Intravenous Catheter Placement (Anesthesia)

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Editor(s): Lee A. Fleisher, MD, FACC, FAHA Lee A. Fleisher, MD, FACC, FAHA

Robert Dunning Dripps
Professor and Chair
Department of Anesthesiology and Critical Care

Professor of Medicine
University of Pennsylvania School of Medicine
| Robert Gaiser, MD Robert Gaiser, MD

Professor of Anesthesiology and Critical Care
Department of Anesthesiology and Critical Care
University of Pennsylvania School of Medicine

Contributor(s): Ashish Sinha, MD, PhD Ashish Sinha, MD, PhD

Assistant Professor of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania
University of Pennsylvania School of Medicine
| Elizabeth Watson, MD Elizabeth Watson, MD

Post-Doctoral Fellow, Department of Anesthesiology and Critical Care
Hospital of the University of Pennsylvania
| Acknowledgements Acknowledgements

Jeremy D. Kukafka, MD
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

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Gail A. Van Norman, MD
Clinical Associate Professor
Department of Anesthesiology
Univ of Washington
Seattle, WA

Elizabeth J. Watson, MD
Post-Doctoral Fellow
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

Liang Xue, BS
Research Assistant
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

  • IV access is usually needed for anesthesia care, laboring patients, trauma patients, hospital inpatients, and patient care requiring any of the following:
    • Emergency administration of medications
    • Fluid resuscitation
    • Administration of blood products
    • Elective administration of intravenous antibiotics, chemotherapeutic agents, or other treatments
    • Administration of diagnostic substances, such as methylene blue, indocyanine green, indigo carmine, or intravenous contrast agents
  • Patients donating blood products
Absolute Contraindications
  • None
Relative Contraindications
  • Avoid extremities that have massive edema, burns, or injury; in these cases other IV sites need to be accessed.
  • Avoid going through an area of cellulitis; the area of infection should not be punctured with a needle because of the risk of inoculating deeper tissue or the bloodstream with bacteria.
  • Avoid extremities with an indwelling fistula; it is preferable to place the IV in another extremity because of changes in vascular flow secondary to the fistula.
  • An upper extremity on the same side of a mastectomy should be avoided, particularly if an axillary node dissection was carried out, because of concerns of previous lymphatic system damage and adequate lymphatic flow.
  • Very short procedures performed on pediatric patients, like placement of ear tubes
  • Bleeding diathesis
  • Medication administration that will take longer than 6 days (preference is then for a peripherally inserted central catheter)
  • Type of fluid to be administered through peripheral IV is too caustic; hypertonic solutions and some therapeutic agents should not be infused in a peripheral IV.
  • Gloves
  • Appropriate catheter of case-appropriate size, commonly 18 gauge for adults, smaller for infants/neonates, and larger if large blood loss or rapid fluid resuscitation is predicted for the procedure
  • IV set of tubing and bags
  • Alcohol swabs
  • Adhesive tape only or tape and clear adhesive dressing
  • Gauze
  • Tourniquet

The relevant anatomy depends upon placement of the IV catheter. Common sites of IV catheterization are as follows:

  • Veins of the hand
  • Veins in the forearm and arm
    • Cephalic vein of the forearm and arm
    • Basilic vein of the forearm and arm
    • Median cubital vein in the antecubital fossa
  • Veins in the dorsal foot
  • Saphenous vein
  • External jugular vein
  • Veins of the scalp (usually in neonates)

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • Always wash hands after placing an IV catheter.
  • Before injecting medication into an IV or before connecting a new fluid bag to the IV, cleanse the port site with an alcohol swab (70% alcohol) and allow to air-dry.
  • Evaluate the IV site at the time of new injections and regularly to ensure that no infiltration has occurred and that IV injection agents are intravascular, not subcutaneous.
  • Evaluate the IV site daily for evidence of infection: rubor (redness), calor (warmth), dolor (pain), and tumor (swelling). Palpate the site to ensure that there is no pain near or around the catheter. If the site is covered by tape and there is tenderness at the catheter site, remove the tape to evaluate the catheter site.
  • If evidence of infection exists, remove the IV catheter and place another in a different location.
  • Encourage patients to report any changes or discomfort at the catheter site.
  • Antibiotic prophylaxis (oral or topical) is not indicated for peripheral IV indwelling catheters.
  • If an IV does not have a constant infusion flowing through the tubing, anticoagulant flush solutions are used in catheters to prevent thrombi and fibrin deposits. A commonly used solution is 5 mL of saline with 10 U/mL heparin.
  • Change the catheter site dressing immediately if the dressing is loose, wet, or visibly soiled.
  • Promptly remove any intravascular catheter that is no longer essential.
  • Replace peripheral venous catheters at least every 72 to 96 hours in adults to prevent phlebitis. Leave peripheral venous catheters in place in children until IV therapy is completed, unless complications (e.g., phlebitis and infiltration) occur.
  • When adherence to aseptic technique cannot be ensured (e.g., when catheters are inserted during a medical emergency), replace all catheters as soon as possible and after no longer than 48 hours.
  • Catheter tips do not need to be routinely cultured.

Common Complications

  • Inability to identify a vein for catheter placement
  • Failing to get a “flash” once the catheter is inserted
  • A flash appears, but there is no further blood flow.
  • Failing to thread the catheter into a vein after the needle is retracted
  • Infiltration; remove the catheter and apply pressure
  • Kinking of the catheter; usually the catheter must be removed

Infrequent Complications

  • Difficult IV access
  • Minor bleeding
  • Infection
    • Localized site infection
    • Cellulitis
    • Superficial thrombophlebitis

Serious and/or Rare Complications

  • Infiltration of a caustic material, such as a chemotherapeutic agents or Pentothal, which can lead to severe pain, tissue irritation, vasospasm, necrosis, and sloughing of tissues
  • Abscess formation
  • Catheter-related bacteremia
  • Bacterial endocarditis
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