What peripheral IV sites should be avoided? A comprehensive guide

September 25, 2025 •

4 min read

According to studies, a significant percentage of peripheral IVs fail before the prescribed therapy is complete. Understanding what peripheral IV sites should be avoided is crucial for healthcare professionals and patients alike to prevent complications and ensure effective treatment.

Quick Summary

Healthcare providers should avoid inserting peripheral IVs in areas of joint flexion, the lower extremities, compromised or damaged tissue, and limbs affected by surgery or disease to minimize risks like nerve damage, infiltration, and infection.

Key Points

Flexion Points: Avoid inserting IVs in areas of joint flexion, like the wrist and antecubital fossa, to prevent kinking, occlusion, and patient discomfort.
Lower Extremities: Lower limbs should generally be avoided in adults due to a higher risk of infection and thrombophlebitis, prioritizing upper extremities instead.
Compromised Veins: Never use a site that is bruised, infected, scarred, or has a history of infiltration or phlebitis, as this increases the risk of complications.
Surgical History: Always check a patient's medical history for conditions like mastectomy, lymph node dissection, or AV fistulas, which restrict IV access to specific limbs.
Nerve Proximity: The ventral surface of the wrist should be avoided due to the high risk of nerve damage, including to the median nerve.
Thorough Assessment: A comprehensive patient assessment is the most important step for choosing the safest and most effective peripheral IV site.

Understanding the Fundamentals of IV Site Selection

Proper site selection is the cornerstone of safe and effective peripheral intravenous (IV) therapy. While many veins are visible, not all are suitable for cannulation. Choosing the right site involves a thorough assessment of the patient's medical history, current condition, and the purpose of the infusion. Selecting an inappropriate site can lead to serious complications, including nerve damage, hematoma, extravasation, and infection, causing unnecessary pain and prolonging hospital stays.

General Assessment Prior to IV Insertion

Before a needle is ever inserted, a healthcare provider should perform a comprehensive assessment. This includes:

Reviewing medical history: Look for conditions such as previous mastectomies, lymph node dissection, or the presence of an arteriovenous (AV) fistula or graft.
Inspecting the limb: Check for any signs of infection, bruising, edema, or previous damage that could compromise the vein.
Considering patient factors: Evaluate the patient's age, mobility, and the type of medication being administered. Certain vesicant medications, for example, may require a central line instead of a peripheral one.
Prioritizing the non-dominant arm: Whenever possible, the non-dominant arm should be used to allow the patient more freedom and comfort.

Key Peripheral IV Sites to Avoid

The Ventral Surface of the Wrist

Inserting an IV on the palm-side (ventral) surface of the wrist is highly discouraged. This area is a high-risk zone for nerve damage, particularly the median nerve, which runs very close to the surface here. A misplaced catheter can compress or directly injure this nerve, leading to persistent pain, numbness, and limited hand function. In addition to the nerve risk, the veins in this area are typically small and fragile.

The Antecubital Fossa (Inner Elbow)

Although the veins in the antecubital fossa are often large and easily accessible, this is a poor choice for a peripheral IV for long-term use. As a joint flexion point, repeated bending of the elbow can cause the catheter to kink, resulting in an occlusion. More importantly, it can cause the catheter tip to move, potentially puncturing the vein and leading to infiltration or extravasation. This site is generally reserved for drawing blood or short-term emergency access.

Veins in the Lower Extremities

In adult patients, the lower extremities should be avoided for peripheral IV access unless absolutely necessary. This area has a higher risk of developing complications such as thrombophlebitis (inflammation of the vein) and infection. In neonates and infants who are not yet walking, lower extremity veins may be considered as an alternative. However, this is always a secondary choice to upper extremity sites and requires careful assessment.

Areas of Compromised or Damaged Tissue

Any area showing signs of damage or compromise is a site to be avoided. This includes:

Bruised, infected, or scarred areas: These sites can harbor bacteria and increase the risk of infection. Scar tissue can also make vein access difficult and painful.
Sites with previous infiltration or phlebitis: A vein that has been damaged by a previous IV attempt is prone to further injury and is often sclerosed (hardened), making re-entry challenging and risky.
Sites distal to a previous attempt: Never insert an IV distal to an already failed attempt, as fluids from the previous infiltration may interfere with cannulation and increase the risk of further complications.

Special Circumstances and Contraindications

Patient history is crucial for identifying additional sites to avoid.

Patients with Mastectomy or Lymphedema

For patients who have undergone a mastectomy with axillary lymph node dissection, or those with lymphedema, IV access should be avoided in the affected arm. This is because the compromised lymphatic drainage can increase the risk of infection and further exacerbate the swelling. Some facilities require a 'limb alert' bracelet to clearly mark the restricted limb.

Patients with Arteriovenous (AV) Fistula or Graft

An AV fistula or graft, often used for dialysis, creates an artificial connection between an artery and a vein. Placing an IV in an arm with a fistula or graft is strictly contraindicated, as it can damage the access site and potentially compromise the patient's long-term dialysis treatment. Venipuncture is prohibited in these limbs to protect the critical vascular access.

Best vs. Worst Practice for IV Site Selection


Feature	Preferred Sites (e.g., Forearm)	Avoided Sites (e.g., Wrist, Antecubital)
Vein Characteristics	Straight, well-dilated, and free from valves.	Small, tortuous, or located near a joint or valve.
Patient Comfort	Allows for natural movement without pain or kinking.	Leads to discomfort or kinking with movement.
Risk of Complications	Lower risk of nerve damage, infiltration, or phlebitis.	Higher risk of nerve injury, infection, and catheter failure.
Purpose of Infusion	Suitable for most routine short-term infusions.	Generally unsuitable for long-term infusions; high risk.
Assessment	Vein is visible, palpable, and located in a stable area.	Vein is near a joint, artery, or nerve, or in damaged tissue.

The Role of Technology in Modern IV Access

Healthcare professionals now have access to technologies like ultrasound, which can be invaluable for placing IVs in patients with difficult venous access. Ultrasound guidance can help visualize deeper veins, reduce the number of attempts, and decrease the risk of complications associated with blind insertion.

For more detailed information and the latest guidelines, please consult official healthcare resources. A great starting point is the Centers for Disease Control and Prevention (CDC)'s recommendations for infection control. CDC Infection Control Guidelines

Conclusion: Prioritizing Patient Safety

Patient safety and comfort are paramount in all medical procedures, and peripheral IV insertion is no exception. Knowing what peripheral IV sites should be avoided is a fundamental skill for medical staff and a critical piece of knowledge for patient advocacy. By carefully assessing each patient, understanding the risks associated with certain anatomical locations, and prioritizing the best possible site, healthcare providers can minimize complications and deliver the highest quality of care. Choosing the path of least resistance is not always the best option; a thoughtful approach to site selection is a key component of preventing adverse events and ensuring a positive patient experience.

Frequently Asked Questions

The ventral side of the wrist should be avoided due to the high risk of nerve damage, particularly to the median nerve, which can be compressed or injured by a misplaced catheter. The veins in this area are also often small and more fragile.

Placing an IV in the antecubital fossa, or the bend of the elbow, is risky because it is a joint flexion point. Frequent movement can cause the catheter to kink or become dislodged, leading to infiltration, occlusion, and discomfort for the patient.

In adults, using the lower extremities for peripheral IV access is generally avoided due to an increased risk of complications like thrombophlebitis and infection. In neonates and non-ambulatory infants, it can be a considered site if upper extremity options are not viable.

No, an IV should not be placed in an arm on the same side as a mastectomy with lymph node dissection. The compromised lymphatic system increases the risk of infection and lymphedema, so a 'limb alert' is often used to prevent accidental punctures.

Before insertion, inspect the potential site for signs of compromise, including bruising, swelling, redness, infection, or scarring. A compromised vein may also be hard (sclerosed) or difficult to palpate. Avoid any site that has been previously used and has a history of complications like infiltration.

A poorly chosen IV site can lead to several complications, including nerve damage, infiltration (fluid leaking into surrounding tissue), extravasation (a vesicant drug leaking into tissue), phlebitis (vein inflammation), and local or systemic infections.

The best practice is to start by assessing the patient's medical history and the upper extremities. Look for straight, well-dilated veins in the forearm, starting distally and moving proximally if necessary. Always choose a site free from joints, arteries, nerves, and compromised tissue.