Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.

In this column, I’ll describe the best approach to starting a difficult IV in a patient with small, deep, or hidden veins. This information is based on my experience in personally starting IVs on over 25,000 surgical patients in 34+ years as a clinical anesthesia attending.


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.


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