How to Start an IV: Tips on IV Insertion and Rolling Veins

IV insertion is a basic skill but one of the hardest to master. The sharpshooters got there through practice and reps. Many factors affect how you insert a catheter; control them rather than rushing or taking shortcuts. Here are the tips that build that skill.

IV Therapy Tips for Starters

1. Stay focused and prepared. Hitting it on one try depends on preparation and skill. Both you and the patient should be composed, since a rushed, nervous procedure tends to fail. Allay anxiety by explaining the procedure, ask about the patient's IV history, and keep them warm to prevent vasoconstriction.

2. Exude confidence. Reassure the patient you know what you are doing; your confidence steadies both of you.

3. Assess for needle phobia, a response to previous insertions. Watch for tachycardia and hypertension before insertion, then bradycardia and a blood pressure drop on insertion, with pallor, diaphoresis, and syncope. A soothing tone, education, keeping needles out of sight until the last minute, and topical anesthetics all help.

4. Observe infection control. Wear gloves; insertion is invasive and requires aseptic technique. Wipe the site with an alcohol pad to reduce microorganisms and to visualize the vein more clearly.

5. Assess the vein. A well-hydrated person has firm, supple, bouncy veins, the right fit for insertion. Dehydrated patients are harder to hit, so take your time and avoid aiming for a vein too frail to withstand the puncture.

6. Feel rather than look. If you cannot see a suitable vein, trust your fingers over your eyes. A tendon may feel like a vein, but palpating it through a range of motion shows it is not.

7. Ask your patient, who may know which veins work from previous IVs.

8. Use an appropriate cannula size. Match the gauge to the patient. Smaller gauge number means larger lumen diameter; larger gauge number means smaller diameter. A needle bigger than the vein will injure it and blow it.

9. Consider the use. Smaller gauges cannot accommodate blood transfusion or parenteral feeding. Larger lumens allow higher flow rates and higher concentrations. Needleless equipment minimizes vein injury during and after insertion.

10. Insert in the non-dominant hand first so the patient keeps the dominant hand free. If you cannot find a site there, use the dominant hand.

Vein Selection

11. Start with distal veins and work proximally, so you do not lose the sites below a proximal stick.

12. Use a BP cuff rather than a tourniquet for patients with low BP, older patients, or difficult veins. For hypovolemia, use a larger vein, since small veins collapse faster. Inflate to the lowest pressure first and watch for the veins. Inverting the cuff keeps the tubing off the limb and out of the site. A cuff is a wider, more comfortable tourniquet that compresses evenly and adjusts to the exact pressure needed.

13. Apply the tourniquet correctly, tight enough to hinder venous flow but not arterial, so blood enters the extremity but meets resistance leaving, distending the veins. Place it snugly about 20 to 25 cm above the insertion site. Feel for the radial pulse; if you cannot palpate it, the tourniquet is too tight.

14. Puncture without a tourniquet if the patient has adequately filled but fragile veins, since tourniquet pressure can blow a delicate vein on puncture.

Making the Vein More Visible

15. Use gravity. Let the arm dangle off the side of the bed to promote venous filling. Gravity slows venous return and distends the veins, making them easier to palpate.

16. Use a warm compress. Apply a warm, moist compress over the area before insertion and before cleansing, leaving it for 10 to 20 minutes to dilate the vein.

17. Do not slap the vein. Veins have nerve endings that react to painful stimuli by contracting, making them harder to find, and slapping adds pain.

18. Flick or tap the vein with your thumb and second finger, which releases histamines and dilates it.

19. Feel the vein. Wrap a tourniquet above the site and gently palpate, pressing up and down. Use the same fingers each time to learn the feel of a bouncy vein. Tap gently, do not slap.

20. Fist clenching. Have the patient clench and unclench the fist to compress distal veins and aid filling.

21. Use the multiple-tourniquet technique. With two or three latex tourniquets, apply one high on the arm for 2 minutes, a second at mid-arm below the antecubital fossa, and a third if needed. Collateral veins should appear.

22. Vein dilation with nitroglycerine. Apply nitroglycerine ointment to the site for one to two minutes to dilate a small vein, then remove it during your final alcohol disinfection.

23. Flow where you want it to go. Rub the alcohol pad in the direction of venous flow to push blood past the valves and improve filling.

24. Clean vigorously and widely, so tape and dressing adhere to clean, dry skin and another vein is prepped in case one shows up.

25. Use a vein locator. Transilluminator lights and pocket ultrasound illuminate vein pathways, useful in infants and small children. Watch for burning skin and limit contact time.

Insertion of the IV Catheter

26. Stabilize the vein. Pull the skin taut just below the entry site to support the vein and reduce pain. Make sure the alcohol has dried first.

27. Insert directly atop the vein. Starting from the side can push it sideways even when anchored.

28. Prevent kinking. A hardened or scarred vein risks kinking the cannula.

29. Twirl the catheter hub. Insert with a slight rotating motion to glide over mild obstructions, tortuosity, fragility, or frictional resistance.

30. Bevel up. Keep the bevel facing up, the sharpest part of the needle, so it glides in.

31. Use a 15-30 degree angle. Hold the catheter at a 15-30 degree angle over the skin, bevel up, and tell the patient you are inserting the needle.

32. Feel for resistance. If none, advance carefully. If you feel resistance, stop, since you may disrupt and injure the vein.

33. The flashback. Once you see backflow of blood, remove the tourniquet, fully advance the catheter, and remove the needle. Secure the catheter and open the line to start therapy.

34. Don't go all in. Once you get the flashback, stop and lower your angle. Advancing further may puncture through the vein.

35. Don't rush the fluid. Start the infusion slowly, as if working with fragile veins, since rushing can blow the vein.

36. Release the tourniquet first. Once the catheter is in the vein, untie the tourniquet before advancing to prevent it from blowing under pressure.

Securing the IV Line

37. Tape the tubing properly. Improper taping across the cannula causes pain during infusion. Tape the tubing away from the cannula site, keeping the catheter secured and accessible.

38. Limbs in motion. When the limb is moving (as in an ambulance), lock the arm in extension and block flexion at the elbow.

39. Go with the flow when taping. Run tubing laterally in the direction of motion to prevent coiling or tangling.

40. Use stress tape to prevent yanking. Use one or two stress tapings so a snagged line does not pull directly on the site. Do not tape excessive loops, do not tape on the proximal side of a flexing joint, and do not wrap tubing around a digit (clenching can pull it out). A double-back with a short loop secures it well.

41. If it leaks. A small leak at the moment of insertion may still be usable if the catheter tip advances proximal to the leakage. Test with a non-irritating fluid and watch carefully for extravasation before reuse.

42. Do not probe for a vein. "Fishing" is painful, especially if you probe into muscle or tendon. If you get no flashback, do not dig. You have likely missed or been deflected by a rolling or hard vein. Pull back and redirect rather than starting over.

Special Considerations

43. Older and pediatric patients have smaller, more fragile veins. Use small gauges that still allow proper flow, and choose the site carefully. The hands are often safest, but stabilize well, since children gesticulate and elderly patients are fall-prone.

44. Dark skin tone. Use a BP cuff inflated to visualize the vein through distention. Wiping a cotton swab along the vein also helps visualize it in pediatric, elderly, and dark-skinned patients.

45. Veins with valves: use the floating technique. Prominent valves feel like little bumps, common in weightlifters. Float them open by attaching primed extension tubing and gently flushing normal saline via syringe while advancing the catheter.

46. Bifurcating veins have an inverted V-shape and are less likely to roll. Access below the bifurcation for the highest cannulation success.

47. Call the vein whisperer. After reasonable unsuccessful attempts, get another provider, NICU, anesthesia, or vascular surgery staff, before all the veins are used up.

48. On restraints. Infants and children may need a limb splinted or restrained. Place the tourniquet before securing the splint.

49. Papoose or mummy wrap. For some children whose agitation cannot be safely relieved, a papoose or mummy wrap helps. Explain to the family that it gives the best chance of first-attempt success.

50. Learn distraction. Let children blow bubbles, sing, or count.

51. Starting an intraosseous line. In an emergency, if you cannot start an IV in a critically ill child, an intraosseous line goes directly into the bone marrow cavity, an excellent entry for fluids, blood products, and drugs. The marrow is a non-collapsible vein; fluid enters circulation via venous sinusoids.

52. Detecting infiltration in an obese or edematous patient. Compare the limb's skin turgor and size with the opposite extremity and inspect for swelling, coolness, blanching, discoloration, and leakage. If unsure, place a tourniquet proximal to the site, tight enough to restrict venous flow; if the infusion continues without a pump, you have confirmed infiltration.

53. Evaluate for infiltration. Occlude the vein proximal to the site: if the fluid keeps flowing, the cannula is probably outside the vein; if flow stops, the device is still in the vein.

54. Check for patency. Lower the fluid container below the site and watch for backflow of blood in the tubing. If blood appears, the device is still in the vein.

55. In case of infiltration. Remove the device immediately, elevate the extremity, apply a warm or cold compress, and restart in the opposite extremity.

Pediatric Patients

56. Keep calm and calm the child. Soothe an infant beforehand with a pacifier. Bottle or breastfeeding while you start the line is fine if the parent wants to hold the baby.

57. Insert in the nondominant hand. Hand veins in the nondominant hand are preferable for small children of walking age and infants.

58. Use an immobilizer. The antecubital (AC) is a good location for children, but an immobilizer board may be needed to keep the line patent.

59. Scalp veins. In neonates, scalp or foot veins are sometimes easier to access.

60. Advance on flashback. With preemies and small newborns, advance the catheter, not the needle, after the initial flashback. Immature veins blow easily if you advance the needle.

61. Think TB skin test. Stick almost flush with the skin in neonates and newborns, since their veins are close to the surface.

62. Less pain. Use anesthetic creams or sprays for children.

63. Know your distractions. For a toddler (ages 1-3), try singing, pacifiers, or musical toys.

64. Communicate. With children ages 4 and up, be honest. Tell them it will hurt, but only for a minute, and reassure them they will not lose all their blood. Stickers or small toys to hold still help.

65. Avoid tourniquets if you can. Apply traction with your hands and use coworkers. Tourniquets raise the risk of blowing veins in children.

66. Dangle that arm. Letting the arm hang before sticking increases blood flow, making veins easier to feel and see.

67. Know when to stop. Repeatedly sticking a patient 4 or 5 times blindly is not good care. Get someone more experienced.

Additional Tips

68. Use firm traction. All veins roll, worse in older people with thin skin. Hold firm traction at the top and bottom of the site with your non-dominant hand before sticking, or you will chase the vein and risk stabbing through it.

69. Feel, don't just look. The juiciest veins are often the ones you cannot see. Practice feeling veins you can see, noting the difference between vein and muscle, until you can stick by feel.

70. Use a tourniquet, or don't. If you can feel and see a large vein, skip the tourniquet. Tying it too tight can blow the vein on puncture. If you blow a vein with a tourniquet, try the next access without one.

71. Use an appropriate-sized needle. Everyone wants the big 18g access, but it is not always appropriate, and too large a needle blows the vein. Use the biggest access you can; sometimes a 22g is all you can do.

72. Don't let misses haunt you. Everyone misses veins. No one is successful 100% of the time. Let the losses go, stay confident on the next attempt, and take every IV you can, since reps build the skill.