insert procedure video here

Below you will find a step by step walkthrough of peripheral intravenous catheter insertion, complete with animations of the critical steps of the procedure.

 

Explain the Procedure

Explain the procedure to the patient. Tell the patient that the procedure may be mildy painful, but is brief. Ask that he / she hold the extemity completely still until the completion of the cannulation. Take time to answer any questions that the patient might have.

The patient should be laying in the bed, with the opposite bed rail up, to prevent injury should the patient faint during the procedure.

Gather Your Equipment

Prior to beginning the procedure, gather all the required equipment. Once the cannula has been inserted, it will be attached to a connecting tubing. This can be flushed with saline and secured to the arm without intravenous fluids attached (i.e. a "saline lock".) If IV fluids are going to be infused, the bag of fluid will need to be attached to IV tubing (a "drip set") prior to the procedure.

 

To "spike" the IV bag, first remove the plug from the bottom of the bag. Next, remove the protective cap from the end of the IV tubing, and firmly insert the sharp spike into the bag. Squeeze the drip chamber with your fingers until it is halfway full of fluid. Finally, open all clamps and allow the solution to course the tubing, flushing all air out of the line. Once this is done, tighten the regulating clamp again.

 

Hang the bag on an IV pole. Care should be taken not to contaminate the end of the tubing.

 

At some institutions, a connector tubing is customarily attached to the hub of the catheter. This tubing can be flushed with saline and secured to the extremity, and functions as a "saline lock", which maintains intravenous access without infusing fluids. When needed, medications can be administered directly into the connector tubing, or IV tubing can be attached to the connector to infuse fluids. If you are using a connector, it should be pre-flushed with normal saline to prevent air from entering the bloodstream. If phlebotomy is to be performed at the same time of catheter insertion, the connector should NOT be flushed, to prevent dilution of the blood sample. (See below for more information.)

prepare the patient

After selecting the site of insertion, a tourniquet should be applied to the extemity. This should be placed tight enough to engorge the vein, but not so tight that it causes the patient undue pain. If the vein fails to engorge, the extremity should be held in a dependent fashion, or warmed, as detailed in the Preparation section.

The site should then be cleansed with an alcohol prep or povidone iodine swab. Use a circular motion, working your ways outwards from the site.

Is alcohol is used, a moderate amount of friction should be applied, and the area should be rubbed for 60 seconds. A quick swipe is simply not effective. If iodine is to be used, it should be applied and allowed to dry for at least 30 seconds, and then wiped cleaned with an alcohol prep. (Weinstein 2001)

Insert and Advance Catheter

1. Apply distal traction to the vein by using your non-dominant thumb. This is an imporant point that is often overlooked. Traction stabilizes the vein and prevents it from "rolling" during the insertion sequence.

2. The angiocatheter is gripped between the thumb and middle finger of the dominant hand.

3. The needle is inserted bevel-up. The initial angle of entry should be approximately 15-30 degrees.

4. Successful entry into the vessel is indicated by return of blood into the flash chamber.

 

5. Lower the angle of the angiocatheter, so that the catheter can be advanced in a plane as close to parallel to the vein as possible. This prevents the catheter from penetrating the posterior wall of the vein and infiltration of the IV.

 

6. Holding the hub of the plastic catheter with your index finger, the needle is withdrawn several millimeters. This covers the tip of the needle with the plastic catheter, which also guards against puncturing the posterior wall of the vein.

 

7. The catheter is pushed over the needle with the index finger, until the hub of the catheter abuts the skin.

 

Two points deserve special consideration. First, it is the plastic catheter, NOT THE NEEDLE, that should be advanced into the vein. If the sharp tip of the needle is the leading point, vessel injury and resultant infiltration is likely. Secondly, the catheter should never be forced into the vein. If resistance is met, do not advance the catheter, and consider one of the troubleshooting measures listed below.

Attach tubing / phlebotomy / Flush

1. Once the catheter is fully advanced, the traction can be released. Then, use the thumb and index finger of your non-dominant hand to hold the hub of the catheter. The other fingers are used to tamponade the vein, just beyond the tip of the catheter, to prevent blood from leaking out.

 

2. Remove the needle, and retract the needle (if it is so equipped.)

 

3. Attach the connecting tubing and apply a dressing (e.g. Tegaderm; tape may also be used.)

 

4. Blood may drawn at this point by attaching a vacutainer to the connecting tubing. (Please refer to the Phlebotomy chapter for further details.) Remember, if you are planning on drawing blood, the connector tubing should NOT be pre-flushed with saline to prevent dilution of the sample.

 

5. Remove the tourniquet.

 

5. Flush the line with normal saline. If the line does not flush easily, it may not be patent or may have infiltrated. See the troubleshooting section below for measures that may be tried.

Final steps

1. Tape the connecting tubing to the skin. A loop ("U" shape) should be incorporated to prevent any tension placed on the line from pulling out the catheter.

 

2. IV fluids may be attached to the connecting tubing, if desired.

 

3. Carefully throw all sharps away in an approved sharps bucket or box.
Troubleshooting

Confirmation of Placement

Proper IV placement is confirmed by a smooth saline flush without evidence of extravasation into the subcutaneous tissues. The ability to draw blood provides further confimation but is not a requirement since blood flow may be obstructed by a valve or from vein collapse due to suction.

 

Infiltration

Infiltration occurs when the vein is damaged during insertion and the infused fluid flows into the subcutaneous tissues instead of the vein. Infiltration has occured if a subcutaneous mass occurs during flushing or infusion of fluids; also, the line will be hard to flush and / or fluid from an IV bag will not flow. If infiltration occurs, the catheter must be removed and another attempt should be pursued. Refer to the Complications section for more information on cofirmation of placement and infiltration.

Inability to advance catheter

Occasionally it will be difficult to advance the catheter into the vein, despite a good flashback of blood during initial venepuncture. This can occur due to a venous valve, or to a tortuous vein. The catheter should never be forced into the vein, and this is likely to damage the vessel and cause infiltration. Several tricks are available in this situation:

  • Vary the amount of traction placed on the vein. First, try to pull the vein a bit tauter and advance the catheter. If unsuccessful, traction can be reduced (or even released) and further attempts at advancement can be pursued.
  • "Float" the catheter in. If the catheter can be partially advanced but meets resistance before insertion is completed, infusing saline through the line (via a flush or IV fluids) during advancement may facilitate passage. (The fluids act to distend the vessel and opens valves.) Excessive pressure should not be used in order to prevent infiltration.
  • Secure the catheter while it is partially inserted. If a long cather is used (1" or longer) it may be possible to have a patent line with only part of the catheter in the vein. This is not ideal and should not be relied upon unless other access is not available. If this method is chosen, free flow of fluids and absence of infiltation must be assured, and extra care should be taken in securing the line.

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