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Vascular Access Procedures
© 2006 American Heart Association
Selection of Site and Priorities of Vascular Access
Introduction
After the needs for oxygenation and ventilation have been addressed
in an ill or injured child, the next management priority is vascular
access. Vascular access may be established for the purposes of fluid
resuscitation, administration of fluids, electrolytes, nutrition or
medication, laboratory testing, and monitoring of hemodynamics.
The site and priorities of vascular access depend on the provider's
experience and expertise and the clinical circumstances. In performing
any vascular access procedure, the provider should analyze the
clinical situation, implement universal precautions, and follow sterile
protocols.
During
Advanced Life
Support
Vascular access is vital for drug and fluid administration during
advanced life support, but it may be difficult to achieve in the pediatric
patient.1-5 Consider the following when evaluating vascular access
options:
• Rapid establishment of vascular access is more important than site
of access.
• During treatment of severe shock, establish intraosseous (IO) access
if you cannot rapidly achieve venous access.5-9 When practical
pursue IO and peripheral or central venous access simultaneously.
• During pediatric cardiac arrest, attempt to establish vascular access
at a site that will not require interruption of compressions or
ventilation.10 Immediate IO access is recommended if no other
intravenous (IV) access is already in place.
• If central venous access is needed during CPR or decompensated
shock, the safest site to attempt access is the femoral vein.
Establishing access through the femoral vein does not require interruption of CPR, and airway management is less likely to be
complicated if this site is used.
• Central vascular access may be achieved via umbilical vessel
catheterization in the young neonate if the umbilical vessels are still
patent.
• Arterial cannulation enables direct and continuous measurement of
blood pressure and access to sample blood for evaluation of
oxygenation and ventilation and acid-base balance.
During attempted resuscitation if an endotracheal (ET) tube is in place
but vascular access is not yet available, you may administer lipidsoluble resuscitation drugs through the ET tube.11 These drugs can be
recalled using the mnemonic LEAN:
© 2006 American Heart Association
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• Lidocaine
• Epinephrine
• Atropine
• Naloxone
Because drug absorption through the tracheobronchial tree and
resulting drug levels and effects are unpredictable, administration of
resuscitation drugs by any vascular or IO route is preferred to the
tracheal route.
Note: Intracardiac administration of drugs during closed-chest CPR is
not recommended. Intracardiac injections increase the risk of coronary
artery laceration, cardiac tamponade, pneumothorax, and intramyocardial injection with resultant acute myocardial necrosis.12-14
During
Nonemergent
Situations
Peripheral venous cannulation is the preferred method of vascular
access in most nonemergent situations. A large-bore catheter is
commonly used to gain access in the proximal upper extremity. Smallbore plastic catheters allow easy and reliable venous cannulation in
most infants and children.
During
Postresuscitation
During postresuscitation a central venous catheter is the preferred
method of access. It provides secure access and enables monitoring
of central venous pressure. But to avoid complications and delays,
only providers with significant experience and expertise should
perform this procedure.
Implementation of
Universal
Precautions
Universal precautions are infection control measures intended to
reduce the exposure and transmission of blood and other body fluid
pathogens between patients and healthcare workers. According to the
“universal precautions” principle, blood and body fluids from all
patients are considered infectious regardless of the infection risk
posed by the patient. While performing vascular access procedures,
be particularly careful to following safe practice standards in the
handling of sharps.
Do the following to implement universal precautions:
• Wash hands with soap and water before and after procedures.
• Use protective barriers such as gloves, gowns, masks, goggles.
• Use sterile or disinfected instruments and equipment.
• Use single-use disposable equipment for all injections.
© 2006 American Heart Association
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• Discard contaminated sharps immediately in puncture-proof and
liquid-proof containers as appropriate.
• Place soiled linen in leakproof biohazard bags and dispose of the
bags appropriately.
• Adopt locally appropriate policies and guidelines.
Intraosseous Access
Introduction
Establishing vascular access in a critically ill or injured child in shock
can be difficult, but prompt IV or IO access is essential to administer
needed fluids and medications. Few providers can perform advanced
access techniques such as venous cutdown or central venous access
quickly and safely. A delay in establishing vascular access can be life
threatening. Delays can be avoided by use of IO cannulation.
IO cannulation is a relatively simple and effective method of rapidly
establishing vascular access when timely fluid or drug administration is
needed and other means have failed or are outside the expertise of
the provider. It provides access to a noncollapsible marrow venous
plexus, which serves as a rapid, safe, reliable route for administration
of drugs, crystalloids, colloids, and blood during resuscitation. IO
access can be performed safely in children of all ages, and it can often
be achieved in 30 to 60 seconds. In certain circumstances (eg, severe
shock with severe vasoconstriction or cardiac arrest), it may be the
initial means of vascular access attempted. IO cannulation delivers
fluid and medications to the central circulation within seconds.
Do not delay establishing IO access during the resuscitation of a
critically ill or injured child if no IV access is already in place.
Sites
Many sites are appropriate for IO infusion. The proximal tibia, just
below the growth plate, is often used. The distal tibia just above the
medial malleolus, the distal femur, and the anterior-superior iliac spine
are also used.
Contraindications
Contraindications to IO access include
• fractures and crush injuries near the access site
• conditions in which the bone is fragile, such as osteogenesis
imperfecta
• previous attempts to establish access in the same bone
© 2006 American Heart Association
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Avoid IO cannulation if infection is present in the overlying tissues.
Intraosseous Procedure
Procedure
You may use the following procedure to establish intraosseous
access:
Step
1
2
3
Action
• To establish access in the proximal tibia, position the leg
with slight external rotation.
• Identify the tibial tuberosity just below the knee joint. The
insertion site is the flat part of the tibia, about 1 to 3 cm
(about 1 finger’s width) below and medial to this bony
prominence (Figure 1).
Always use universal precautions when attempting vascular
access. Disinfect the overlying skin and surrounding area
with an appropriate agent.
• The stylet should remain in place during insertion to
prevent the needle from becoming clogged with bone or
tissue.
• Stabilize the leg on a firm surface to facilitate needle
insertion. Do not place your hand behind the leg.
Note: If a standard IO needle or bone marrow needle is not
available, a large-bore standard hypodermic needle can be
substituted, but the lumen may become clogged with bone or
bone marrow during insertion. Short, wide-gauge spinal
needles with internal stylets can be used in an emergency,
but they are not the preferred needles for IO use because
they bend easily. A hemostat can be used to help control the
needle during insertion. Use at least an 18-gauge spinal or
hypodermic needle for this purpose.
• Insert the needle through the skin over the anteromedial
surface of the tibia in a direction perpendicular to the tibia.
This directs the needle to avoid injury to the growth plate.
• Use a twisting motion with gentle but firm pressure.
• Continue inserting the needle through the cortical bone
until there is a sudden release of resistance as the needle
enters the marrow space. If the needle is placed correctly,
it should stand easily without support.
© 2006 American Heart Association
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Figure 1. A, General landmarks for IO insertion in the leg of an infant. B,
Locations for IO insertion in the proximal tibia and distal femur in older
children. C, Location for IO insertion in the iliac crest. D, Location for IO
insertion in the distal tibia. E, Technique for immobilizing the leg while
twisting the IO needle into the leg of an infant.
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5
6
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• Remove the stylet and attach a syringe.
• Aspiration of bone marrow contents and blood in the hub of
the needle confirms appropriate placement. Blood may be
sent to the lab for study. (Note: Blood or bone marrow may
not be aspirated in every case.)
• Infuse a small volume of saline and observe for swelling at
the insertion site or posteriorly in the extremity opposite the
insertion site. (Swelling will be observed if the needle has
penetrated into and through the posterior cortical bone).
Fluid should easily infuse with saline injection from the
syringe.
There are several methods to stabilize the needle. You may
place tape over the flange of the needle to provide some
support and position gauze padding on both sides of the
needle for additional support.
When connecting IV tubing, tape the tubing to the skin to
avoid displacing the needle from tension placed on the
tubing.
Volume resuscitation can be delivered via a stopcock
attached to extension tubing or by infusion of fluid under
pressure. When using a pressurized fluid bag, take care to
avoid air embolism.
© 2006 American Heart Association
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After IO
Insertion
Any medication that can be administered IV can be given by
the IO route, including vasoactive drug infusions such as an
epinephrine drip. Follow all bolus medications with a saline
flush.
After IO needle/catheter insertion keep the following points in mind:
• Check the site frequently for signs of swelling and needle
displacement.
• Delivery of fluids or drugs through a displaced needle may cause
severe complications, such as tissue necrosis or compartment
syndrome.
• IO needles are intended for short-term use, generally less than 24
hours. Replacement with long-term vascular access is usually
accomplished in the intensive care setting.
© 2006 American Heart Association
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Central Venous Access
Introduction
Central venous cannulation provides a more stable and reliable route
of venous access than peripheral venous cannulation. It is a useful
option when you cannot achieve peripheral cannulation or when the
child is stabilized and there is time to establish more secure vascular
access. Central venous access also allows hemodynamic monitoring
and sampling of central venous blood for laboratory access. Use of
this route eliminates problems resulting from administration of irritating
or vasoconstrictive medications. This is because there is lower risk of
extravasation, and medications are diluted by high-volume central
venous blood flow.
Complications
Complications of central venous catheterization occur more frequently
in infants and children than in adults. The most common complications
are infection, thrombosis, and suppurative thrombophlebitis. The
following actions may reduce the risk of complications:
• Limit central venous cannulation to patients with appropriate
indications.
• When possible, practice meticulous aseptic technique during
catheter insertion and maintenance.
• Remove the catheter as soon as possible.3,15,16
When adherence to aseptic technique cannot be ensured (ie, when
catheters are inserted during a medical emergency), replace all
catheters as soon as possible and after no longer than 48 hours.17
As for all procedures, providers should perform central venous
cannulation only when the potential benefits outweigh the risks. A
provider experienced in the technique and knowledgeable of the
unique features of central venous anatomy in infants and children
should perform or directly supervise the procedure.16,18-21
Doppler
Devices
Knowledge of anatomic landmarks is essential for successful and safe
placement of a central venous catheter. Doppler or ultrasound devices
may help you locate central vessels, and they can improve your
success rate for central venous cannulation.22-27
Seldinger
Technique
The Seldinger (guidewire) technique16 is especially useful for
establishing central vascular access. This technique allows
© 2006 American Heart Association
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introduction of catheters (Figure 2) into the central venous circulation
after initial venous entry is achieved, using a small-gauge, thin-walled
needle or an over-the-needle catheter.
Once you achieve free flow of blood through the small needle or
catheter, thread a flexible guidewire through the needle or catheter
into the vessel. Then withdraw the needle or catheter over the
guidewire while holding the guidewire in place (Figure 2). To facilitate
passage of the catheter or introducing sheath, incise the skin and
superficial subcutaneous tissue using a No. 11 blade; insert the blade
directly over the site where the guidewire enters the skin. For most
catheters you will pass a dilator over the guidewire into the vessel and
then remove the dilator before you place the catheter. Finally, pass a
large catheter or a catheter-introducing sheath over the guidewire into
the vessel and withdraw the guidewire.
Figure 2. Seldinger technique for catheter placement. A, insert the needle into the
target vessel and pass the flexible end of the guidewire into the vessel. B, Remove
the needle, leaving the guidewire in place. C, Using a twisting motion, advance the
catheter into the vessel. D, Remove the guidewire, and connect to an appropriate
flow device or monitoring device. Modified from Schwartz AJ, Cote CJ, Jobes DR,
Ellison N. Central venous catheterization in pediatrics. Scientific exhibit.
Femoral Vein
Cannulation
Access to the femoral vein (Figure 3) allows access to the inferior vena
cava. Providers frequently use the femoral vein for emergency
vascular access because it is relatively easy to cannulate. Fewer
© 2006 American Heart Association
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immediate complications occur when this site is used.20,28,29
Cannulation also does not require interruption of compressions or
ventilations. The Seldinger technique is probably the most reliable
method to access the central venous system through the femoral vein
during an emergency. In general the right femoral vein is preferable for
cannulation. It is easier to approach from the right side when the
operator is right-handed, and the catheter is less likely to migrate into
the posterior lumbar venous plexus. Such migration could lead to
erosion into the subarachnoid space.30 See the “Femoral Vein
Catheterization Procedure.”
External
Jugular Vein
Cannulation
Cannulation of the external jugular vein is relatively safe because the
vein is superficial and easy to see. The major disadvantages of this
site are
• potential compromise of the airway by extension and rotation of the
neck to expose the vein
• a low success rate for central placement of the catheter because the
angle of entry of the external jugular vein into the subclavian vein is
acute.31,32
See the “External Jugular Vein Catheterization Procedure.”
Internal
Jugular Vein
Cannulation
Figure 3 shows the internal jugular vein in relation to the carotid artery,
sternocleidomastoid muscle, and clavicle. The right internal jugular
vein is preferable to the left because there is less chance of producing
a pneumothorax (the dome of the right lung and pleura is lower than
that on the left side) and risk of injury to the thoracic duct is eliminated.
The catheter can pass in a direct route from the internal jugular vein
directly through the innominate vein into the superior vena cava.
Three approaches are possible for internal jugular venous cannulation:
the posterior, anterior, and central (middle) routes.3,32 No one
approach is clearly superior to the others.33-37 The high central route
appears to be the most widely used, but the provider should choose
the route based on experience.
See the “Internal Jugular Vein Catheterization Procedure.”
© 2006 American Heart Association
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Figure 3. Central veins of the thorax and neck in relation to surrounding anatomy.
Subclavian
Vein
Cannulation
The subclavian vein in infants and children can be cannulated through
the infraclavicular route.38-40 The complication rate, however, is high
when this route is used during emergencies, particularly in infants.40,41
For this reason the subclavian vein is generally not the route of choice
for small children when urgent access is needed. But a skilled provider
may prefer the subclavian vein. The procedure does not require
immobilization of an extremity, so the catheter will not limit movement
of the patient after insertion. See the “Subclavian Vein Catheterization
Procedure”.
Figure 4. Femoral vein. A, Anatomy. B, Cannulation technique.
© 2006 American Heart Association
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Femoral Venous Catheterization Procedure
Procedure
You may use the following procedure for femoral venous
catheterization (Figure 4B):
Step
1
2
3
4
5
6
Action
Restrain the leg with slight external rotation. Place a small
towel or diaper under the buttocks of the infant to flatten the
inguinal area. Placing the infant in this position will make
the angle of entry less acute and facilitate entry into the
vein.
Identify the femoral artery by palpation or, if pulses are
absent, by finding the midpoint between the anterior
superior iliac spine and the symphysis pubis. Note that
pulsations in the femoral area during chest compressions
may originate from either the femoral vein or femoral
artery.42 If CPR is in progress, attempt needle puncture
midpoint, as the point of pulsation may be arterial or venous
during CPR.
Use a long (1-inch to 1.5-inch) 25-gauge needle to
administer local anesthetic. You may also use this needle to
help locate the femoral vein. Using sterile technique, access
the femoral vein using a thin-walled needle. Insert the
needle one finger’s breadth below the inguinal ligament and
just medial to the femoral artery. Apply gentle negative
pressure to an attached 3-mL syringe and slowly advance
the needle. Direct the needle parallel to the arterial pulse
(generally toward the umbilicus) at a 45° angle.
When you observe a free flow of blood into the syringe,
separate the syringe from the needle and advance a guidewire through the needle. Remove the needle and advance
the appropriate central venous catheter over the guide-wire
using the Seldinger technique (described earlier).
Once you document free blood return and free flow of
infusate, secure the catheter or catheter-introducing sheath
in place with suture material. Apply a sterile, occlusive
dressing.
Obtain an x-ray to verify that the tip of the catheter is
correctly positioned.
Note: Steps 4 through 6 are common to most central venous
catheterization sequences.
© 2006 American Heart Association
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External Jugular Vein Catheterization Procedure
Procedure
The external jugular vein provides another portal to the central
venous circulation. Although this vein is an excellent site for
venous access, it can be difficult to thread a guidewire or
catheter into the central circulation because the angle of entry
into the subclavian vein is acute. You may use the following
procedure for external vein catheterization:
1
2
3
4
5
Restrain the child in a 30° head-down (Trendelenburg)
position with the head turned away from the side to be
punctured (Figure 5). Auscultate and document
bilateral breath sounds before you start the procedure.
The right side is preferable.
Using sterile technique puncture the skin slightly distal
to or beside the visible external jugular vein with a 16gauge or 18-gauge needle. This puncture will facilitate
entry of the catheter through the skin.
Use the tip of the middle (3rd) finger of your
nondominant hand to temporarily occlude the vein just
above the clavicle, mimicking the effect of a tourniquet.
Stretch the skin over the vein just below the angle of
the mandible. Allow the vein to distend fully and then
use the thumb of the nondominant hand to immobilize
the vein.
For peripheral cannulation, insert a short over-theneedle catheter into the vein and proceed as described
for peripheral venous cannulation. For central venous
access, insert a guidewire through the over-the-needle
catheter, remove the short catheter, and insert a longer
catheter-over-guidewire device as described for
cannulation of the internal jugular vein.
Note: Follow steps 4 through 6 in “Femoral Venous
Catheterization” to complete catheterization of the external
jugular vein. Auscultate and document breath sounds. If you
attempted central venous catheterization, verify on a chest x-ray
that the tip of the catheter is correctly positioned at or above the
junction of the superior vena cava and right atrium. Rule out
pneumothorax and hemothorax.
© 2006 American Heart Association
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Figure 5. Positioning of patient for cannulation of internal or external jugular vein.
Internal Jugular Vein Catheterization Procedure
Procedure
The following technique is commonly used with the anterior, central,
and posterior routes of internal jugular vein cannulation. The right side
of the neck is preferable for several reasons:
• The dome of the right lung and pleura is lower than that on the left,
so the risk of pneumothorax is reduced.
• The path from the right internal jugular vein to the right atrium is
more direct.
• Risk of injury to the thoracic duct is eliminated.
You may use the following procedure for internal jugular vein
catheterization:
Step
1
2
3
Action
If no cervical spine injury is present, hyperextend the
patient’s neck by placing a rolled towel transversely
beneath the shoulders.
Restrain the child in a 30° head-down (Trendelenburg)
position with the head turned slightly away from the side
to be punctured (Figure 5).43
Auscultate and document bilateral breath sounds before
you start the procedure.
Identify the sternocleidomastoid muscle and clavicle.
© 2006 American Heart Association
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4
Use a long (1-inch to 1.5-inch) 25-gauge needle to
administer local anesthetic. You may also use this needle
to help locate the internal jugular vein. Use the Seldinger
technique to access the internal jugular vein. If the patient
is breathing spontaneously with no positive-pressure
support, prevent inadvertent movement of air into the
superior vena cava. To prevent this air movement, use
your finger to occlude any open needles or catheters
during patient inspiration and try to thread the guidewire
during exhalation. If the guidewire advances into the right
atrium, premature atrial contractions may occur. Advance
the catheter to the junction of the superior vena cava and
right atrium (determine the distance beforehand from
surface landmarks).
Note: Follow steps 4 through 6 in “Femoral Venous Catheterization” to
complete catheterization of the external jugular vein. Auscultate and
document breath sounds. Verify on a chest x-ray that the tip of the
catheter is correctly positioned at or above the junction of the superior
vena cava and right atrium. Rule out pneumothorax and hemothorax.
Common
Approaches
There are 3 common approaches for cannulation of the internal jugular
vein (Figure 6). The provider should become familiar with 1 technique
rather than randomly attempt all 3.
• Anterior route. Use your index and middle (2nd and 3rd) fingers to
palpate the carotid artery medially at the anterior border of the
sternocleidomastoid muscle. Introduce the needle at the midpoint of
this anterior border at a 30° angle to the coronal plane. Direct the
needle caudad and toward the ipsilateral nipple (Figure 6A).
• Central route. Identify a triangle formed by the 2 portions
(sternoclavicular heads) of the sternocleidomastoid muscle with the
clavicle at its base. Introduce the needle at the apex of this triangle
at a 30° to 45° angle to the coronal plane. Direct the needle caudad
and toward the ipsilateral nipple. If you do not enter the vein,
withdraw the needle to just below the skin surface and redirect the
needle directly caudad along the sagittal plane (ie, less lateral). Do
not direct the needle medially across the sagittal plane because you
will likely puncture the carotid artery (Figure 6B).
• Posterior route. Introduce the needle deep into the sternal head of
the sternocleidomastoid muscle at the junction of the middle and
lower thirds of the posterior margin (eg, just above the point where
the external jugular vein crosses this muscle). Direct the needle
toward the suprasternal notch (Figure 6C).
© 2006 American Heart Association
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Figure 6. Technique for catheterization of internal jugular vein. A, Anterior route. B,
Central route. C, Posterior route.
© 2006 American Heart Association
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Subclavian Vein Catheterization Procedure
Procedure
You may use the following procedure for subclavian vein
catheterization:
Step
1
2
3
4
5
6
7
Action
If no cervical spine injury is present, hyperextend the
patient’s neck and open the costoclavicular angles by
placing a rolled towel directly beneath and parallel with the
thoracic spine.
Restrain the child in a 30° head-down (Trendelenburg)
position with the head turned away from the side to be
punctured. Slightly flexing the neck and turning the head
toward the puncture site when using the right side approach
in infants may improve the likelihood of correct catheter
position.44 The right side is preferable.
Auscultate and document bilateral breath sounds before you
start the procedure.
Identify the junction of the middle and medial thirds of the
clavicle.
Use a long (1-inch to 1.5-inch) 25-gauge needle to
administer local anesthetic. You may also use this needle to
help locate the subclavian vein (see step 6).
Flush the needle, catheter, and syringe with sterile saline.
Using sterile technique, introduce a thin-walled needle just
under the clavicle at the junction of the middle and medial
thirds of the clavicle. Slowly advance the needle while
applying gentle negative pressure with an attached syringe;
direct the needle toward a fingertip placed in the
suprasternal notch. The syringe and needle should be
parallel with the frontal plane, directed medially and slightly
cephalad, beneath the clavicle toward the posterior aspect of
the sternal end of the clavicle (ie, the lower end of the
fingertip in the sternal notch) (Figure 7).
Once you obtain a free flow of blood, indicated by backflash
into the syringe, rotate the bevel to a caudad position. This
position will facilitate placement of the catheter or guidewire
into the superior vena cava. Carefully disconnect the syringe
while stabilizing the position of the needle. Place a finger
over the hub of the needle to prevent entrainment and
embolism of air.
During a positive-pressure breath or spontaneous
exhalation, insert a guidewire through the needle. Advance
the guidewire into the right atrium. Entrance of the guidewire
© 2006 American Heart Association
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into the right atrium often produces premature atrial
contractions. If atrial or ventricular arrhythmias occur,
withdraw the guidewire a few centimeters. Complete
cannulation of the vein using the Seldinger technique.
Demonstrate free blood return from all ports of the catheter
and, subsequently, free flow of infusate. If blood does not
immediately flow back freely, the catheter may be lodged
against a vessel wall or the wall of the right atrium. Slightly
withdraw the catheter and repeat aspiration. (You may
perform this withdrawal/aspiration sequence twice.) If you
still do not observe blood return, you must assume that the
catheter is not in the vessel and remove the catheter.
Note: Follow steps 5 and 6 in “Femoral Venous Catheterization”
to complete catheterization of the subclavian vein. Auscultate
and document breath sounds. Verify on a chest x-ray that the
tip of the catheter is correctly positioned at or above the junction
of the superior vena cava and right atrium. Rule out
pneumothorax and hemothorax.
Figure 7. Cannulation of the subclavian vein.
© 2006 American Heart Association
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