Intravenous (IV) access is essential in anesthesia and surgery for rapid and reliable administration of fluids and medications. While upper extremity veins are preferred due to lower complication rates and easier access, there are situations (such as trauma, burns, or inaccessible upper extremity veins) where IV access in the lower extremities is required to proceed with anesthesia and surgery.
The most common lower extremity sites for peripheral IV access are the great saphenous vein at the ankle and the lesser saphenous vein, chosen for their superficial locations and consistent anatomy. In emergency or critical care situations, the femoral vein is preferred for central venous access because it is large, easy to identify, and suitable for rapid infusion. However, IV access in the lower extremities carries unique risks, particularly a higher incidence of complications such as thrombophlebitis, deep vein thrombosis (DVT), and catheter-related infections compared to upper extremity sites. These risks are amplified in adults due to factors such as slower blood flow, increased limb dependence, and a higher prevalence of peripheral vascular disease. Because of these concerns, guidelines consistently recommend limiting the duration of lower extremity IV access and transitioning to upper extremity access as soon as possible (1).
Recent advances in ultrasound technology have significantly improved the safety and success rates of acquiring IV access in the lower extremities, making ultrasound an increasingly useful tool for anesthesia and surgery. Ultrasound guidance provides direct visualization of veins, which not only facilitates cannulation in patients with difficult vascular access but also reduces the risk of complications such as arterial puncture or multiple failed attempts. Several studies support the use of ultrasound for both peripheral and femoral vein cannulation, showing improvements in first-pass success rates and reductions in procedure-related complications (1). This is particularly relevant for central access via the femoral vein, which, while easy to access, is associated with higher rates of infection and thrombotic events compared to central access via the subclavian or internal jugular vein. In a landmark study, Merrer et al. found that femoral catheterization had higher rates of both infection and thrombosis than subclavian access, reinforcing the recommendation that femoral sites should be reserved for specific clinical situations or emergencies (2).
IV access in the lower extremities is generally considered safer and more feasible in pediatric patients than in adults because children have fewer vascular comorbidities and their veins are less prone to thrombosis. However, complications such as infiltration, infection, and phlebitis still occur and require regular evaluation and prompt intervention if problems arise (3). In adult patients, early removal and routine monitoring are essential strategies to reduce complications, especially in those with risk factors for thrombosis or infection.
To minimize risk, several key practices are recommended: use of ultrasound guidance, strict aseptic technique during insertion, regular inspection of the IV site, and prompt removal of lower extremity catheters when no longer needed. Providers should monitor for signs of DVT, such as swelling, pain, and erythema, as well as for local or systemic infection. In addition, when femoral access is required for central venous catheterization, careful attention to catheter care protocols and early transition to safer sites are critical to reducing adverse outcomes (4).
Although lower extremity IV access is sometimes unavoidable in anesthesia and surgery, its use is associated with increased risks. Modern techniques such as ultrasound have improved the safety profile of these procedures, but clinicians must remain vigilant for potential complications and limit the use of lower extremity access when possible. With careful management, lower extremity IV access can be a safe and effective option for patients with limited alternatives.
References
- Witting MD. IV access difficulty: incidence and delays in an urban emergency department. J Emerg Med. 2012;42(4):483-487. doi:10.1016/j.jemermed.2011.07.030
- Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001;286(6):700-707. doi:10.1001/jama.286.6.700
- Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994;331(24):1601-1606. doi:10.1056/NEJM199412153312401
- Dargin JM, Rebholz CM, Lowenstein RA, Mitchell PM, Feldman JA. Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access. Am J Emerg Med. 2010;28(1):1-7. doi:10.1016/j.ajem.2008.09.001