Peripheral venous cannulation, a widely performed medical procedure in which an IV is inserted into a peripheral vein, has significantly advanced medical practice by enabling the safe administration of medications, fluids, blood products, and nutritional supplements through peripheral intravenous (IV) catheters. IV access is primarily sought for therapies that are either impractical or less effective through alternative routes. For instance, patients with severe vomiting or abdominal pain from a surgical condition may benefit from IV hydration and nutritional support. However, certain conditions can complicate IV insertion.

The decision to opt for peripheral rather than central venous access depends on clinical circumstances, with peripheral catheters preferred for shorter durations, when direct access to central circulation isn’t necessary, and when smaller gauge catheters suffice. Generally, peripheral access is considered safer, easier to obtain, and less painful compared to central access.

Initial success rates of peripheral IV placement typically fall between 65 to 86 percent. However, IV insertion can result in adverse effects, such as phlebitis, extravasation of IV fluids, bruising, and hematoma formation. Emergency circumstances may increase the risk of imperfect placement. However, in healthy patients, there are usually little to no adverse effects that would complicate IV insertion.

Prior to IV placement, it is essential to assess patient risk factors to minimize complications. Absolute contraindications to peripheral venous catheter placement are minimal, usually related to specific cannulation site issues. The only absolute contraindication is when equally effective therapy can be administered through a less invasive route (e.g., orally). Some caution is exercised when using a limb with significant motor and/or sensory deficits, with anecdotal evidence suggesting a slightly increased risk of deep vein thrombosis. However, routine placement of a standard length peripheral IV catheter is not definitively linked to an elevated baseline risk, particularly in upper extremities. Relative contraindications to IV placement include the presence of arteriovenous fistulas in a limb; in these cases, catheter placement could alter blood flow or damage the fistula. Additionally, firm-to-palpation veins, sclerosed veins (e.g., from IV drug abuse), veins with signs of phlebitis or thrombosis, and puncture sites with recent unsuccessful attempts should be avoided, as these conditions can complicate IV insertion and decrease the chance of success. Finally, IV placement through infected tissue, burned tissue, or extremities with massive edema is not advised due to the risk of systemic infection.

Difficult peripheral IV catheter placement is encountered in 8 to 23 percent of cases. Factors associated with challenges include a history of difficult IV access, non-visible venous network, diabetes, IV drug use, sickle cell disease, cancer or chemotherapy treatment, female sex, extremes of age, dark skin tones, underweight or obese body habitus, and a cannulated vein with a dilated diameter <3 mm. In cases of anticipated difficult IV access, the most experienced clinician should attempt placement, utilizing aids or ultrasound guidance. For example, emergency department technicians with extensive experience have shown higher success rates in placing catheters on the first attempt in children with anticipated difficult IV access. After IV placement is successful, physicians should periodically reassess the catheter to verify proper placement, confirm patency, and examine the site for redness, edema, pain, tenderness, and other signs of potential complications. References 1. Saseedharan S, Bhargava S. Upper extremity deep vein thrombosis. Int J Crit Illn Inj Sci 2012; 2:21. 2. Pandolfi M, Robertson B, Isacson S, Nilsson IM. Fibrinolytic activity of human veins in arms and legs. Thromb Diath Haemorrh 1968; 20:247. 3. Jacobson AF, Winslow EH. Variables influencing intravenous catheter insertion difficulty and failure: an analysis of 339 intravenous catheter insertions. Heart Lung 2005; 34:345. 4. Rodríguez-Calero MA, Blanco-Mavillard I, Morales-Asencio JM, et al. Defining risk factors associated with difficult peripheral venous Cannulation: A systematic review and meta-analysis. Heart Lung 2020; 49:273. 5. van Loon FHJ, van Hooff LWE, de Boer HD, et al. The Modified A-DIVA Scale as a Predictive Tool for Prospective Identification of Adult Patients at Risk of a Difficult Intravenous Access: A Multicenter Validation Study. J Clin Med 2019; 8. 6. Shaukat H, Neway B, Breslin K, et al. Utility of the DIVA score for experienced emergency department technicians. Br J Nurs 2020; 29:S35. 7. Herrera AJ, Corless J. Blood transfusions: effect of speed of infusion and of needle gauge on hemolysis. J Pediatr 1981; 99:757. 8. Acquillo G. Blood transfusion flow rate. J Assoc Vasc Access 2007; 12:225. 9. Sandhu NP, Sidhu DS. Mid-arm approach to basilic and cephalic vein cannulation using ultrasound guidance. Br J Anaesth 2004; 93:292.