UBC Objectives: Procedures: Peripheral venous access (adult, child, infant)

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Demonstrate skill in the procedures relative to pediatrics

My approach to peripheral venous access, be it for an adult, child, or infant, is derived from Procedures Consult: Intravenous cannulation. This procedure is done both to obtain blood for investigations or to infuse IV fluids. It can be life-saving, and so contraindications (abnormal overlying skin, abnormality of the extremity, and infusions of substances that can be damaging to veins) really are relative contraindications. For these contraindications, it may warrant a poke in a central vessel instead.

Equipment

• Gloves (nonsterile is fine)
  
• Antiseptic solution (chlorhexidine is ideal)
  
• Rubber elastic tourniquet
  
• Local anesthesia (optional, ex: 1% lidocaine with 25-gauge needle and small [1-3 mL] syringe)
• IV catheter (usually 22-gauge is appropriate)
• Supplies for phlebotomy if needed (ex: 5-10 mL syringes or vacuum bottles, specimen bottles)
• IV fluid or saline "lock" setup with saline flush
• IV tubing (for infusion)
• Cotton balls or gauze (for bleeding)
• Sterile dressing

Procedure

1. Obtain informed consent
2. Position the patient supine or in a supported position (one that would be safe to faint in!)
3. Universal body fluid precautions
4. Organize equipment within reach, and prep/ensure all equipment is not defective (ex: set up IV tubing, pre-flush saline locks)
5. Place the tourniquet 5 to 10 cm proximal to the anticipated venipuncture site
   
6. Find your vein (consider favouring nondominant extremity, distal vein depending on needle/IV gauge, avoid over joint, ideally engorged)
   
7. Cleanse skin (don't re-palpate!)
   
8. Local anesthesia (if doing it, this is your moment - 0.5 mL is all that is required)
   
9. Apply traction distal to vein with thumb of your nondominant hand
   
10. Insert needle with thumb and middle finger of dominant hand, 15 degrees from surface of skin for a teensy vessel, up to 45 degrees for a massive vessel
    
11. Observe for flash of blood, then stop
    
12. Lower angle of needle to less than 15 degrees and advance 1-2 mm
    
13. Then, using index finger of dominant hand, advance catheter further over needle without also advancing needle
    
14. Release traction and use nondominant hand to tamponade skin overlying catheter insertion point, then remove the needle and activate safety (needle retraction) device
    
15. Obtain blood samples as needed, then release the tourniquet, then the needle, then cover site with bandage and apply pressure for 5 min and label any samples. Alternatively, attach IV tubing and secure catheter to patient ("U" shape position to decrease tension on tubing at site of insertion). Check all the connections and be sure everything is working right, from the bag to the skin.