Venous Access Matthew L. Paden, MD Emory University Children’s Healthcare of Atlanta at Egleston

Peripheral IV Butterfly & angiocaths Short catheters generally placed in forearm, hand or scalp veins Short term therapy and unable to handle caustic chemicals (chemotherapy) Butterfly’s and Angiocaths Butterfly are straight needles inserted directly into the vein and remain. Angiocaths contain a flexible catheter over the needle. The needle serves as a introducer to the vein, when removed the flexible catheters remains.

Peripheral Sites Veins of the Forearm 1. Cephalic vein 2. Median Cubital vein 3. Accessory Cephalic vein 4. Basilic vein 5. Cephalic vein 6. Median antebrachial vein

Peripheral Sites Veins of the Hand 1. Digital Dorsal veins 2. Dorsal Metacarpal veins 3. Dorsal venous network 4. Cephalic vein 5. Basilic vein

Peripheral IVs Try to cannulate the most distal veins first Drugs or fluids put through the cannula may extravasate at the upstream failed cannula site Transillumination Topical nitropaste

Infiltration

Extravasation

Extravasation

Phlebitis

Cellulitis

Types of Central Vascular Access Devices Non-tunneling Tunneling Implanted Non-tunneling Percutaneous catheters Peripheral VADs Peripherally inserted central VADs Tunneling Hickman Broviac Groshong Implanted Ports

Non-Tunneling Direct venipuncture through the skin into a selected vein. Peripheral IV Peripherally inserted central catheter Percutaneous catheters

Non-Tunneling - PICC Peripherally inserted central catheters (PICC) Midline Central venous catheter inserted at or above the antecubital space and then advanced until the distal tip of the catheter is positioned at the superior vena cava or superior vena cava and right atrial junction. Central venous catheter inserted at or above the antecubital space (basilic vein) and then advanced until the distal tip of the catheter is positioned at the superior vena cava and right atrial junction.

Non-tunneling - PICC Useful for patient receiving long term medication therapy, chemotherapy or TPN Used for frequent blood sampling Distal end positioned at the superior vena cava or junction of superior vena cava and right atrium http://elizabeth.typepad.com/blog/images/doublelumenpicc_1.jpg

Non-Tunneling - PICC Peripherally inserted central catheters (PICC) Central venous catheter inserted at or above the antecubital space (basilic vein) and then advanced until the distal tip of the catheter is positioned at the superior vena cava and right atrial junction. http://connection.lww.com/Products/taylor5e/documents/Ch46/jpg/46_009.jpg

Non-Tunneling - Midlines Used for shorter term intravenous therapy (up to 4 weeks) Used for frequent blood sampling Distal end positioned at the proximal end of the upper extremity

PICC versus Midline http://www.vygon.it/linea58/images/Midline%20255.jpg http://www.vygon.it/page.php?sid=03cc0ac9c96b9397cf8c9e8c0a52de76&pageid=PROPG36N

Non-Tunneling – PICC and Midline examples at the antecubital & above

Non-Tunneling – CVC Percutaneous catheters Also known as: Central Venous Catheters (CVC) Subclavian, femoral or internal jugular Single, double or triple lumen The percutaneous approach is commonly used in vascular procedures. This involves a needle catheter getting access to a blood vessel, followed by the introduction of a wire through the lumen of the needle. It is over this wire that other catheters can be placed into the blood vessel. This technique is known as the modified Seldinger technique. http://en.wikipedia.org/wiki/Percutaneous

Non-tunneling - CVC Tip advanced to superior vena cava or SVC and right atrium junction As with PICC, appropriate for patients requiring long term chemotherapy or TPN http://www.lhsc.on.ca/critcare/icu/elearning/crrt/temporaryaccess.jpg

Non-tunneling CVC subclavian site Proximal ends of the catheters terminate externally at the skin. They are secured in place with sutures. http://www.icu-usa.com/tour/images/equipment/iv_line_1.gif

Tunneling Hickman® Broviac® Groshong® Tunneled catheters are usually called by their brand names:  Broviac, Groshong, and Hickman.  The Hickman catheter, like the Broviac catheter, has an open-ended line inside the vein.  In contrast, the Groshong catheter has small, valve-like openings in the line's tip. http://www.cancerhelp.org.uk/cancer_images/Hickman.gif

Tunneling Inserted into a central vein via percutaneous venipuncture or cut down Catheter then tunneled under the skin in the subcutaneous tissue and exited in a convenient location Dacron cuff hold the catheter in place

Tunneled Hickman Catheter The Hickman catheter, which is made of silastic (a silicone elastomere), comes in double-lumen and triple-lumen varieties. These catheters can stay in place for weeks to months; some patients have had the same Hickman catheter for years! http://faculty.mercer.edu/summervill_j/jeanchiang/Mvc-088s.jpg

Tunneling - Broviac® Similar to the Hickman catheter, but is of smaller size. This catheter is mostly used for pediatric patients. 

Tunneling - Groshong® Similar to Hickman® and Broviac® with closed ended patented 3-way valve. Negative pressure opens valve inward, permitting blood aspiration. Positive pressure opens valve outward, allowing infusion. At neutral pressure, valve remains closed, reducing risk of air embolism, blood reflux and clotting. http://focosi.immunesig.org/CVC_tunnelled_Groshong_multilumen.jpg Bard Access Systems

Implanted VADs - Ports Some brand names: Catheter attached to a self-sealing silicone septum surrounded by a titanium, stainless steal or plastic port Port sutured under the skin Some brand names: Port-a-cath® Infus-a-port® Power Port ® You may introduce samples of implanted VADs – Ports. http://www.longtransplantatie.nl/arian/_images/port-a-cath.jpg http://www.steripolar.fi/img/tuotteet/imp_lportit.jpg

Implanted VADs - Ports Catheter runs from port to superior vena cava at the right atrium No part of the device is exposed outside the body Can deliver chemotherapy, TPN, antibiotics, blood products and blood sampling

Implanted VADs - Ports Can only be accessed with special needle called a HUBER needle Contains a deflecting, non-coring point Non-Coring needles are sharp needles with the heel of the needle has been 'sandblasted' to minimize coring. Non-Coring-Septum-Penetration Needles feature a deflected point (the tip is raised above the centerline to minimize contact with tissue or media). Huber is a trademark of the Becton Dickinson (BD) company and Huber needles are identical to Popper's non-coring-septum-penetration needles. http://www.popperandsons.com/faq/needles.asp#faq15

Insertion Complications Inadvertent Arterial Puncture Hematoma Formation Extravasation Infection Phlebitis Pneumothorax Instructor notes: You can advise the students that these are complications seen during or shortly after the insertion of the devices. Theses are a “for your information”. Inadvertent arterial puncture: if puncture occurred and left unnoticed, blood would leak into the compartment and potentially impede circulation to the extremity, distal to the puncture. Hematoma Formation: Large hematoma formation under the skin may lead to impaired circulation to the extremity and pressure on tendons and ligaments. If not contraindicated, the head of the bed can be elevated. Extravasation: Leakage of fluid into the subcutaneous tissues around the vein. Depending of the type of fluid, severe pain and tissue necrosis can occur. Symptoms can occur in the chest, clavicle area, port pocket or along the subcutaneous tunnel during or after infusion. Most often occurs with peripheral catheters. If suspected stop infusion immediately, contact medical control and document. Infection: Gram-positive aerobes from the skin are the cause in 50% of all catheter infections. Also an increase is seen in multi-lumen catheters. Less infection with implantable ports than with tunneled catheters. Sign/Symptoms: Erythema, tenderness, swelling, tracking up the extremity, fever, chills, purulence/inflamed exit site. Removal and IV antibiotics will be needed. Phlebitis: Inflammation of the vein. Intimal damage occurs as the result of internal or external trauma. It may be from the actual puncture of the vein or from an infusion of a caustic chemical (potassium chloride or antibiotic) Powder in examination gloves have been noted as a possible cause. Signs/Symptoms: redness, swelling and pain at the insertion site. Difficulty infusing fluids. Long red streak along the vein path may also be present. Most common with PICC lines. Pneumothorax: generally associated with central venous devices inserted via the subclavian.

Adult Insertion Complications

Systemic Complications Infection Deep Vein Thrombosis Pulmonary Embolism Superior Vena Cava Syndrome Instructor notes: These complications may be seen by EMS providers. Although we will NOT be removing central lines, an understanding of the complication is necessary. Paramedics should contact medical control if they ever were suspect. Infection: Staphylococci and fungal infections are the most common. Signs/Symptoms: Chills, fever, positive culture. Deep Vein Thombosis: damage to the endothelial lining of the vein, resulting in fibrin deposits at the point of cellular damage. It can be only along the wall of the vein (Mural Thrombosis) or completely occluded (Venous Thrombosis). It can occur with any CVC, but very rarely in the subclavian vein. Signs/symptoms: distended neck or arm vein on the affected side, collateral circulation on the chest, non-pitting edema on the arm. Pulmonary Embolism: Foreign body or air pocket that entered the pulmonary circulation. Sign/symptoms: sudden sub-sternal chest pain, difficulty breathing, tachycardia, hypotension, cyanosis. Unless contraindicated place patient on left side with legs elevated. Superior Vena Cava Syndrome: Compression of the superior vena cava. This can occur slowly or acutely. Relatively rare but can be fatal. Often caused by tumor mass or enlarged node placing pressure on the vena cava. Patient dx usually bronchogenic cancer (lung cancer) but can also be lymphoma, breast cancer and GI tract metastases. Signs/Symptoms: Difficulty breathing, cough, JVD, progressive upper extremity, neck & facial edema, Dilation of superficial veins of the upper chest, head ache, visual disturbances. Place patient in Fowler’s position contact medical control.

Mechanical Complication Catheter tip migration Broken or damaged catheter Catheter occlusion Catheter tip migration: Sometimes during insertion the tip of the catheter can migrate into a jugular vein, accessory veins or right atrium. The tips are verified through chest x-ray or fluoroscopy. Occasionally the tip may migrate due to the volumetric blood flow through the chambers of the hear and venous return to the heart. Signs & Symptoms: frequent vomiting and/or cough. Jugular vein migration: jaw pain, teeth or ear pain, JVD on insertion side, gurgling sound during infusion. Right Atrium migration: Chest pain, difficulty breathing, Palpitations, arrhythmia. Contact medical control is suspected. Broken or damaged catheter: The catheter can be damaged or broken by the following means: excessive pressure during flushing, long needles into injection caps, improper clamping of the catheter, use of scissors or sharp objects on the catheter (dressing changes), improper use of a guide wire during insertion, unseen kinking or extended periods of time. Catheter rupture/breakage outside the skin can be detrimental due to possible air embolisms. Internally may go undetected permitting fluid infiltration and swelling with caustic substances causing necrosis. Catheter occlusion: There are many different reason why occlusions can occur. Mechanical: kinked tubing, closed clamps, clogged injection cap or filter, IV pump malfunction, Malposition of catheter, empty IV bag, tip lodged against vein wall. Thrombotic occlusion: drug precipitation, TPN precipitation or other IV solution, mural thrombosis, total venous thrombosis, portal reservoir obstruction, “Reverse Ball-valve” effect (fluids cannot be infused, but blood can be aspirated) Fibrin Sleeve/Fibrin tail occlusion related to platelet aggregation and fibrin deposits

Femoral Vein Adults – DVT Excess infection risk “Potentially inaccurate CVP”

Femoral Vein Kids – Better risk profile Ease of insertion, compressible No difference in DVT – ref 1-2 Same infection risk (maybe lower) – ref 3-5 Accurately reflects RAP if no increase in abdominal pressures – ref 6-8 1. Beck C, et al. J Ped 1998;133:237-41. 2. Jacobs B, et al. Crit Care Med 1999;27:A29 3. Casado-Flores J, et al. Ped Crit Care Med 2001;2:57-62. 4. Richards M, et al. NNIS Pediatrics 1999;103:103-9 5. Stenzel JP, et al. J Ped 1989;114:411-5. 6. Fernendez E, et al. Ped Crit Care Med 2004;5:14-18 7. Lloyd R, et al. Pediatrics 1992;89:506-8. 8. Ho K, et al. Crit Care Med 1998;26:461-4.

Femoral anatomy Vein is medial to the artery Froehlich’s theorem Superficial distal to inguinal ligament, then dives deep 0.5-2cm inferior to the inguinal ligament

Quiz Question What are the anatomic landmarks to determine where to stick for the femoral vein in a pulseless patient? A. 1/3 of the distance from the anterior superior iliac spine to the pubic tubercle B. ½ the distance between the pubic tubercle and the anterior superior iliac spine C. 1/3 of the distance from the pubic tubercle and the anterior superior iliac spine D. None of the above

Quiz answer D. None of the above The femoral ARTERY lies ½ the distance between the pubic tubercle and the anterior superior iliac spine. The femoral vein is 0.5-1.5 cm medial to this depending on the size of the patient.

Straight vs. Frog leg “The optimal positioning of the leg can vary according to the preference of the operator.” Discuss

Procedure 30-45 degree angle to skin 2 methods Stick with negative pressure on syringe while entering and exiting Insert needle, and only negative pressure on removal Allows you to better stabilize the needle by resting your hand on the thigh

Procedure Blood flash - Insert wire Small incision Wire not going smoothly Needle no longer in vessel False tracking in subcutaneous tissue Thrombus Advancing into lumbar veins Small incision Blade directed away from wire

Procedure Twisting motion of dilation Remove dilator Advance catheter Remove wire Aspirate and flush all ports Secure line with sutures Sterile dressing

Seldinger Technique

Procedure Wheeler – “Confirmation of proper CVC position is required after placement of all CVC’s”

Warnings If you hit the artery – pressure until hemostatic Wire should float – should never have resistance If can’t pull the wire through the needle – remove both wire and needle together so you don’t sheer off the wire Never let go of the wire Catheter tip “pointing too cephalad” – in lumbar veins

Complications 74 of 89 (83%) – no complications Other 15 – minor bleeding/hematoma 94.4% success rate Median duration 5 days 21% <3 days 26% 7-14 days 43% 4-7 days 10% >14 days Long term – 8 leg swelling, 11 BSI Venkataraman, et al. Clin Ped 1997;36:311-9.

Complications 45 months – 395 CVL – 162 femoral No insertion complications Mean duration 8.9 days 9 noninfectious complications 4 thrombosis, 1 perforation, 1 embolism, 2 bleeding “The low incidence of complications in this study suggests that the femoral vein is the preferred site in most critically ill children when CVC is indicated.” Stenzel JP, et al. J Ped 1989;114:411-5

Site Selection 9/18/2018

Subclavian Vein When to use it Relative contraindications May be better for long term access Obese – clavicle gives you a landmark Shock – less likely to collapse Relative contraindications Trauma to the area Coagulopathic

Subclavian Anatomy Begins as axillary vein, eventually joins the IJ to become the inominate or brachiocephalic Anterior scalene separates the SCA from SCV Most common is infraclavicular approach

Positioning Head down 15-30 degrees Rolled towel placed longitudinally between scapulae Tilt head toward side of catheterization Reduced catheter malposition in infants

Quiz Question What is the anatomic landmark on the clavicle where you insert the needle? A. 1 cm below the junction of the middle and lateral thirds of the clavicle B. 1 cm below the junction of the middle and medial thirds of the clavicle C. 1 cm below the middle third of the clavicle D. 1 cm below the lateral third of the clavicle

Quiz Answer What is the anatomic landmark on the clavicle where you insert the needle? B. 1 cm below the junction of the middle and medial thirds of the clavicle

Procedure Needle inserted 1 cm below junction of middle and medial thirds of the clavicle Marched down clavicle and parallel to frontal plane Bevel directed caudal Blood flash during insertion or withdrawal

Procedure Regular Seldinger technique Watch for dysrhythmias with wire insertion

Confirmation Position should be in the distal SVC FDA – “the catheter tip should not be placed in or allowed to migrate into the heart” 34% mortality rate with CVC related pericardial effusions in pediatrics

Complications Inability to cannulate SCA puncture/cannulation Catheter misplacement Pneumothorax Hemothorax Nerve injury

Complications 100 patients - 1/3 of patients <1 year 92% overall success rate 89% in emergencies Major complications 4 pneumothorax, 2 BSI Venkataraman, et al. J peds 1998;113:480-5.

Site Selection 9/18/2018

Internal Jugular Vein When to use it Relative contraindications High rate of success Compressible if coagulopathic Lung hyperinflation (less likely to get pneumothorax than subclavian) Transvenous pacing via RIJ Relative contraindications Ongoing CPR – difficult to access Cervical trauma/increased ICP

Internal Jugular Anatomy Lateral to carotid artery in sheath Beneath the triangle formed by the sternal and clavicular heads of the SCM and the clavicle

Quiz Question All of the following are correct about a left internal jugular cannulation EXCEPT: A. LIJ has a more acute angle at connection with subclavian B. Lower pneumothorax risk compared to right because right pleural dome is higher C. Lymphatic duct adjacent to junction of LIJ and innominate vein D. Reduced risk of carotid puncture because of its caudo-cephalad structure

Quiz answer B is the correct answer to the question Reasons to go right – The left has : More acute angle at connection with subclavian Left pleural dome is higher (more pneumothorax risk) Lymphatic duct adjacent to junction of LIJ and innominate

Internal Jugular Positioning Trendelenberg 15-30 degrees Shoulder roll Head turned away from side of insertion

Procedure – Median approach Needle insertion – approximately one half the distance between the mastoid and the sternal notch 20-30 degree needle angle Seldinger technique – watch for dysrhythmias

Posterior Approach

Anterior Approach

Procedure Finder needle techniques Ultrasound Consider when: Poor landmarks (obese) Coagulopathic Carotid artery disease in adults Ultrasound

Ultrasound Image of Right Neck

Correct IJ placement CXR provided by Jeremy P. Feldman, MD E-Bay Fellow in Pulmonary Vascular Disease

Complications Arterial puncture more common than subclavian Pneumo/hemo thorax very rare Catheter malpositioning similar to subclavian

Site Selection 9/18/2018

Axillary Vein Find axillary artery Get PIV just inferior to it in axillary vein Wire it up Appropriate size catheter? 226 neonates done with 9 failures 47 critically ill kids (14d-9y) 79% cannulation rate Rare complications – similar thrombosis rates to subclavian and internal jugular

Temporary Dialysis Catheters We have available : 7 French Triple Lumen regular CVL 7 French 10 cm Double Lumen Medcomp 8 French 9cm Double Lumen Mahurkar 12 French 13 cm Triple Lumen Mahurkar 12 French 20 cm Triple Lumen Mahurkar

Vascular Access for Pediatric CRRT: Pros and Cons of Femoral Site Relatively larger vessel may allow for larger catheter higher flows Ease of placement No risk of pneumothorax Preserve potential future vessels for chronic HD Shorter femoral catheters with increased % recirculation Poor performance in patients with ascites/increased abdominal pressure Trauma to venous anastamosis site for future transplant

Vascular Access for Pediatric CRRT: Pros and Cons of IJ/SCV Site Tip placement in right atrium decreases recirculation Not affected by ascites Preserve potential vein needed for transplant SCV stenosis (SCV) Superior vena cava syndrome Risk of pneumothorax in patients with high PEEP Trauma to veins needed potentially for future HD access

Femoral versus IJ catheter performance 19 > 20 cm 7 < 20cm 13 IJ Qb 250 ml/min (ultrasound dilution) Recirculation measurement by ultrasound dilution method Little et al: AJKD 36:1135-9, 2000

Femoral versus IJ catheter performance Type Number Qb (ml/min) Recirculation(%) 95% CI Femoral 26 237.1 13.1* 7.6 to 18.6 > 20cm 19 233.3 8.5** 2.9 to 13.7 < 20cm 7 247.5 26.3** 17.1 to 35.5 Jugular 13 226.4 0.4* -0.1 to 1.0 * p<0.001 ** p<0.007 Little et al: AJKD 36:1135-9, 2000

Femoral versus IJ catheter performance: Pediatrics (Gardner et al, CRRT 1997 Quinton 8 Fr; n = 20; 120 Treatments) P value NS NS NS NS