IV placement is an essential part of our anesthetic and resuscitative skills, yet it remains a pesky and challenging skill to acquire. There are innumerable variations in vein structure, type, skin texture, soft tissue density, and vascular anomalies that challenge your learning curve. It’s a humbling skill that takes time, repetition, and resilience to develop. This is a challenge shared across the board: nurses, techs, paramedics, medical students, phlebotomists, and physicians alike struggle with intravenous access. While a smooth IV placement can make you look confident and skilled, a failed attempt can quickly erode a patient’s trust. It’s an unfair but inevitable part of the job. In time, you’ll become an expert. But before that happens, you’ll struggle, and you’ll need to be patient with yourself. Some of the most difficult patient interactions you’ll have in healthcare will stem from failed IVs.

When you’re starting out, keep things simple. For awake patients, try to stay out of trouble. Stick to visible, easily accessible veins and small-gauge catheters. For anesthetized patients, take those opportunities to gently increase the difficulty: try larger gauges, attempt trickier veins. This is a low-stakes way to get comfortable with different techniques and refine your skillset.

Catheter design affects technique, and this is an important nuance. With smaller catheters (24, 22), once you see flash in the chamber, you can thread the catheter right away. But with larger catheters (18, 16, or 14), you’ll need to advance the needle further into the vein before threading the catheter. This usually means you have to lower your angle slightly and move the whole unit forward before attempting to thread. It’s subtle, but that distinction is part of what makes large-bore IVs more challenging to place.

Ultrasound-guided IVs are a great option for patients with poor vascular access, and you’ll get a lot of use out of this skill over time. That said, it requires practice and comes with its own set of risks. Ultrasound-placed IVs tend to enter the vein deeper beneath the skin, meaning less catheter is actually inside the vein. That makes them more prone to dislodgment. During placement, you may also inadvertently puncture the vein in multiple places, which increases the risk of infiltration. These IVs must be watched closely, particularly if you’re administering large volumes or giving pressors. If you find yourself spending an excessive amount of time on an ultrasound IV, it’s worth considering a central line instead.