What’s the best approach to starting difficult IVs in a patient with small, deep, or hidden veins?

Anesthesiologists become experts at inserting an intravenous (I.V.) catheter.  In my career of 20,000+ anesthetics, I’ve started at least one I.V. per patient, and some cases required more than one I.V.  Some I.V’s are easy, and would present no challenge to a first-year nursing student, but some patients have veins that are small, deep, rolling, invisible, or scarred over, and only an expert will succeed.

Almost every adult anesthetic begins with the intravenous injection of sedative drugs, so every anesthesiologist needs to become expert in I. V. insertion.  As a demonstrative case, let’s tackle a world-class difficult situation:

Your patient is obese, weighing in at 300 pounds, and her arms are cylinders of fatty tissue.  She has a past history of surgery for breast cancer, and she had the lymph nodes removed under her left arm.  Therefore, I.V. attempts in her left arm are prohibited.  In addition, she had intravenous chemotherapy for months, which used up every decent vein in her right arm.

Here are my time-tested tips to successfully locate a vein and insert the I.V. on a difficult patient such as this:

  1. Lie the patient down, supine and horizontal.  Blood will pool where gravity takes it.  If a patient is sitting upright, or has their legs dangling, the blood will pool in dependent regions such as the veins of the legs, rather than the veins of the upper extremities where you are looking.
  2. Apply a standard rubber tourniquet to the upper arm.  Then, on top of this tourniquet, apply the blood pressure cuff from an automated blood pressure machine.
  3. Activate the blood pressure cuff in “Stat” mode, or repeatedly inflate the cuff in “Manual” mode.  The pneumatic blood pressure cuff is a superior venous tourniquet, and will be most effective in making even small veins grow prominent.
  4. Examine the arm carefully for the best vein.  Do this by both inspection and palpation.  Sometimes the cord of the vein can be felt, even when it can not be seen.  Rather than sticking the patient’s arm in multiple places, over and over, until she looks like a pin-cushion, be patient and do not start until you’ve found the very best location.
  5. Stimulate the skin over this vein by snapping your forefinger at the site.  This local stimulation makes veins grow, perhaps by releasing a regional veno-dilator, or by blocking a regional veno-constrictor.  All I can tell you is that, whatever the mechanism, this technique definitely works.
  6. Choose a standard I.V. catheter, either a 20-gauge or 22-gauge.  Butterfly needles are NOT preferred, because they require leaving a needle in the small vein, rather than the plastic I.V. catheter.
  7. ALWAYS anchor the skin over the vein by pulling distally with your non-dominant thumb, while you insert the I.V. catheter with your dominant hand.  This anchoring and stretching of the skin distally prevents the vein from rolling or moving during your insertion attempt.DSCN0160
  8. When you first hit the vein, and blood begins to flow into the hub of your catheter, you MUST advance the device an additional 1-3 millimeters before you attempt to advance the catheter forward over the needle into the vein.  And you MUST NOT move the non-dominant thumb away from its task of stretching the skin distally, so that the vein stays stationary. The I.V. catheter device is a catheter-over-a-needle device.  When the needle tip first enters the vein, the catheter tip is not in the lumen of the vein yet.  The  1-3 millimeter advance moves the tip of the plastic catheter into the vein.DSCN0160
  9. Patients have four extremities.  If you are unsuccessful in locating a vein in either arm, you can move to the foot and ankle region to start an I.V. there.  Follow the same steps outlined above.

10. If you can not locate a vein in any extremity, consider the external jugular veins on the side of the patient’s neck.  With the patient positioned slightly head down, these veins are often prominent.  The external jugular vein swells when the patient performs a Valsalva maneuver, such as when you ask them to “bear down as if you are having a bowel movement.”  You do not need to start a central venous catheter (CVC) in the external jugular vein.  A simple 1- ¼ inch, 20-gauge peripheral I.V. catheter will suffice.  Because the size and diameter of the external jugular vein is larger than most arm veins, and because the external jugular vein is usually quite superficial, cannulating this vein can be very easy in skilled hands.  I attach a 3 c.c. syringe onto the hub of the intravenous catheter device before I attempt the insertion, and then I aspirate back with negative pressure as I advance the device.  Once the catheter is inside the external jugular vein, the syringe will fill with blood, and you can advance the catheter into the vein.  I usually fixate the catheter with tape, rather than suturing the catheter in place.

Those are my tips for difficult I.V. inserting.  Follow these steps, and with experience and patience, you will become the intravenous-insertion expert at your hospital.


Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.


In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:









  1. Nice blog – could you discuss placing an I.V. in the Great Saphenous vein of the lower leg? I’ve been told by some that this is the go-to vein when all else fails – have you had much luck? This is often a blind stick so landmarks are key – could you also discuss that aspect?

  2. This may be a double comment – could you please discuss placing an IV in the Greater Saphenous Vein of lower leg – land marks, success rate, opinion? Thanks

    1. In 30 years of performing anesthetics I’ve occasionally used the greater saphenous vein for a percutaneous peripheral IV when there were no useful veins in the upper extremities. The vein is located anterior to the medial malleolus. I’ve cannulated this vessel using the same techniques I describe in my IV Placement article. I haven’t made it my practice to attempt to cannulate the vein blindly if I could not see or palpate it.

      1. God bless you, you are a agent of God in assisting healing. I am filled with admiration at your role in life

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