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The Art and Science of Peripheral IVs


Trial_and_Error.pngThe peripheral IV (PIV) is the first real test of CA-1. PIVs can’t be taught – they can only be learned through trial and error. By Nabil Othman, MD

When I started CA-1, Dr. Robert Naruse told me the best way to learn is to show up early. I quickly realized why: showing up early meant you could make your mistakes when no one else was watching. I would wake up at exactly 5:45 am so I could walk into the operating room at 6:15 am. I committed all the traditional CA-1 mistakes, including stabbing myself with sterile needles while drawing up drugs, spraying myself with Ancef, and accidentally priming blood tubing with air. After 30 minutes of mistakes, I would arrive in preop at 6:45 am. That way I had 30 minutes to talk to my patient and place the peripheral IV before the case started at 7:15 am.

I purposely gave myself extra time so I could observe, tinker, and learn. I stumbled upon some basic lessons early. Talking to patients is a great distraction. Vein selection is just as important as good technique. Elderly veins need more time to fill up. They also bleed more if you blow the vein. If the patient is a difficult stick, the back of the forearm usually has a large vein coursing obliquely over the ulna towards the medial condyle. After a few months I developed my own rules and habits.

I relied heavily on objective data and protocols to guide me. A flash of blood inside the angiocath meant I was inside the vein. The bevel was advanced a defined length every time based on the size of the IV. Tension was always applied distal to the IV insertion. My limited toolbox of tricks produced reasonable results I was successful most of the time, but some veins remained beyond my reach.

My perspective changed about six months into CA-1, when I saw Dr. Nadeem Hamid place a 20g without seeing a flash blood in the angiocath chamber. I was perplexed. I ask him how he knew he was in the vein. He laughed at me and said, “When you have been doing this as long as I have you can feel the needle going through the wall, the loss of resistance inside the vein, and the catheter sliding into place.”

I thought he was lying to me until a month later, when I placed a 20g PIV in the wrist of a coding patient in ventricular tachycardia. I didn’t see flash but I did feel a loss of resistance. I thought to myself, “It’s worth a shot.” Then I slid the catheter into place. Much to my surprise, the IV worked!

For the first time I had noticed the loss of resistance when the angiocath goes through the vein wall into the lumen. My ability to “feel” veins was bolstered by my pediatric anesthesiology rotation. Baby veins were young and crisp the loss of resistance was undeniable. By the end of my rotation, I could tell when a catheter was in a vein before I saw a flash of blood. Perhaps Dr. Hamid was telling the truth? He is a pediatric anesthesiologist after all.

Lessons Learned

As a CA-3 my toolbox of techniques continued to expand, I learned antecubital veins can have large valves that sometimes require inserting the catheter halfway, then using a saline flush to open the valve prior before threading the rest of the catheter. If you try to force the catheter past the closed valve the vein will blow. Forearm veins sometimes require tension applied proximal rather than distal to the insertion site (and sometimes both). After chemotherapy, veins become remarkably fragile better to use an IV one size smaller than you think you need. Every patient became an exception to the rules I had established as a CA-1.

Now, as I prepare to graduate residency, I realize I think of peripheral IVs completely differently. I also show up in the morning a little later and don’t feel the need to place all of my IVs. My scientific left-brain protocol has slowly evolved into an artistic right-brain approach. Thinking has become feeling. The answer to most questions has become, “It depends.”

Even though my PIV success rate approaches 100%, I still miss sometimes. Just when you think you know everything, a blown vein reminds you will never fully figure it out. The peripheral IV has a way of humbling even the most confident anesthesiology residents – and that’s ok. It’s the fluidity of circumstance, coupled with practical experience, that makes it an art.

Nabil_Othman.jpgNabil Othman, MD is an anesthesiologist in Los Angeles, California. He earned his bachelor’s degree in Biochemistry from Oakland University in Rochester, Michigan, followed by his medical degree at Wayne State University in Detroit, Michigan. Currently, he is in his final year of anesthesiology residency at Cedars Sinai Medical Center. After residency, he will complete a critical care fellowship at the Texas Heart Institute. When he is not an indentured servant in the hospital, he enjoys CrossFit, telling everyone he knows about CrossFit, and planning dangerous hikes in Hawaii with his college roommates. He blogs at

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