The initial needle stick can be very unpleasant for some people and a startled patient may move suddenly, making the procedure more difficult.

If your operating room has a practice that allows IVs to be started in seated patients, always ask about and watch for vasovagal reactions. It seems counterintuitive, but often the patients who have the worst vasovagal reactions are the youngest and healthiest. One of the authors once saw a strapping young ex-marine slide right out of his chair onto the ground. Of course, there was a huge ruckus in the preoperative area. His family said, “oh, we forgot to tell you, he does that all the time.”

Choose a location that is convenient for you and the surgeon. For example, don’t place an IV in the right hand if the patient is having a right-sided carpal tunnel release. Consider carefully before starting an IV in the foot of a patient with diabetes or significant soft tissue changes in the lower extremities. Some anesthesia providers will do it, but the podiatrists tend to advise against it.

Use a tourniquet to engorge veins. A great technique before placing the tourniquet is to have the patient exercise the extremity against resistance
for 20 seconds and then “hang” the extremity in a dependent position. This will provide a manyfold increase in blood flow to the extremity. To avoid cutting off arterial flow, do not make the tourniquet too tight. Put the tourniquet as close to the location of the vein that is being accessed as possible, so you don’t forget to remove it. Consider the use of a forcing function as well—the person who puts the tourniquet on the patient is responsible for removing it—to make sure this happens, put a tourniquet on yourself or your pen or your stethoscope at the same time. Be especially careful if you have put a tourniquet on the lower leg, for some reason, these seem to be “forgotten” more often than tourniquets placed on the upper extremity.