UUCI Health · Department of Neurology
APP Class II · Procedural Competency Series · 2026
●  Procedure 12·Bedside / standard·Standard tier
12.

Peripheral IV

Placement.

Landmark & ultrasound-guided short peripheral catheter placement.
Chadwycke R. Smith, MSN, NP, AGACNP-BC
APP Education · Department of Neurology
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology
Version 2.0 · 2026-05-11
Peripheral IV · UCI Neurology APP Class II
01 / 23
UUCI · APP Class II
Procedure 12 · Peripheral IV
02 · Why this matters
Phlebitis / infiltration without disciplined technique
30–40%
of PIVs develop phlebitis or infiltration without site rotation and standardized technique — and the most common invasive procedure in the hospital is the most under-taught.
  • Most-performed invasive procedure in the hospital — aggregate harm signal is real.
  • Failed attempts delay fluids, antibiotics, contrast, and clot lysis — measurable.
  • Vesicant-through-PIV (norepinephrine, CaCl2, hypertonic saline) drives the catastrophic-extravasation tail.
  • INS 2024 sets the practice floor for catheter selection, dwell time, and dressing care.
Infusion Nurses Society. Infusion therapy standards of practice. J Infus Nurs. 2024;47(1S):S1–S285
Nickel B. Crit Care Nurse. 2019;39(1):61–71 · PMID 30710037
Peripheral IV · Why this matters
02 / 23
UUCI · APP Class II
Procedure 12 · Peripheral IV
03 · Course objectives

What you'll leave with — six competencies.

01 · Cognitive

Indications & vesicant exclusion.

Differentiate PIV-appropriate from central-only infusates — vasopressors, concentrated electrolytes, TPN, pH <5 or >9, osmolarity >900 mOsm/L.

02 · Cognitive

Gauge & site selection.

Match gauge to indication per INS 2024 (14–24 g) and apply the distal-to-proximal forearm-preferred site hierarchy.

03 · Psychomotor

Landmark insertion.

Anchor, bevel-up at 10–30°, flash, drop to 5–10°, advance off stylet, release tourniquet, flush, secure.

04 · Psychomotor

Ultrasound-guided rescue.

Apply the Dawson rule (≥50% intravascular) and INS pre-scan thresholds for difficult-access PIV.

05 · Cognitive

Complication recognition.

Differentiate infiltration from extravasation; recognize phlebitis, hematoma, arterial puncture, nerve injury early.

06 · Affective

Documentation & escalation.

Document site, gauge, attempts, US use, flush, dressing; escalate vesicant orders to central / midline access.

Peripheral IV · Course objectives
03 / 23
UUCI · APP Class II
Section I of IV
I.
Section one

Anatomy & site selection.

The vein you choose matters more than how skillfully you advance the needle. Distal to proximal · forearm first · antecubital is a trap.
Objectives C-3 · C-4 — slides 5–7
Peripheral IV · Section I
04 / 23
UUCI · APP Class II
Procedure 12 · Peripheral IV
04 · Site anatomy

Forearm workhorses — cephalic, basilic, median.

Henry Vandyke Carter, Gray's Anatomy Fig 576 — cephalic, basilic, and median forearm veins, the workhorse anatomy for adult PIV placement
Henry Vandyke Carter, Gray's Anatomy (1918), Fig 576. Public domain.
Adult default — non-dominant forearm
  • Cephalic (radial side) · basilic (ulnar side) · median antebrachial (between) — long, straight segments, away from flexion.
  • Distal to proximal — start where you can live with failure, escalate up the arm only when needed.
  • Avoid the AC fossa for routine access — flexion kinks the catheter, blunts flow, shortens dwell.
  • Hand veins acceptable when forearm fails — higher pain, lower dwell, more infiltration; avoid near radial artery / median nerve at the wrist.
  • Skip the affected limb — mastectomy-ipsilateral, AVF extremity, paretic limb, lymphedema side, burned or infected skin.
  • No lower-extremity PIV in adults — DVT risk and dwell are both worse.
Infusion Nurses Society. J Infus Nurs. 2024;47(1S):S1–S285 · §6.4 site selection
Peripheral IV · Site anatomy
05 / 23
UUCI · APP Class II
Procedure 12 · Peripheral IV
05 · Gauge selection

Match the gauge to the indication.

GaugeColorIndicationSite preference
14 g Orange Major trauma · massive transfusion · flow rates ~270 mL/min AC fossa or large forearm vein
16 g Grey Trauma · rapid transfusion · flow rates ~180 mL/min AC fossa or large forearm vein
18 g Green Power-injection contrast · blood products · rapid resuscitation AC fossa or large forearm — default trauma-bay gauge
20 g Pink Most adult inpatients — maintenance fluids, antibiotics, routine meds Forearm cephalic / basilic / median
22 g Blue Small veins · elderly · oncology with prior chemotherapy Forearm or dorsal hand — smallest gauge meeting the indication
24 g Yellow Extremely small veins · fragile skin · pediatric Dorsal hand · short dwell expected
Infusion Nurses Society. J Infus Nurs. 2024;47(1S):S1–S285 · §6.3 device selection. Smaller gauge → less mechanical phlebitis, longer dwell.
Peripheral IV · Gauge selection
06 / 23
UUCI · APP Class II
Procedure 12 · Peripheral IV
06 · Indications · vesicant exclusion

When to place — and what not to run.

Appropriate PIV use
  • Short-term IV fluid, electrolyte, and crystalloid resuscitation
  • Non-vesicant medications — antibiotics, antiemetics, analgesics (verify each agent)
  • Iodinated contrast for CT (pump-rated catheters, typically 18–20 g in AC fossa)
  • Bridge access while midline / PICC / CVC is being arranged
  • Access-deficient patient with no central indication
Infusion Nurses Society. J Infus Nurs. 2024;47(1S):S1–S285
Do NOT run through a PIV
  • Vasopressors — norepinephrine, epinephrine, vasopressin, phenylephrine (extravasation → necrosis)
  • Concentrated electrolytes — KCl > 10 mEq/100 mL · hypertonic saline ≥ 3% prolonged · CaCl2
  • Chemotherapy vesicants — anthracyclines, vinca alkaloids, mitomycin (oncology central only)
  • TPN (PPN acceptable short-term peripherally)
  • pH < 5 or > 9 · osmolarity > 900 mOsm/L — central / midline only
Institutional short-term emergency exception for low-dose peripheral norepi exists — time-limited, monitored, central access in parallel.
Peripheral IV · Indications & exclusions
07 / 23
UUCI · APP Class II
Procedure 12 · Peripheral IV
07 · Pre-procedure · time-out

Before you puncture — verify infusate.

  • 01
    Verbal consent. Indication, expected sensation ("sharp scratch, then pressure"), what to report during (burning, paresthesias) and after (swelling, redness, leaking, pain).
  • 02
    Allergy & access history. Chlorhexidine, latex, adhesives, prior contrast reactions · recent draws, blown veins, indwelling lines, AVF laterality, mastectomy side.
  • 03
    Site choice confirmed. Avoid mastectomy-ipsilateral arm, AVF extremity, paretic limb, lymphedema side, infected or burned skin.
  • 04
    Infusate appropriateness. Confirm ordered agents are PIV-appropriate — flag vesicants, vasopressors, CaCl2, hypertonic saline, IV contrast. Escalate before puncture.
  • 05
    Time-out called. Per TJC UP.01.03.01 — right patient, right indication, right extremity, allergies reviewed, consent confirmed.
TJC standard

UP.01.03.01

Universal Protocol applies to PIV placement — verification, allergy / access history, formal time-out before puncture.
The Joint Commission. Universal Protocol UP.01.03.01.
TJC Hospital Accreditation Standards · 2024.
Peripheral IV · Pre-procedure verification
08 / 23
UUCI · APP Class II
Key fact · POCUS rescue
Egan et al · Emergency Medicine Journal · 2013
70%
first-attempt success in difficult-IV patients with ultrasound versus 30% palpation alone. After two failed landmark attempts — ultrasound is the next step, not a third blind stick.
01
Linear
probe.
02
Long
catheter.
03
Dawson
rule.
04
Pre-scan
thresholds.
Egan G et al. Emerg Med J. 2013;30(7):521–6 · PMID 22886890
09 / 23
UUCI · APP Class II
Procedure 12 · Peripheral IV
08 · Equipment

What's on the table — before you puncture.

Standard PIV kit
  • Catheter-over-needle, 14–24 g (BD Insyte Autoguard or equivalent)
  • Tourniquet
  • Chlorhexidine 2% / alcohol 70% applicator
  • Saline-primed extension set (T-connector or saline lock)
  • 10 mL preservative-free 0.9% saline flush
  • Transparent semipermeable dressing (CHG-impregnated for high-risk sites)
  • Tape · dressing label (date / time / gauge / initials)
  • Non-sterile gloves
  • Sharps container at bedside
  • Warm compress for difficult access
Ultrasound-guided adjuncts
  • High-frequency linear probe (10–15 MHz)
  • Sterile probe sleeve · sterile gel
  • Long catheter — ≥ 4.5 cm, often 6–8 cm for upper arm targets
  • Basilic / brachial / cephalic in the proximal upper arm are the typical US targets
  • Short-axis approach with dynamic tip tracking
Egan G et al. Emerg Med J. 2013;30(7):521–6 · INS. J Infus Nurs. 2024;47(1S):S1–S285
Peripheral IV · Equipment
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UUCI · APP Class II
Section II of IV
II.
Section two

Landmark
technique.

Five steps · each a checkpoint. The art is in the small motions — the angle, the traction, the flatten-and-advance after flashback.
Objectives P-1 · P-2 · P-3 · P-4 · P-5 · P-6 — slides 12–15
Peripheral IV · Section II
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UUCI · APP Class II
Procedure 12 · Peripheral IV
09 · Tourniquet · prep

4–6 in proximal · CHG 30 s + 30 s dry.

  • Apply tourniquet 4–6 in proximal to planned puncture — tight enough to engorge, loose enough to leave a radial pulse.
  • Palpate for a soft, bouncy, straight segment — caliber and patency matter more than surface visibility.
  • Chlorhexidine 2% / alcohol 70% — concentric circles, center out, 30 s scrub + 30 s air-dry. No blotting, no fanning.
  • Tourniquet stays on ≤ 2 min total — beyond that → hemoconcentration, false lab values.
  • If you re-palpate the prepped skin with non-sterile gloves — re-prep.
Infusion Nurses Society. J Infus Nurs. 2024;47(1S):S1–S285 · §6.5 skin antisepsis & tourniquet
Ultrasound short-axis view of antecubital fossa veins — caliber and patency assessment more reliable than surface inspection
Hellerhoff. Oberflaechliche Venenthrombose kubital — US. Wikimedia Commons. CC BY-SA 4.0.
Peripheral IV · Tourniquet & prep
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UUCI · APP Class II
Procedure 12 · Peripheral IV
10 · Steps 1–3

Anchor, flash, seat.

01

Anchor ·
bevel up.

  • Non-dominant thumb 2–3 cm distal to puncture — traction along long axis, prevents rolling
  • Bevel up · catheter tip aligned to long axis of vein
  • Approach angle 10–30° on standard adult forearm
  • Warn before contact — "sharp scratch coming"
02

Flash ·
drop · advance.

  • Advance until give + flashback in chamber — stylet in lumen, catheter not yet
  • Drop angle to 5–10°, advance unit 1–2 mm further
  • Hold stylet steady; advance catheter off stylet with dominant hand
  • If flash stops or pulses — vein transfixed; withdraw, reassess
03

Seat to
the hub.

  • Lower angle flush with skin · advance catheter to hub in single smooth motion
  • Mild resistance at valves expected — never force; rotate / small flush to open
  • Partial seating = most common cause of early infiltration
  • Do not flush before tourniquet release
Infusion Nurses Society. J Infus Nurs. 2024;47(1S):S1–S285 · §6.6 catheter insertion technique
Peripheral IV · Steps 1–3
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UUCI · APP Class II
Procedure 12 · Peripheral IV
11 · Step 04 · bevel-up insertion

Traction below — bevel up.

Bevel-up peripheral cannulation with non-dominant thumb providing skin traction distal to the puncture site
HoRaMi. Placement of intravenous cannula 3. Wikimedia Commons. CC BY-SA 3.0.
What this view shows
  • Non-dominant thumb anchoring skin distal to the planned puncture — traction along vein long axis
  • Catheter held in dominant hand · bevel oriented up
  • Approach angle on a typical adult forearm — flatter for superficial, steeper for deep
  • Stylet still partially seated · operator's eyes on the flash chamber, not the skin
  • Free hand stays ready to retract the stylet, advance the catheter, and engage safety
Infusion Nurses Society. J Infus Nurs. 2024;47(1S):S1–S285
Peripheral IV · Step 04 · insertion
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UUCI · APP Class II
Procedure 12 · Peripheral IV
12 · Steps 4–5 · release · flush · secure

Tourniquet off, then flush.

Step 04 — release & flush
  • Release the tourniquet first. Then engage the safety stylet retraction mechanism — sharps protection before anything else.
  • Connect a saline-primed extension set
  • Flush 3–5 mL of preservative-free 0.9% saline slowly
  • Observe for resistance, swelling, pain at the site — if any, pull the catheter
  • Confirm: no wheal, no surrounding induration, smooth flush
Step 05 — secure & document
  • Loop the extension set away from puncture — strain relief
  • Transparent occlusive dressing over insertion site
  • Label dressing: date · time · gauge · initials
  • Document in EMR: site, laterality, gauge, attempts, US use, flush, dressing, baseline skin/extremity exam
Secured peripheral IV in a hand vein with two-port hub and transparent occlusive dressing — strain-relief loop visible
User:Mattes. Intravenöser Zugang an Handvene mit zwei Anschlüssen. Wikimedia Commons. CC BY-SA 3.0.
Single attempt per provider · escalate after two failed attempts.
Peripheral IV · Release · flush · secure
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UUCI · APP Class II
Section II.b · Ultrasound rescue
II.b
When landmarks fail

Ultrasound
rescue.

Two failed landmark attempts is the gate. Past that, ultrasound is the next step — not a third blind stick, not a colleague's hands on the same arm.
Objectives C-5 — slide 17
Peripheral IV · Section II.b
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UUCI · APP Class II
Procedure 12 · Peripheral IV
13 · Ultrasound-guided PIV

Dawson rule · pre-scan · short-axis.

Clinical setting showing peripheral IV access alongside PICC site — context for escalation beyond landmark technique
Jakembradford. PICC Line and IV Placement. Wikimedia Commons. CC BY-SA 4.0.
When · where · how
  • Indication — after two failed landmark attempts, or no peripheral vein palpable
  • Probe — high-frequency linear, 10–15 MHz
  • Target — basilic and brachial veins in proximal upper arm (typical); cephalic above AC also
  • Catheter — long, ≥ 4.5 cm, often 6–8 cm
  • Approach — short-axis · dynamic tip tracking · "bee-sting" view
  • Thread under direct visualization — advance catheter beyond bevel into lumen
Dawson rule · INS 2024 pre-scan

≥ 50% of catheter intravascular for adequate dwell · vein depth < 1.5 cm · diameter > 3 mm · catheter length 1.75–2.5 in.

Egan G et al. Emerg Med J. 2013;30(7):521–6 · PMID 22886890 · INS. J Infus Nurs. 2024;47(1S):S1–S285
Peripheral IV · Ultrasound-guided rescue
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UUCI · APP Class II
Procedure 12 · Peripheral IV · Critical checkpoint
Critical safety checkpoint · recognize on sight

Infiltration vs extravasation
— different response.

Infiltration · non-vesicant

Non-vesicant fluid in subcutaneous tissue. Site is cool, soft, swollen; patient reports tightness. Stop infusion. Remove catheter. Elevate. Warm or cool compress per agent. Document.

Extravasation · vesicant

Vesicant in tissue. Site is dusky, blistered, painful. Stop infusion. Leave catheter in. Aspirate residual drug from hub. Antidote per agent. Photograph. Notify pharmacy + primary team.

The agent decides the response
Check the infusate before
you pull the catheter.
Nickel B. Crit Care Nurse. 2019;39(1):61–71 · PMID 30710037
INS. J Infus Nurs. 2024;47(1S):S1–S285
Peripheral IV · Infiltration vs extravasation
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UUCI · APP Class II
Procedure 12 · Peripheral IV
14 · Complications

What can go wrong — on sight.

01 · Mechanical

Infiltration.

Non-vesicant in tissue · cool, soft swelling. Stop, remove, elevate, compress per agent.

02 · Vesicant

Extravasation.

Vesicant in tissue · dusky, blistered. Stop, leave catheter, aspirate, antidote, photograph.

03 · Mechanical

Phlebitis.

Pain, erythema, palpable cord. Mechanical / chemical / infective. Remove, elevate, warm; replace elsewhere.

04 · Mechanical

Hematoma.

Local bruising at puncture or post-removal. Pressure + elevation; rarely requires intervention.

05 · Immediate

Arterial puncture.

Bright pulsatile blood. Withdraw, hold pressure, reassess; rarely requires vascular consult.

06 · Neurologic

Nerve injury.

Sudden electric paresthesia on puncture (median at wrist, radial at thumb). Withdraw immediately, document, neuro check.

07 · Delayed

Catheter-related BSI.

Uncommon with short PIV; rises sharply after 96 h dwell with poor dressing care. Remove on signs of infection.

08 · Rare

Air embolism.

Prevented by priming the extension set and capping ports. Trendelenburg + left lateral decubitus if suspected.

Nickel B. Crit Care Nurse. 2019;39(1):61–71 · PMID 30710037 · INS. J Infus Nurs. 2024;47(1S):S1–S285
Peripheral IV · Complications
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UUCI · APP Class II
Procedure 12 · Peripheral IV
15 · Pitfalls

Four errors we see — repeatedly.

01

Vesicant through a PIV.

Norepinephrine, CaCl2, hypertonic saline, chemo vesicants — these belong central / midline. Escalate the order before you puncture; do not run and document later.

02

Flushing into a tourniqueted limb.

Release the tourniquet before you flush. Flushing into closed venous outflow drives infusate into soft tissue — a wheal at the site is the tell.

03

Missed mastectomy / AVF history.

Skipping the time-out because PIV "feels low-stakes" is how the wrong arm gets cannulated. The history check is the discipline.

04

Three blind sticks before escalation.

After two failed landmark attempts — ultrasound, midline, or central. Not a third blind puncture, not a colleague's hands on the same arm.

Peripheral IV · Pitfalls
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UUCI · APP Class II
Procedure 12 · Peripheral IV
16 · UCI FPPE · OPPE

Your competency pathway.

StageTriggerScope
FPPEBoard approval of PIV privilegeFirst 5 independent placements · aggregate review by APP Director + CRNI · closed within 3 mo
OPPEContinuous baseline · TJC MS.08.01.03Every 6 mo · 10% sample (min 2, max 10) · 100% review on any extravasation event
TriggerVesicant extravasation · contrast-extravasation w/ compartment · 2+ failures w/ harm in 90 d · safety eventAd-hoc focused review per §3 structure · min 5 subsequent cases
Lapse< 10 PIVs over 24 moRepeat skills checklist + 1 proctored case rated Independent
Tracked OPPE indicators
  • First-attempt success rate ≥ 75%
  • Extravasation rate near zero · 100% per-case review on any
  • Documentation completeness 100% (site, gauge, attempts, US use, flush, dressing, baseline exam)
  • Appropriate-medication-for-access rate 100% · institutional exception tracked separately
  • Time-out per TJC UP.01.03.01 documented 100%
Standard tier Bedside / standard; simulation optional.
Peripheral IV · FPPE / OPPE pathway
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UUCI · APP Class II
Procedure 12 · Peripheral IV
17 · References & acknowledgments

Sources of truth.

  1. 01Infusion Nurses Society. Infusion therapy standards of practice. J Infus Nurs. 2024;47(1S Suppl 1):S1–S285.
  2. 02Infusion Nurses Society. Infusion therapy standards of practice. J Infus Nurs. 2021;44(1S):S1–S224. PMID 33394637.
  3. 03Egan G, Healy D, O'Neill H, et al. Ultrasound guidance for difficult peripheral venous access: systematic review and meta-analysis. Emerg Med J. 2013;30(7):521–6. PMID 22886890.
  4. 04Nickel B. Peripheral intravenous access — applying infusion therapy standards of practice to improve patient safety. Crit Care Nurse. 2019;39(1):61–71. PMID 30710037.
  5. 04bBahl A, Alsbrooks K, Zazyczny KA, et al. An improved definition and SAFE rule for predicting difficult intravascular access (DIVA) in hospitalized adults. J Infus Nurs. 2024;47(2):96–107. PMID 38377305.
  6. 04cStefanos SS, Kiser TH, MacLaren R. Management of noncytotoxic extravasation injuries: a focused update on medications, treatment strategies, and peripheral administration of vasopressors and hypertonic saline. Pharmacotherapy. 2023;43(4):321–337. PMID 36938775.
  7. 05Marino PL. Marino's The ICU Book, 4th ed. Wolters Kluwer; 2014. Ch 1 & 3 — vascular access & vesicant pharmacology.
  8. 06Lee K, ed. The NeuroICU Book, 2nd ed. McGraw-Hill; 2018. Ch 34 — neuro-ICU procedures.
  9. 07Massachusetts General Hospital. Internal Medicine Housestaff Manual, 2024–2025 ed. Section: US-guided peripheral IV.
  10. 08Massachusetts General Hospital. Department of Medicine Point-of-Care Ultrasound Manual ("Gray Book"), 2021–2022 ed.
  11. 09The Joint Commission. Universal Protocol UP.01.03.01. TJC Hospital Accreditation Standards; 2024.
  12. 09aThe Joint Commission. Universal Protocol UP.01.01.01 — preprocedure verification; use a standardized list (H&P, signed consent, nursing & preanesthesia assessment, labeled imaging, required equipment/devices). National Patient Safety Goals (HAP); effective January 2025.
  13. 09bThe Joint Commission. NPSG.01.01.01 EP 1 — use at least two patient identifiers (room number is not an identifier) before any treatment or procedure. National Patient Safety Goals (HAP); effective January 2025.
  14. 09cThe Joint Commission. NPSG.07.01.01 EP 1 — implement CDC and/or WHO hand-hygiene categories IA, IB, IC. National Patient Safety Goals (HAP); effective January 2025.
  15. 09dThe Joint Commission. NPSG.03.04.01 — label all medications, medication containers, and solutions on and off the sterile field (name, strength, amount, diluent, expiration). EP 4 requires two-individual verification when preparer ≠ administrator. National Patient Safety Goals (HAP); effective January 2025.
  16. 10The Joint Commission. HR.01.06.01 — staff are competent to perform their responsibilities. 2024.
  17. 11The Joint Commission. MS.08.01.01 / MS.08.01.03 — FPPE / OPPE requirements. 2024.
  18. 12California Code of Regulations. 16 CCR §1474 (CA BRN scope) · 16 CCR §1399.541 (CA PA scope).
  19. 13UCI APP Class 2 Training Plan Process. Department of Neurology, University of California, Irvine. April 2026.
Peripheral IV · References
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UUCI · APP Class II
Procedure 12 · Peripheral IV
End of module · Procedure 12

Now —
the post-test.

Stream A
12-item post-test
≥ 10 / 12
Stream B
Skills checklist
task-trainer or DOPS
Live
3 proctored cases
per UCI DOP
FPPE
First 5 independent
aggregate review
Routing: IDPC → Department Chair → APP Director per UCI Medical Staff Bylaws.
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology.
UCI Health · APP Education
Version 2.0 · 2026-05-11
Peripheral IV · End
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