Nurses from many different practice areas frequently ask this question. The patient has many visible veins on their chest or breast area, so why can’t we use those for insertion of a short peripheral I.V. catheter when there are no veins in the upper extremity? Take a close look at the picture below, especially how these veins appear.
There are many reasons why using these veins is not good practice. First, the nurse must be concerned about WHY those superficial veins of the chest are so visible. The answer here is simple – changes in venous return due to injury, surgery, or some type of disease process. There can easily be vein thrombosis or stenosis that is restricting the blood flow and causing these veins to be so prominent. Engorged veins of the chest are a classic sign of vein thrombosis. Infusion into these veins will add to the problem of venous return.
The second thing to be concerned about is the tortuous nature of those veins. Notice in the picture below how these visible veins are not lying in a relatively straight path. It would be most difficult to get a catheter to advance into those veins. There is no method to distend these veins for venipuncture.
The risk of infiltration/extravasation is a third factor. There are numerous cases of severe extravasation injury due to leakage from a CVAD insertion site and from a needle used for accessing an implanted port. I have seen lawsuits where a total mastectomy was required due to these events. Many times these questions come from nurses in the emergency department. And many times these nurses will need to give vesicant medications such as calcium chloride or calcium gluconate, 50% dextrose, or high concentrations of potassium – all are vesicants that can produce severe tissue damage if they leak from the vein into the subcutaneous tissue. Even if the prescribe I.V. therapy is only for fluids, the alteration in normal venous return will cause fluid to overflow the puncture site and into the subcutaneous tissue.
The fourth factor is there is no research to support this practice and it is not recognized by any professional organization.
Fortunately, there are much better alternatives. All nurses with responsibility for performing peripheral catheter insertion MUST have the skill of vein palpation. This skill can easily be learned. Practice palpating the upper extremity for veins before choosing a site on all patients. Always use the same finger of the same hand for this technique. Press downward and feel for an elastic rebound of a healthy vein beneath your fingertip. Do not simply rub your finger over the skin surface, as this will not provide useful information about the vein condition. If the vein feels hard or cord-like, it is sclerosed and should not be used. Palpation may not work for every patient due to vein changes from many courses of infusion therapy, or disease processes such as diabetes. Nevertheless, you may be surprised at the unseen, palpable veins you will be able to find when you have mastered this skill.
If the situation requires rapid access, choose an intraosseous device. Again, insertion is a skill to be learned. The intraosseous route provides rapid assess and is now recommended when time is critical. Do not waste time searching for a peripheral vein and making many unsuccessful attempts. This delay only adds to the risk for the patient.
Finally, if time is not a critical factor, use an infrared light device or ultrasound to locate veins in the upper extremity that you cannot palpate. Again, these are more skills that must be learned and your facility must make the investment into providing these devices. However, these devices are well documented to increase the success of peripheral venipuncture in patients with difficult venous access
The bottom line is that superficial veins of the chest or breast area should never be used for insertion of a peripheral catheter because the risks are much greater than the benefits. Moreover, there are many other alternatives.
Author: Lynn Hadaway
Lynn Hadaway has more than 35 years experience in infusion nursing and adult education. Her experience comes from multiple acute care settings, healthcare manufacturing, continuing professional education.