PIV Insertion in the NICU: What Every Nurse Should Know

Little Bits to Grow Your Knowledge

Peripheral IVs (PIVs) are one of the most frequently used tools in the NICU, but they’re far from simple. In our tiniest patients, inserting and maintaining a peripheral IV takes skill, planning, and a deep understanding of neonatal physiology. Whether you’re brand-new or simply need a refresh, this post walks you through the what, why, and how of NICU PIV placement—step by step.

Why Do NICU Babies Need a PIV?

Peripheral IVs provide immediate, temporary access for:

• IV fluids (like D10 or D12.5)

• Antibiotics and other short-term medications

• Blood transfusions (with correct compatibility and line priming)

• Emergency meds (such as antiepileptics or prostaglandins while awaiting central access)

• Short-term parenteral nutrition

Because these infants may be NPO, unstable, or have limited access points, every poke matters. Being intentional from the beginning can make a huge difference in their care.

Step-by-Step: How to Prepare and Insert a PIV in the NICU

1. Take Time to Assess

Before you even grab supplies, spend time looking—and feeling—for the best vein. Learn your baby’s anatomy. Move slowly and methodically. "Shopping around" is one of the most important steps.

2. Choose the Right Site

Good sites: hands, feet, forearms, scalp (if trained and cleared).
Avoid: bruised or injured areas, limbs with a PICC or arterial line, surgical sites, or any area with compromised skin integrity.

Aim for fewer attempts by selecting the most appropriate site the first time.

3. Enhance Vein Visibility

• Use a warm pack or heel warmer to promote vasodilation.

• Consider lowering the extremity below heart level to increase venous filling.

• Tourniquets or soft rubber bands can help—but avoid excessive pressure on fragile skin.

• A vein finder may be helpful, but use with caution as it can distort depth and shape.

Look for a vein that’s straight, well-filled, and free of visible valves or curves.

4. Gather Your Supplies

• 24g catheter (yellow hub-most common)

• Skin prep (ChloraPrep or Alcohol or per unit policy)

• Saline flush

• 2x2 gauze

• Transparent dressing

• Tape and securement device (arm board, Tegaderm, other tape)

• Gloves

• Sucrose (if ordered)

• Helper (don’t go it alone!): this may be your best supply!

5. Prep the Site and Baby

• Swaddle or contain non-targeted extremities for comfort

• Ensure the baby is warm to prevent vasoconstriction

• Clean the insertion site thoroughly and let it dry completely

• Pull the skin taut to prevent the vein from rolling

6. Insert With Confidence

• Use a 10–15° angle—neonatal veins are very superficial

• Bevel up

• Advance slowly and watch for flashback

• Once flashback is seen, thread the catheter fully into the vein

• Release the tourniquet and confirm placement

7. Confirm Before Securing

Flush with saline gently. A well-placed line will:

• Flush easily with no resistance

• Show no blanching, swelling, or leaking at the site

• Have a smooth blood return if applicable

If it doesn’t look or feel right—pull it and try again. It's better to start over than risk infiltration.

Maintaining the Line: ACT Checks

Once your PIV is in, maintenance is everything. In the NICU, we use ACT checks hourly:

• A = Access: Is it still flushing easily?

• C = Compare: Any changes in color, size, or warmth compared to the other limb?

• T = Touch: Does it feel firm, cool, or painful?

Even a beautiful IV can infiltrate quickly—stay vigilant.

What Fluids Are Safe for PIVs in the NICU?

• Maximum dextrose concentration: D12.5% (higher requires central access)

• Never give blood products with dextrose—use a separate primed line

• Some medications (dopamine, TPN, certain electrolytes) are not PIV compatible—always check your drug reference

When in doubt, pause and verify.

Don’t Forget Parent Education

Parents are part of the care team. Include them by teaching:

• How to hold or reposition the baby without dislodging the IV

• What signs to look for: redness, swelling, loose tape, wetness around the site

• How long the IV may be in and why it’s needed

• That it’s okay to speak up—they’re their baby’s voice

Final Thoughts

A PIV may seem routine, but in the NICU, no procedure is ever truly "simple." PIV insertion requires skill, intention, and constant assessment. By slowing down and doing it right, we reduce pain, preserve veins, and improve outcomes.

Every poke matters.
Every baby matters.
And every NICU nurse should feel confident and empowered to place and maintain a safe, secure PIV.