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

2. 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.

3. 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

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

5. 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

6. Infiltration

7. Extravasation

8. Extravasation

9. Phlebitis

10. Cellulitis

11. 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

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

13. 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.

14. 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

15. 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.

16. 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

17. PICC versus Midline

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

19. 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.

20. 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

21. Non-tunneling CVC subclavian site
Proximal ends of the catheters terminate externally at the skin. They are secured in place with sutures.

22. 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.

23. 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

24. 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!

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

26. 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.
Bard Access Systems

27. 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.

28. 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

29. 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.

30. 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.

31. Adult Insertion Complications

32. 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.

33. 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

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

35. 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:
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.

36. 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

38. 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

39. 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 cm medial to this depending on the size of the patient.

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

41. 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

42. 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

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

44. Seldinger Technique

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

46. 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

47. 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.

48. 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

52. Site Selection
9/18/2018

53. 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

54. 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

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

57. 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

58. 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

59. 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

60. Procedure Regular Seldinger technique
Watch for dysrhythmias with wire insertion

61. 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

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

63. 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.

67. Site Selection
9/18/2018

68. 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

69. 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

71. 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

72. 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

73. Internal Jugular Positioning
Trendelenberg degrees
Shoulder roll
Head turned away from side of insertion

74. 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

75. Posterior Approach

76. Anterior Approach

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

78. Ultrasound Image of Right Neck

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

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

82. Site Selection
9/18/2018

83. 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

84. 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

86. 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

87. 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

88. 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

89. 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

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