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site selection for peripheral IV's
I have recently read conflicting information regarding the best site selection for peripheral IV access. The INS text Infusion Nursing An Evidence Based Practice states that the superficial veins in the hand and forearm should be the primary veins used. They further state that access should start at most distal point and work proximally. This is also written in the INS Standards of Practice. The CDC recommendations for Prevention of Intravascular Catheter-Related Infections also states that the hand veins are preferable due to a lowered risk for phlebitis and infection than the veins in the wrist or forearm. Now I have seen articles stating the hand veins should be avoided. What should my practice be?
The basic principle is now

The basic principle is now and has always been to start low and work upward. Hand veins are contraindicated when you are infusing a vesicant medication because of the vast network of tendons, ligaments, and nerves that control fine motor skills of the hand. A vesicant med can destroy these leaving the patient without hand function. Minor and major complications are reported to be more common in the veins of the wrist and hand. Site selection is a nursing judgment based on the type of therapy, purpose of therapy and length of therapy. For a pre-op patient going for a gallbladder removal the hand is acceptable. For an oncology patient receiving adriamycin, the hand is not acceptable. I have just reviewed the CDC guidelines and do not find any statement about a lower risk of phlebitis and infection in the hand veins. So I am confused about what you are referring to. Can you be more specific? Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

The 2002 MMWR CDC Prevention

The 2002 MMWR CDC Prevention of Catheter Related Infection document actually compares phlebitis rates from hand veins, versus wrist and UPPER arm (not forearm).

Phlebitis rates would be higher in the wrist area because of mechanical trauma d/t wrist flexion.

Upper arm would have the same issue if the IV is near the antecubital area, and, if the catheter was not long enough to pass through the extra tissue depth of the upper arm and rest in less traumatic manner in the vein.  Usually infiltration occurs in this situation - but you might not notice phlebitis as immediately because of the tissue depth covering the vein.

This is the reference the CDC lists for that statement:

Maki DG, Mermel LA. Infections due to infusion therapy. In: Bennett JV, Brachman PS, eds. Hospital Infections. 4th ed. Philadelphia: Lippencott-Raven, 1998:689--724. 

As Lynn states - site determination depends directly on indications for catheter use, as well as expected duration of patient IV therapy. 

I think if you also consider the amount of blood flow around the catheter, you'll have additional useful clinical information.  For e.g.: if an average 2mm vein has 10ml blood/minute flowing through it and you place an 18 gauge catheter in that vein, you've filled 25% of the vein with catheter.  Off the top of my head - most hand veins will be smaller, or considerably smaller, than 2mm.  (You wouldn't necessarily be using an 18 gauge catheter, but those are the stats I have in my head at the moment).

I can usually avoid using hand veins (but not always).  Anecdotally they are less comfortable for the patient, and even if secured well I see more complications related to use of these veins.  They're helpful for beginners to use who haven't developed their sense of palpation, but I would be very selective about using them.

If you know the venous anatomy of the forearm well, most of the time you can find great access sites and still be able to work distally to proximally, avoiding the distal cephalic and wrist area.

This doesn't give you a black/white answer about your practice related to hand veins, but hopefully will be of some assistance. 

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

The key word is vesicant.  Phenergan is a vesicant as well as vancomycin and many other aciidic pH drugs - no hands for those drugs


Kathy Kokotis

Bard Access Systems

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