The bevel-down technique


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The Ambulance Driver's Perspective
by Kelly Grayson

The bevel-down technique

Get more comfortable treating sick kids with this IV insertion technique

By Kelly Grayson

Early in my career, I discovered a love for pediatrics. Most medics count calls involving children among their most stressful, but I've always been one of those weird types who looked forward to them. Doesn't matter if it's a fussy infant or a sullen adolescent, I'm in my comfort zone when dealing with kids.

My parents would tell you that my comfort in assessing and treating children can be traced to a childhood fascination with veterinary medicine; the two disciplines have much in common. My ex-wife, on the other hand, would probably tell you that kids and I get along because they intuitively sense that I'm developmentally stuck at age seven.

In truth, it's probably a little of both.

But being the guy who is comfortable dealing with sick kids is a double-edged sword, because whenever the call came in for a pediatric transfer, I got it. If a medic needed backup on a pediatric code, I was sent if I was anywhere nearby. When I worked in the ER as a paramedic, I was the designated kid-sticker. The rewards of helping sick children are substantially lessened when you're the guy everyone asks to perform painful procedures on them.

But in my years as a medic, I've learned a few techniques to minimize the muss and fuss of poking squirming children with sharp objects: First, minimize the lag time between telling the kid about a painful procedure and actually doing it; second, bribery works; and third, use the bevel-down IV technique.

Most of us were taught to start our IV's bevel-up, but when you're trying to thread a plastic catheter into a tiny little vein, quite often the leading edge of your trocar pierces the opposite wall of the vein before you're ready to advance the catheter.

So there you are, needle in the vein, catheter still outside it. Perhaps you try to shallow the angle of your needle and advance a bit, and as often as not, you see the hematoma form at the same time you notice flashback in the catheter hub.


If you've ever had that happen to you, try inserting your IV catheters bevel-down. Doing so will make the angle of insertion much more shallow, thus minimizing the chance of poking the very end of that needle through the opposite wall before the tip of your cannula enters the lumen of the vein.

It's an old trick, first taught to me by a neonatal intensivist in my very first PALS class some fifteen years ago. It takes some practice, and with certain types of shielded IV catheters, more than a little gymnastics, but the technique can be mastered with all types of shielded catheters. Or, if you prefer, keep a few of the old, non-shielded IV catheters on hand especially for this purpose.

The medical literature on the technique is equivocal, with most studies showing no increase in success when comparing bevel-down IV insertion compared to the conventional technique. However, like most studies involving matters of technique, it is hard to quantify the individual skill level of the provider or their familiarity with the technique being evaluated.

If sticking tiny little veins in pediatric patients — or, for that matter, geriatric patients — always makes you pause, consider using the bevel-down IV technique. If you have access to an IV therapy manikin, practice the technique on it. You may find it a useful trick one day.

About the author

Kelly Grayson, NREMT-P, CCEMT-P, is a critical care paramedic in Louisiana. He has spent the past 18 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the LA Association of Nationally Registered EMTs.

He is a frequent EMS conference speaker and contributor to various EMS training texts, and is the author of the popular blog A Day In the Life of an Ambulance Driver. The paperback version of Kelly's book is available at booksellers nationwide. You can follow him on Twitter (@AmboDriver) or Facebook (, or email him at

The comments below are member-generated and do not necessarily reflect the opinions of or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
David Legare David Legare Wednesday, February 08, 2012 4:28:08 AM I wonder if the studies are skewed due to the practitioner being unfamiliar and/or apprehensive of the bevel down technique. I've always had problems with Pediatric patients under the age of 2. I wonder if the bevel down technique would help improve my success rate.
Richard Shockley Richard Shockley Saturday, November 24, 2012 9:43:46 AM I learned to use this in my last pals class. I now keep a few non-shielded 22g and 20g catheters in the truck just for this purpose. I never liked trying it with the shielded catheters. I have noticed that once you get a good feeling for the change of technique it makes it alot easier for smaller veins though. I have used it more for geriatrics then pediatrics recently as that is what makes up to majority of my transports.
Dominick Walenczak Dominick Walenczak Saturday, November 24, 2012 9:51:22 AM What other changes in approach or insertion angle are required of this technique? Only times I've done the bevel down technique would probably be while learning how to first start an IV or maybe during some long clinical hours. I found it hard to actually pierce the skin, as opposed to giving them a scratch.
Eric Harbison Eric Harbison Saturday, November 24, 2012 9:54:33 AM I work mainly in the pediatric part of the ER and I have never heard of the bevel down technique used in kids. I know for adults you are to insert the catheter at a 15-30 degree angle. For kids, if you level off the catheter during insertion to about 10 degrees and as soon as you are under the skin, level the needle almost flush with the surface of the skin and advance. Doing this will help you get a lot better success using the bevel up technique. As far as bevel down, I have no leg to stand on as to it's benefits, but the subject is intriging.
Greg Loftus Greg Loftus Sunday, November 25, 2012 4:34:08 PM nice trick
John Snow John Snow Sunday, November 25, 2012 5:04:48 PM In my experience, bevel down has always hurt like hell!
Jack Fitzgerald Jack Fitzgerald Sunday, November 25, 2012 5:11:31 PM When I deal with kids I enter the skin almost flat with the skin and have good luck with that. But I will try using this. Thanks Kelly for sharing.
Tim Talladino Tim Talladino Monday, November 26, 2012 3:52:04 AM I would advocate the "going really shallow" and taking your time to find a nice decent size vein appropriate to the catheter size. Always had great luck with 24 ga and "slow and gentle" tecnique.
Tim Talladino Tim Talladino Monday, November 26, 2012 3:53:35 AM With most kids and their stressed parents you have "one shot and one shot only' to get it on the first stick.
Tim Talladino Tim Talladino Monday, November 26, 2012 3:57:26 AM Never heard or tried this technique....let alone heard of anyone advocate or teach it. Would just wonder if it was questioned would it stand up to scrutiny of peers and or administrators(Ems or nursing).
Tim Talladino Tim Talladino Monday, November 26, 2012 3:58:54 AM Can just hear the echoes of "who taught you that? or "where did you learn that?"
James J Wohlers James J Wohlers Monday, November 26, 2012 1:52:50 PM Have done this a number of times with success and a number of times without. Interesting part about this article, you can see how the archaic dogma of ems education is thrown about.
Terrie Fenton Terrie Fenton Wednesday, December 05, 2012 2:06:56 AM This is great information. Thanks for sharing.
Deborah Baldwin Phillips Deborah Baldwin Phillips Wednesday, December 05, 2012 3:28:07 AM As a new to a Community Hospital ER RN I thank you for this gem. I am thankful to hear of your love for pediatrics. Due to personal reasons I am learning to cope with the anxiety when a little one comes in. Placing an IV is the source for more anxiety. I look forward to using your technique. Thanks for your article.
Hideyuki  Iwayama Hideyuki Iwayama Monday, April 01, 2013 12:15:25 PM I never heard of this technique. But quite interesting!