Download Use of Intravenous Access in Resuscitation

USE OF INTRAVENOUS
ACCESS IN
RESUSCITATION
SITES, TECHNIQUES, POTENTIAL
COMPLICATIONS
OBJECTIVES
† Overview
† Peripheral Venous Access
„ Sites
„ Techniques
„ Potential Complications
† Central Lines
„ Sites
„ Seldinger Technique
„ Potential Complications
† Venous Cutdown
„ Sites
„ Techniques
„ Potential Complications
OVERVIEW
† Minimum of two large caliber IVs (1416 Gauge)
† U/E peripheral IV preferred
† When establishing IV, blood should
be drawn
† Avoid veins that drain from neck
trauma, into an affected traumatic
extremity, or the side of a chest or
abdominal trauma
U/E Peripheral IV - Anatomy
† Success of cannulation depends on
knowledge of anatomy
† Antero-Radial side forearm – Cephalic
vein
† Ulnar posterior forearm – Basilic vein
–easily accessed if elbow flexed and
cannulator stands at head of patient
U/E Peripheral IV - Anatomy
† Antecubital veins – Medial Cubital,
Basilic, Cephalic
† Easily cannulated – but restricted
elbow motion
† Above elbow – larger Basilic and
Cephalic veins – more difficult to see
U/E Peripheral IV - Anatomy
L/E Peripheral IV - Anatomy
† Dorsal venous arch splits into the
greater saphenous vein medially and
the lesser saphenous vein laterally
† Greater saphenous vein most easily
accessible at the ankle, but may also
be cannulated below the knee and
below femoral triangle
L/E Peripheral IV - Anatomy
† Greater saphenous vein passes 1 cm
anterior to medial malleolus where it
lies next to the periosteum
L/E Peripheral IV - Anatomy
External Jugular Vein
† Formed below the ear and behind the
angle of the mandible, passes
obliquely across the
sternocleidomastoid, under the
middle of the clavicle to join the
subclavian vein
† Presence of valves
† Flow dependent on neck position
External Jugular Vein
Materials Required for Peripheral IV
Line Insertion
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Alcohol pads
Tourniquet
Gauze
Tegaderm
Intravenous catheter
1-in tape
¼-in tape
Gloves
Inspection and Positioning
† Place a 1 inch tourniquet on the
upper arm
† Palpate with index and middle fingers
of nondominant hand
Tourniquet
Cannulation
† Clean site with Alcohol
† Stabilize the vein – position thumb
alongside vein and pull down. Place
index finger more cephalad and push
upward
† Agiocath between thumb and
forefinger of dominant hand, bevel
up, angled 10-30 degrees, parallel to
vein
Cannulation
† When flash is seen, advance catheter a few
millimeters more to ensure it has entered
vein, not just wall
† Loosen stylet - advance catheter only
† Occlude vein at tip of catheter, remove
needle, attach IV line, release tourniquet
† Blood samples may be drawn at this time
Cannulation
Securing the IV
External Jugular Cannulation
† Place patient in Trendelenberg to fill
External Jugular
† Rotate head to opposite side
† Align cannula in the direction of the vein
with point aimed toward ipsilateral shoulder
† Puncture midway between angle of jaw and
midclavicular line, lightly compressing the
vein above the clavicle
Complications - Peripheral IV
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Phlebitis
Extravasation
Nerve Damage
Air Embolism
Bruising
Thrombosis
Phlebitis
† Presence of palpable cord
accompanied by warmth, erythema,
tenderness, and induration
Extravasation
† Infiltration relatively minor and
common complication of IV therapy
† If infusions hypertonic, vasopressors
or chemotherapies – risk of skin
sloughing
† If dopamine or norepinephrine
extravasates, phentolamine may be
used as antidote – skin injected with
small aliquots of 50:50 dilution
Extravasation of Phenytoin
Air Embolism
† Significant, but rare
† Symptoms of Chest pain, SOB,
Sudden vascular collapse, Cyanosis,
Hypotension
† If suspected, place pt in LLD with
head and chest tilted downward
Central Lines
† Subclavian
† Internal Jugular
† Femoral
Subclavian Vein - Anatomy
† Continuation of axillary vein at outer
edge of first rib
† Joins IJ to become innominate vein 34 cm proximally
† Valveless
† After crossing first rib, lies posterior
to the medial third of the clavicle
† Anterior scalene muscle is posterior
to vein, anterior to subclavian artery
Subclavian Vein - Anatomy
† Phrenic nerve runs over anterior
surface of scalene and immediately
behind the junction of subclavian and
IJ veins
† Thoracic duct (L) and lymphatic duct
®, pass over anterior scalene muscle
and enter subclavian near junction
with IJ
Internal Jugular - Anatomy
† Emerges in neck deep to posterior
belly of digastric muscle
† At origin, courses adjacent to spinal
accessory, vagus, and hypoglossal
nerves as well as internal carotid
artery
† Tributary veins enter IJ at level of
hyoid bone
Internal Jugular - Anatomy
† IJ, ICA, and Vagus nerve course
together in carotid sheath…..IJ is
antero-lateral
† Lateral & slightly anterior to carotid
† Level of thyroid cartilage, IJ just deep
to SCM
† Emerges from under apex of triangle
of two heads of SCM
† Joins subclavian behind clavicle
Internal Jugular - Anatomy
† Lower cervical region, carotid deep
paratracheal location
† Brachial plexus separated from IJ by
scalenus anterior
† Phrenic nerve anterior to scalenus
anterior muscle
† Stellate ganglion anterior to lower
brachial plexus
Femoral Vein - Anatomy
† Just medial to the femoral artery
below inguinal ligament
† Beneath lies psoas muscle and hip
† As progress more distal, femoral vein
becomes posterior to femoral artery
† NAVEL
Seldinger Technique
† Thin walled needle used to access
vessel lumen
† Once introducing needle positioned in
vessel lumen, guidewire is threaded
through the needle and needle
removed
† Wire serves as guide over which
selected catheter placed.
Seldinger Technique
† Introducing needle large enough to
accommodate guidewire is attached
to a small syringe.
† Needle and syringe introduced
together
† When free return of blood, remove
syringe, stabilize needle hub
† Cap needle hub with thumb to
decrease risk air embolism
A. Cannulate vessel
Seldinger Technique
† Flexible end of guidewire threaded
through the needle
† Wire should thread smoothly through
vein without resistance
† If resistance met, remove wire from
needle and reattach syringe to
confirm intravascular placement
† If resistance to wire removal, wire &
needle should be removed together
Seldinger Technique
† If threading easily, advance guidewire
until at least one quarter in vessel
† Once wire in vessel, remove needle
† Make small skin incision at site of
wire. Incision should be width of
catheter to be inserted and extend
completely through the dermis
B. Thread wire through vessel
C. Remove needle
D. Enlarge skin entry with #11
scalpel
Seldinger Technique
† Stabilize guidewire at point of skin
entry and thread dilator/sheath over
wire until 1 cm from skin
† Before dilator/sheath enters skin,
wire must protrude out back of dilator
† Wire must be grasped as
dilator/sheath advanced
† If wire not protruding from prox end
of dilator, pull at skin entry point
E. Catheter sheath and dilator
threaded over wire
F. If prox wire not visible, pull from
skin through catheter until out back
H. Once sheath and dilator well
into vessel, remove dilator and wire
Catheter Insertion Length based on
Height
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R Subclavian = (Hgt/10)-2cm
L Subclavian = (Hgt/10)+2cm
RIJ = Hgt/10
LIJ = (Hgt/10) + 4cm
Subclavian, Infraclavicular
Approach
† Place patient supine with head neutral
+/- arm abduction, small towel or
pillow between shoulder blades to
retract shoulder
† Trendelenburg (10-15o ) decreases
risk air embolism
† Lower pleural dome Right + no
thoracic duct Right = preferred side
Subclavian, Infraclavicular
Approach
† Cleanse the skin well
† Apply sterile gloves and drape area
† If patient is awake, use a local
anesthetic at the venipuncture site
† Introduce a large calibre needle
attached to a 12 mL syringe
(containing 1mL saline) - 1 cm below
junction of middle and medial thirds
of clavicle
Subclavian, Infraclavicular
Approach
† Here, vein lies just posterior to
clavicle and just above first rib
† Needle bevel should be oriented
infero-medially
† Before needle insertion, left index
finger is placed in the suprasternal
notch and thumb is positioned at the
costoclavicular junction
Subclavian, Infraclavicular
Approach
† Hold needle and syringe in the frontal
plane
† Direct needle medially, slightly
cephalad, and posteriorly behind the
clavicle toward the posterior, superior
angle to the sternal end of the
clavicle (toward finger placed in
suprasternal notch)
Subclavian, Infraclavicular
Approach
† Slowly advance the needle while
gently withdrawing the plunger of the
syringe
† When free flow of blood appears,
remove the syringe and occlude the
needle with a finger to prevent and
air embolism
† Insert guidewire while monitoring
ECG for abnormalities
Subclavian, Infraclavicular
Approach
† Remove needle while holding
guidewire in place
† Insert catheter over guidewire to
predetermined depth
† Connect catheter to IV tubing
† Affix catheter to skin (suture)
† Dress area, tape IV tubing
† CXR - line position, R/O Pneumo
Subclavian, Supraclavicular
Approach
† Goal to puncture subclavian vein in
superior aspect as it joins IJ
† Needle inserted above and behind
clavicle, lateral to SCM
† Right side preferred – lower pleural
dome, no thoracic duct, direct route
to SVC
† Trendelenburg position, prep and
drape area
Subclavian, Supraclavicular
Approach
† Entry point 1 cm lat to clavicular head
of SCM and 1 cm posterior to clavicle
† Aim needle to bisect
clavicosternomastoid angle - tip
pointing caudal to contralateral nipple
† Orient bevel medially
† Tip of needle pointed 10o above
horizontal & 45o to saggital
† Vessel puncture at depth of 2-3 cm
Internal Jugular Approach
† Three different IJ approaches:
Central, Posterior, Anterior
† Position in 15-30o Trendelenburg,
head turned slightly away (If c-sp
cleared)
† Cleanse skin well and drape area
† Apply sterile gloves
† If patient awake, use local
anaesthetic at venipuncture site
Internal Jugular – A. Central
Approach
† Identify triangle formed by clavicle
and sternal and clavicular heads of
SCM
† Use marking pen to indicate lateral
border of carotid pulse
† Introduce a large calibre needle
attached to a 12 mL syringe with 0.51 mL of saline, into center of triangle
Internal Jugular – A. Central
Approach
† Direct needle caudally at an angle 30o
posterior to frontal plane, parallel to
course of carotid artery
† Slowly advance needle while gently
withdrawing on syringe plunger
† When free flow of blood appears in
syringe, remove syringe and occlude
needle with a finger
Internal Jugular – A. Central
Approach
† Insert guidewire while monitoring
ECG for rhythm abnormalities
† Remove needle, advance catheter,
remove guidewire, connect to IV
† Suture catheter in place, apply
dressing
† CXR – line position, R/O pneumo
Internal Jugular – B. Posterior
Approach
† Skin entered at lateral edge of SCM
1/3 from clavicle to mastoid process
† Direct needle caudally and medially
toward sternal notch
Internal Jugular – C. Anterior
Approach
† Identify course of carotid artery and
mark with middle and index fingers
† Needle should enter skin at midpoint
of medial aspect of SCM
† Direct needle at angle 30-45o to
coronal plane, caudally toward
ipsilateral nipple
Femoral Approach
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Position pt supine
Cleanse skin and drape area
Apply sterile gloves
Palpate femoral artery…vein is medial
Keeping a finger on the artery,
introduce a large calibre needle
attached to a 12 mL syringe with 0.51 mL of saline
Femoral Approach
† Needle directed toward patient’s
head, should enter skin directly over
femoral vein at 45o angle
† Needle should be held parallel to the
frontal plane
† Direct needle cephalad and
posteriorly, slowly advancing the
needle while withdrawing on syringe
Femoral Approach
† When free flow blood appears in syringe,
remove syringe & occlude needle with
finger
† Insert guidewire and remove needle
† Advance catheter, remove guidewire,
connect to IV
† Suture catheter in place, apply dressing
† CXR & Abd Xray- identify
position/placement
Complication of Central Venous
Access - General
† Vascular
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Air embolus
Adjacent artery puncture
Pericardial tamponade
Catheter embolus
Mural thrombus formation
Large vein obstruction
Local hematoma
Arteriovenous fistula
Complication of Central Venous
Access - General
† Infectious
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Generalized sepsis
Local cellulitis
Osteomyelitis
Septic arthritis
Complication of Central Venous
Access - General
† Miscellaneous
„ Dysrhythmias
„ Catheter knotting
„ Catheter malposition
Complications of Subclavian and
Internal Jugular Approaches
† Pulmonary
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Pneumothorax
Hemothorax
Hydrothorax
Chylothorax
Hemomediastinum
Hydromediastinum
Neck hematoma and tracheal obstruction
Tracheal perforation
Endotracheal cuff perforation
Complications of Subclavian and
Internal Jugular Approaches
† Neurologic
„ Phrenic nerve injury
„ Brachial plexus injury
„ Cerebral infarct
Complications of Femoral Approach
† General (ATLS)
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DVT
Arterial or neurologic injury
Infection
AV fistula
† Intra-abdominal
„ Bowel perforation
„ Bladder perforation
„ Psoas abscess
Venous Cutdown
† Acceptable alternative when unable to
perform percutaneous IV insertion
† No longer mandatory in ATLS due to
speed of central venous access
techniques
Greater Saphenous Vein
† Longest vein, superficial through most of
course
† Most easily accessible at ankle…crosses one
cm anterior to medial malleolus and
continues up anteromedial aspect of leg
† Can expose vessel at ankle : 2 cm ant &
superior to medial malleolus
† Can expose vessel 1-4 cm below knee and
just post to tibia (rare)
† Can expose vessel 3-4 cm distal to inguinal
ligament
Basilic Vein
† Preferred site for venous cutdown in
Upper Extremity
† Generally exposed 2.5 cm lateral to
the medial epicondyle
Venous Cutdown - Equipment
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Curved Kelly hemostat
Scalpel with #11 blade
Small mosquito hemostat
Tissue spreader
Iris scissors
Plastic venous dilator
4-0 silk suture ties
4-0 nylon suture
Gauze
Tape
Arm board
IV catheter
Venous Cutdown - Technique
† Prepare skin
† Drape area
† Infiltrate skin over vein with 0.5%
lidocaine
Venous Cutdown - Technique
† Make full thickness
transverse skin
incision to length of
2.5 cm
† Use blunt
dissection with
curved hemostat
Venous Cutdown - Technique
† Identify vein and
dissect it free
† Elevate and dissect
the vein for a
distance of ~ 2cm,
free it from its bed
Venous Cutdown - Technique
† Hemostat can be
used to pass
proximal and distal
ties for stabilization
of vein
† Distal ligature may
be tied
Venous Cutdown - Technique
† Use a hemostat to
elevate vessel and
stretch it flat
† Incise vessel at 45o
angle through 1/3
to ½ diameter
using #11 blade
Venous Cutdown - Technique
† Use of intracath
needle to make a
separate stab
incision
† Cannula introduced
into the wound by
retrograde passage
through the
introducing needle
Venous Cutdown - Technique
† Cannula threaded
through stab
incision
† Intracath needle
withdrawn
following
introduction of
cannula into wound
Venous Cutdown - Technique
† Identification of
vessel lumen may
be facilitated
through use of a
plastic venous
dilator or elevator
† Small pointed tip
threaded into
vessel to expose
the lumen
Venous Cutdown - Technique
† In larger veins, a
mosquito hemostat
can facilitate the
placement of the
cannula by opening
the lumen and
providing
countertraction
Venous Cutdown - Technique
† Incision closed and
catheter sutured in
place
Venous Mini-Cutdown - Technique
† Locate vessel with
skin incision and
blunt dissection
† Puncture vein
under direct vision
with percutaneous
venous catheter
† Needle introduced
through a separate
stab incision
Venous Mini-Cutdown - Technique
† Over the needle or through the
needle catheters may be used
† Eliminates need for tying or cutting
the vein
Venous Cutdown - Complications
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Cellulitis
Hematoma
Phlebitis
Perforation of posterior wall of vein
Venous thrombosis
Nerve transection
Arterial transection