How to Insert a Venous Catheter

Gather the Necessary Equipment. Inserting a venous catheter is not as challenging as other more intricate procedures, but it still requires basic preparation and careful attention, just like any minor medical intervention. Before you start, make sure that all tools and equipment are within reach, and ensure that all supplies used on the patient's body—especially needles—are new and sterile. To insert a venous catheter, you will need:

• Single-use sterile gloves
• Catheter with an 'internal guide needle' of an appropriate size (usually between 14 - 25)
• IV fluid bag
• Non-latex tourniquet
• Sterile bandage
• Gauze
• Alcohol-soaked cotton balls
• Medical adhesive tape
• Medical waste bin
• Sterile paper (to place small tools for easy access)

Introduce yourself to the patient. An important step in the venous catheter insertion process is introducing yourself to the patient and explaining the procedure you are about to perform. Engaging with the patient and sharing this basic information helps to ensure they are comfortable and that there are no surprises during the process. Additionally, you will need their explicit consent to proceed. Once this is done, ask the patient to lie down or rest on their side where the catheter will be inserted.

• If the patient is nervous, their veins may constrict, a condition known as vasospasm, which can make catheter insertion more difficult. Therefore, it is important to help the patient relax and be as comfortable as possible before proceeding.
• It’s a good idea to ask if the patient has had any issues with venous catheter insertion in the past. If so, they may inform you of areas where catheter placement is easier.

Prepare the IV drip. Next, prime the IV line by hanging the IV bag on a tall stand, allowing the saline solution to flow into the line, and check for air bubbles. If necessary, clamp the line to prevent the solution from dripping to the floor. You must eliminate all air bubbles from the line by tapping, squeezing, or allowing the solution to flow through the tube. Then, label both the IV line and the IV bag with your signature and the date.

• Injecting air bubbles into the patient's bloodstream can result in a dangerous embolism.
• An easy way to remove air bubbles from the IV line is by fully straightening the tubing and opening the valve to the infusion chamber. Then, use the sharp end of the IV line to pierce the IV bag and squeeze the infusion chamber. Open the valve to allow the solution to flow down the tubing without forming any air bubbles.

Select the correct size venous catheter. Typically, the venous catheter is attached to a needle that punctures the vein. Once the needle passes through the vein wall, the catheter remains in place for easy access to the vein. Venous catheters come in various sizes. Smaller catheters are thicker, allowing for faster fluid and blood flow, but they are also more painful to insert. Therefore, it is recommended to choose a catheter slightly larger than necessary.

• Generally, venous catheters sized 14-25 are used. Select a larger (thinner) catheter for children and elderly patients, but opt for a smaller catheter when you need to infuse fluids rapidly.

Wear sterile gloves. Inserting a venous catheter involves puncturing the skin and directly accessing the bloodstream. To prevent dangerous infections, you must wash your hands thoroughly and dry them with a clean towel before proceeding. Then, wear sterile gloves before handling any equipment or touching the patient. If at any point your gloves become contaminated, replace them—it's better to be safe than sorry. Here are situations where most medical standards require gloves to be changed:

• Before touching the patient
• Before performing sterile procedures (like intravenous drug administration)
• After procedures that may involve bodily fluids
• After touching the patient
• After handling items around the patient
• Before interacting with other patients

Locate a prominent vein. You need to find an appropriate site on the patient to insert the venous catheter. For adults, the easiest veins to access are long, straight veins in the forearms, far from joints and as distal as possible. For children, the head, hands, or feet are preferred sites over the legs, arms, or elbows. Although you can insert a catheter into any easily found vein, it’s best to avoid veins on the dominant hand. If the patient has a history of difficulty finding veins, ask the doctor where they have previously administered injections. Patients who have struggled with vein access may be able to point out the easiest spots. Keep in mind that while you may be able to find a vein, there are certain places you should not insert the catheter:

• Areas where the catheter would interfere with surgery
• The same area where the catheter was previously inserted
• Areas showing signs of infection (redness, swelling, irritation, etc.)
• On the arm or leg on the same side as recent breast or cardiovascular surgery (this could lead to complications)

Apply the tourniquet. To make the veins swell and easier for needle insertion, wrap the tourniquet around the back (in the direction of the upper body) at the intended site for the venous catheter. For instance, if you're going to insert the catheter into the inner forearm (a typical spot), wrap the tourniquet around the upper arm.

• Be careful not to make the tourniquet too tight, as it could cause bruising, especially in older individuals. It should be tight, but loose enough to slide a finger underneath.
• Let the arm hang down while applying the tourniquet. This will help the veins stand out more as the blood pools in the arm.

Tap the vein if necessary. If you're unable to locate a suitable vein, try tapping the skin at the intended catheter insertion site. Place your finger along the vein and press gently. You'll feel the vein "push back." Continue pressing up and down for about 20-30 seconds. This will cause the vein to become more prominent.

Disinfect the insertion site. Next, open a sterile alcohol swab (or use an equivalent disinfecting agent like chlorhexidine) and apply it to the skin where you'll insert the needle. Wipe gently but thoroughly to ensure the alcohol is evenly applied. Alcohol will kill any bacteria on the skin and reduce the risk of infection when the needle punctures the skin.

Prepare the venous catheter. Take the venous catheter from its sterile packaging and inspect it to ensure it's intact. Press the backflow chamber to verify it's securely attached. Rotate the catheter to ensure it's only loosely connected to the needle. Remove the protective cap and check the needle carefully, ensuring it doesn't touch anything. If everything looks good, you're ready to insert the needle.

• Ensure the venous catheter or needle doesn't come into contact with anything other than the skin where the needle will be inserted. If it does, it will no longer be sterile, increasing the risk of infection.

Insert the needle. Use your non-dominant hand to gently hold the patient's hand or foot in place, being careful not to touch the area where the needle will be inserted. With your dominant hand, hold the needle and insert it through the skin (with the bevel facing upwards). As you advance the needle deeper into the vein, reduce the angle of insertion, adopting a more shallow approach.

• Look for blood in the catheter's lumen. This is an indication that you’ve successfully accessed the vein. Once you see the blood return, continue advancing the needle another centimeter into the vein.

If you miss the vein, explain to the patient and try again. Inserting a needle into a vein is a delicate procedure, and even experienced doctors and nurses may miss on the first attempt, especially if the vein is not easily visible. If you don't see blood return after inserting the needle, let the patient know you've missed and will try again. Be gentle as this procedure can cause discomfort.

• If you continue to miss, apologize, remove the needle and catheter, and try again with a new needle and catheter on the other arm or leg. Repeated attempts in the same area will cause more pain and leave bruises that take longer to heal.
• Reassure the patient by explaining why you missed, saying something like, “This happens occasionally. It’s no one’s fault. We’ll succeed next time.”

Remove the needle and dispose of it. Maintain pressure on the skin as you carefully withdraw the needle (only the needle—do not remove the catheter) about 1cm from the vein. Slowly advance the catheter into the vein while keeping pressure on the skin. Once the catheter is properly positioned, release the tourniquet and secure a sterile dressing (such as Tegaderm) over the lower half of the catheter to hold it in place.

• Avoid securing the dressing too tightly, as this could obstruct the infusion line.

Remove the syringe needle and attach the infusion line. Use your thumb and index finger to hold the catheter's hub steady in the vein. With your other hand, carefully withdraw the needle (only the needle) from the vein. Dispose of the syringe in the medical waste container. Next, remove the protective cap from the infusion line and carefully connect it to the catheter hub. Twist and lock the infusion line securely in place.

Secure the catheter. Finally, you need to secure the catheter to the patient's skin. Place an adhesive strip over the catheter hub, then wrap a second strip around the infusion line, followed by a third strip over the second one. Use a third piece of tape to secure the other end of the wrap to the catheter insertion site. Wrapping the tape around the infusion line reduces pressure on the catheter, helping the patient feel more comfortable and decreasing the risk of the catheter dislodging from the vein.

• Make sure the tape isn’t twisted as you wrap it to avoid obstructing the fluid flow.
• Don't forget to label the dressing with the date and time the catheter was inserted.

Check the fluid flow into the catheter. Open the valve and observe the formation of drops in the infusion line. To check the flow between the vein and the catheter, apply gentle pressure to the vein (to stop the flow) at a point beyond where the catheter is placed (distal to the upper body). The drops will slow down and eventually stop, then resume flowing once you release the pressure from the vein.

Change the dressing if needed. Catheters left in place for extended periods carry a higher risk of infection compared to those used in short-term procedures or surgeries. To minimize this risk, carefully remove the old dressing, clean the insertion site, and apply a fresh dressing. In general, transparent dressings should be replaced weekly, while gauze dressings need to be changed more frequently, as they don’t allow you to see the wound.

• Don’t forget to wash your hands and put on new gloves before touching the catheter insertion site. This is especially crucial when changing the dressing, as the longer the catheter is in place, the higher the risk of infection.

Remove the intravenous catheter. To remove the catheter, the first step is to close the valve to stop the flow of the infusion. Gently peel off the adhesive tape and dressing to expose the wound and catheter hub. Place a clean gauze pad over the site and apply gentle pressure as you slowly withdraw the catheter. Ask the patient to hold the gauze in place to control the bleeding.

• You should secure the gauze with medical tape like Coban. However, in most cases, just applying gentle pressure is enough to stop the bleeding, so taping may not be necessary.

Dispose of the syringe needle properly. The needle used to insert the intravenous catheter is a sharp medical waste item and must be discarded in a designated sharps container immediately after use. Since the needle can carry infectious agents and even pathogens from one person to another if not disposed of correctly, it should never be thrown into a regular trash bin, even if you are certain the patient is healthy.

Complications related to intravenous catheter placement. Inserting an intravenous catheter is generally a safe procedure, although complications can occur, but the chances are very small. It’s crucial to be aware of the most common complications that can arise, so you can provide the best care for your patients and know when to call for emergency help if needed. Some complications (and their symptoms) associated with intravenous catheter placement are as follows:

• Infiltration: Occurs when the infusion is injected outside the vein into the surrounding soft tissues. The skin in the affected area will swell, feel smooth, and appear pale. While this is usually a minor issue, it can be serious depending on the type of medication being administered.
• Hematoma: Occurs when blood leaks from the vein into the surrounding tissue, often due to accidentally puncturing multiple veins at once. Common signs include pain, bruising, and irritation, and it typically resolves on its own after several weeks.
• Embolism: Happens when air is injected into the vein, often due to bubbles in the infusion tubing. Children are at the highest risk. In severe cases, this complication can cause difficulty breathing, chest pain, pale skin, low blood pressure, and even stroke and heart attack.
• Thrombosis and arterial endothelial inflammation: These life-threatening conditions can occur if the injection is mistakenly administered into an artery instead of a vein. Symptoms include severe pain, compartment syndrome (high pressure on muscles that causes intense “tightness” or swelling), necrosis, motor dysfunction, and even the need for amputation of the arm or leg.

• Record every action taken during the intravenous catheter placement process. Maintaining thorough documentation will help prevent unnecessary complaints and lawsuits.

• Do not attempt to locate the vein more than twice. If you cannot successfully insert the catheter after two attempts, ask for assistance from another technician.
• Only proceed with placing the intravenous catheter if you are a trained healthcare professional.
• Before inserting the catheter, always check the patient’s medical records to ensure there are no specific instructions to follow for that individual.

• Patient monitoring chart
• IV bag holder stand
• IV fluid bag
• Tourniquet
• IV tubing clamp
• Medical tape
• Gloves
• Syringe
• Syringe barrel
• Intravenous catheter
• Betadine solution (or use chlorhexidine-soaked gauze like ChloraPrep®)
• Cotton swabs
• Tap water (for hand hygiene)
• Antibacterial soap
• Medical waste bin
• Sharps disposal container