Editing Nursing Skills and Procedures (section)

=== Site selection and insertion ===
Choose the most distal appropriate site in a nondominant upper extremity and move proximally with subsequent attempts, so that a failed site does not compromise a vein below it. Avoid areas of flexion, the antecubital fossa when other options exist, veins in an extremity with an arteriovenous fistula or graft, the side of a mastectomy with lymph node dissection, an extremity with lymphedema, a paralyzed or postcerebrovascular accident limb, and sites distal to a previous infiltration or phlebitis. Lower extremity veins are avoided in adults because of thrombosis risk.

Gauge selection: 14 to 16 for trauma and rapid volume resuscitation, 18 for blood products and surgery, 20 as a general-purpose adult size and acceptable for blood, and 22 to 24 for fragile, elderly, or pediatric veins. Prepare the skin with chlorhexidine using friction and let it dry completely; drying time is what kills organisms. Apply a tourniquet 10 to 15 cm above the site for no longer than a minute or two, insert bevel up at about 10 to 30 degrees, advance the catheter off the needle after blood return, release the tourniquet, connect and flush, and secure with a sterile transparent dressing labeled with date, time, gauge, and initials.

Peripheral catheters are changed based on clinical indication rather than a fixed schedule in most current guidance, and any catheter inserted under emergency conditions with questionable asepsis is replaced as soon as feasible.