Peripheral IV Access - PIV

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Peripheral IV Access - PIV
Inclusion Criteria
  • 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

Contraindications to topical anesthetics?

Advances with no difficulty?

Swelling developing at puncture site?


Use IV for peripheral infusions

Place topical anesthetic

Remove catheter and choose different anatomic site

  • Advanced too far through posterior wall
  • Withdraw the needle 1 - 2 mm until you see a blood flash then try advancing the catheter
  • Needle entered the vein, but catheter did not
  • Advance the needle a mm or two then advance the catheter
  • Valve or tortuous portion of vein
  • Attach a syringe filled with saline to the catheter then gently infuse fluid through the catheter while advancing


Peak effect

Vasocoolet spray




CO2 injection lidocaine (J-Tip)


Self heating patch (Synera)

20 min

Liposomal lidocaine (ELA-max)

30 min


60 min

Consider intraosseous line, ultrasound guided PIV or central line placement

Select optimal anatomical site

  • Obtain proper supplies
  • Immobilize the area to be accessed
  • Place site at level of the heart (if possible) and apply tourniquet

  • Obtain serum if needed and dispose needle
  • Flush line
  • Secure line with transparent, occlusive dressing

Contraindications to topical anesthetics?

  • Urgent need for IV access
  • Allergy or hypersensitivity
  • Wound or lack of intact skin over anatomic site
  • Medication specific contraindications
  • Lidocaine/EMLA: risk for methemoglobinemia

  • Cleanse with antiseptic and allow to dry
  • Apply slight tension distally to selected site with non-dominate hand avoiding collapse of the vein
  • With needle bevel pointed upward puncture the skin at a low angle (10 - 30 degrees) using a slow, smooth, continuous movement until flash is observed
  • Flatten the angle so the needle is nearly parallel with the skin and advance the needle with catheter 1 -2 mm so the catheter tip sits within the vein
  • Advance catheter over the needle until needle removed

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