Inserting Intravenous Catheters
SYSTEMIC
Systemic complications are rare and include the following:
n Septicemia, or bacteremia, most commonly occurs if aseptic technique is not
followed when placing the IV line or in the afercare: skin not cleansed, cath-
eter placed in an anatomic area that is heavily colonized with bacteria, and so
forth. Care should be taken, with close observation for signs of local infection
and the IV line promptly removed if signs are present.
n Catheter embolization is very rare and results from the distal portion of the cath-
eter end being shearing of by the beveled end of the needle. It can be avoided by
not pulling the catheter sheath back over the needle once it has been threaded
(advanced). If the catheter cannot be threaded completely, follow proper tech-
nique to remove the partially threaded cannula and needle and apply pressure.
n Pulmonary emboli can occur with centrally placed peripheral lines as a result of
the clot formation at the tip of the catheter that dislodges and travels to the lung.
n Air emboli occur when lines are not properly fushed to remove all air before
being connected to the catheter.
ESSENTIAL ANATOMY AND PHYSIOLOGY
Knowledge of the venous anatomy of the upper arm and hand is important in obtain-
ing IV access (Figure 7-1). Te forearm is used, if possible, because it ofers easy acces-
sibility, avoids the wrist, and contributes to increased patient comfort. Avoiding valves
and bifurcations is frequently easier in the lower arm. Te dorsum of the hand ofers
good IV access. Bifurcations and valves should be assessed before IV placement to help
determine the best insertion site. Te bifurcations can be visualized, and the valves can
be palpated as knotlike lumps or tortuous areas in the vein. Tis helps determine the
longest section of obstruction-free vein so the catheter will thread without resistance.
Te metacarpal, basilic, and cephalic veins in the upper extremity are commonly used.
Figure 7-2 illustrates the venous anatomy of the foot. In the pediatric population, the
foot and ankle have adequate circulation, so concern for infection is not increased;
therefore it is an equally acceptable IV site. It ofers easy IV access and is less visible to
small children, which decreases anxiety and the likelihood the IV device will be placed
in the mouth. Having the catheter and tubing on the lower extremity may physically
interfere less with parentchild bonding and breastfeeding. Commonly used lower ex-
tremity veins are the greater and lesser saphenous and medial marginal veins.
PATIENT PREPARATION
n Identify the patient.
n Obtain informed consent, discuss risk/beneft ratio, indication for the place-
ment of the IV, and the procedure.
n Identify allergies (iodine, latex, adhesives, lidocaine).
n Have all necessary supplies prepared.
n Ofer saline or lidocaine injection for anesthesia (if appropriate) to patients
who are more sensitive to pain or anxious.
STANDARD PRECAUTIONS Every practitioner should
use standard precautions at all times when interacting
with patients, especially when performing procedures.
Determining the level of precaution necessary requires
the practitioner to exercise clinical judgment based on
the patients history and the potential for exposure to
body uids or aerosol-borne pathogens (for further
discussion, see Chapter 2).
CHAPTER 7 Inserting Intravenous Catheters 57
Cephalic vein
Superficial veins,
inner aspect of forearm
Superficial veins,
dorsal aspect of hand and wrist
Cephalic vein
Accessory
cephalic vein
Basilic vein
Basilic vein
Median
cubital vein
Median
antebrachial
vein
Cephalic vein
Dorsal venous
vein
Metacarpal
veins
Basilic vein
FIGURE 7-1 Anatomy of the veins of the upper extremity most commonly used in starting intravenous catheters.
Dorsal venous arch
Superficial peroneal nerve
Lesser saphenous vein
Lateral perforator veins
Sural nerve
Lateral marginal vein
Deep peroneal nerve
Medial marginal vein
Medial perforator veins
Saphenous nerve
Greater saphenous vein
FIGURE 7-2 Anatomy of veins of the lower extremity most commonly used in starting intravenous catheters in pediatric patients.
58 CHAPTER 7 Inserting Intravenous Catheters
MATERIALS
n Appropriate-gauge intravenous catheter (have multiple gauges of catheters at
the bedside)
NOTE: Over-the-needle catheters with safety devices are the most commonly
used catheters. Many brands and sizes are commercially available, and one should
take time to get familiarized with the types ofered at your institution. Most institu-
tions ofer only IV catheters with safety devices that retract the needle to reduce
the risk for needlestick. Many institutions ofer closed system sets with needle con-
nectors to reduce the chance of blood contamination or spills and the traditional
over-the-needle safety devices (Figure 7-3). Patient age, location of insertion, and
indication should all be considered in choosing the catheter gauge (size). A 24-gauge
(small bore), 0.5-inch catheter is commonly used in a neonate or small infant. Te
delivery of blood products or trauma necessitate larger bore IV devices, such as 16 or
18 gauge (remember the smaller the number of the gauge the larger the bore of the
IV catheter).
n Gloves and other equipment to practice standard precautions (latex free if
patient is allergic)
n IV fuid
n Administration set (tubing with a drip chamber that has been primed with IV
fuid and has a roller clamp fow regulator and standard connecting)
n IV pole
n Infusion pump preset for infusion based on the desired infusion rate, age of
patient or fuid to be administered
n Antimicrobial agent to cleanse the site
n Tourniquet
n Scissors
n Tegaderm or other nonocclusive dressing and precut -inch tape
n 2 2 inch gauze or 4 4 inch gauze
n Arm board if necessary (if IV placement requires decreased fexion of a joint to
ensure adequate fow)
n Biohazard waste and needle container
n Antiseptic ointment

A B
FIGURE 7-3 Over-the-needle catheter with retraction safety device (A) and closed needle system (B).
Make sure that
standard precautions
are always observed.
CHAPTER 7 Inserting Intravenous Catheters 59
INSERTION OF AN INTRAVENOUS
CATHETER
1. Apply the tourniquet above the elbow in
the upper extremity and the ankle in the
lower extremity to ensure adequate vein
lling. Do this to both arms and feet (only
in pediatric patients) to identify the most
suitable vein for IV catheter placement.
Usually the largest, straightest, most pe-
ripheral vein that is able to accommodate
the size of the catheter to be started is
chosen.
2. Palpate the vein for stability and valves (a
compressible, stable vein that is free of
valves for 1 inch is ideal).
3. Release tourniquet, double-check and se-
cure all required materials, turn on infusion
pump, ush tubing with uid, and ensure
tubing is free of trapped air bubbles.
4. Apply tourniquet snuggly and well proxi-
mal to the chosen site (use less pres-
sure for the very old and very young
because the skin is thinner and easier to
damage).
5. Put on gloves and eye protection.
6. Allow vein to distend to assist the place-
ment of the catheter (tips to facilitate dis-
tention: pat the vein gently, place extrem-
ity in a gravity-dependent position below
the level of the heart, apply heat).
7. Cleanse site with alcohol and approved
aseptic cleanser (chlorhexidine gluconate
or povidone-iodine).
2,3
The site should be
cleansed with a back-and-forth motion for
a minimum of 30 seconds and then al-
lowed to dry.
8. With the nondominant hand, hold the pa-
tients hand (or foot) securely and use the
thumb to gently retract the skin distal to
the insertion site toward the ngers. This
will secure the vein to reduce venous roll-
ing and hold the skin taut.
9. Puncture the vein using direct or indirect
entry (Figure 7-4):

Warn patient of the impending stick.

Direct (one step, used for larger veins):
Hold the over-the-needle assembly at
15 to 20 degrees above the site and
enter the vein directly.

Indirect (two steps, used for smaller
veins): hold the assembly 15 to 20 de-
grees above the site and 20 degrees lat-
eral to the vein, insert the catheter into
the skin, and then advance into the vein.
When the vein is punctured, blood should ap-
pear in the ash chamber (Figure 7-5). Once
the ash is seen, lower the needle assembly
to almost parallel with the skin and thread the
catheter appropriately depending on the type
of deviceeither standard over-the-needle or
self-shielding.
NOTE: Standard over-the-needle catheter:
Advance the device 2 to 3 millimeters more
to ensure both the needle and catheter tip are
inside the vein and the catheter will not be
inadvertently removed when the needle is re-
moved. Hold the needle securely and thread
the catheter while maintaining skin traction,
PROCEDURE
FIGURE 7-4
60 CHAPTER 7 Inserting Intravenous Catheters
remove the needle, and use the retraction
device.
Self-shielding device: Advance the entire as-
sembly, thread catheter while maintaining
traction and holding needle secure, press the
retraction button, and remove the assembly.
10. Apply gentle pressure to the vein just
proximal to the insertion site to secure the
catheter with the nondominant hand, and
release the tourniquet (Figure 7-6).
11. For nonclosed systems, secure the hub to
the catheter and start intravenous uids
(Figure 7-7). For closed systems, ush
with saline as uid or ush run. Inspect
the site for patency. Signicant pain or
swelling indicates the catheter is not suc-
cessfully placed and should be removed.
12. If uid runs free, secure catheter with
Tegaderm or other nonocclusive dress-
ing so the site may be observed for
signs of patency and infection. Apply it
securely. Tape the tubing securely to the
arm and minimize tape-to-skin contact
(Figure 7-8).
NOTE: If IV placement attempt is unsuccess-
ful, never reinsert the needle into the catheter
because it may sheer off the tip and lead to
an embolus. Never reuse the catheter once
it has been removed from the skin; discard
and use a new catheter. If the catheter site is
painful or swollen when uid is initiated, dis-
continue uid, remove catheter, and attempt
again proximal to the unsuccessful site.
FIGURE 7-5
FIGURE 7-6
Continued
CHAPTER 7 Inserting Intravenous Catheters 61
FIGURE 7-7
FIGURE 7-8
Geriatric and
pediatric populations
are more likely to
have fragile, smaller
veins and not as
many venous options
may be present, thus
careful inspection of
all options should be
done before attempt-
ing IV placement.
SPECIAL CONSIDERATIONS
Te geriatric and pediatric populations are more likely to have smaller, more fragile
veins, and fewer venous options may be present; thus careful inspection of all options
should be done before attempting IV placement. Avoid the lower extremity in the elderly
or with any patient who has vascular insufciency. If blood products are not being given,
use a smaller catheter, such as a 24 gauge. In patients younger than 1 year of age, this
is the preferred catheter size. In children, securing the line is critical because they tend
to be more active and more likely to remove the catheter. In the geriatric population, it
may be equally difcult to start an IV in a very large vessel because it may be sclerotic.
Tis makes the vein more difcult to puncture and the catheter more difcult to thread.
FOLLOW-UP CARE AND INSTRUCTIONS
Instruct the patient on signs of infection, including increased discomfort or pain, redness,
or swelling. Have the patient notify the caregiver immediately if any of these occur. Te
intravenous site should be changed every 96 hours to reduce the likelihood of infection.
1
62 CHAPTER 7 Inserting Intravenous Catheters
REFERENCES
1. Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-
Related Infections: 2002; http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm.
2. Centers for Disease Control and Prevention. Guideline for the prevention of intravascular device related
infections. Am J Infect Control. 1996;24:262-293.
3. Nursing-Resource. Insertion of peripheral IV line: http://nursing-resource.com/tag/how-to-insert-iv/.
4. Rivera M, Strauss KW, Van Zundert A, et al. Te history of peripheral intravenous catheters: how little
plastic tubes revolutionized medicine. Acta Anaesthesiol Belg. 2005;56(3):271-282.