1. Placing Peripheral IVs, Central Venous Catheters, and Intraosseous Lines AFAMS Resident Orientation April 8, 2012

2. Outline Basic principles of IV infusions Indications, contraindications, acceptable locations, and complications of placing – Peripheral IVs – Central Lines – Intraosseous Access Brief descriptions of technique for each vascular access procedure

3. Basics of Intravenous Infusion IV Flow rate is proportional to catheter radius 4 IV Flow rate is inversely proportional to catheter length Therefore, fluid flows faster in a wide short catheter than in a narrow long catheter The smaller the catheter Gauge, the wider the catheter radius – 14 G is wider than 20 G

4. Peripheral IV Indications Sample Blood Infuse fluids Infuse blood products Infuse IV medications

5. Peripheral IV Contraindications Extremities with – Massive edema – Burns or injuries – Cellulitis Mastectomy – Concern for adequate vascular flow Indwelling fistula – Avoiding possible vascular damage near a fistula

6. Complications Insertion site infection Superficial Thrombophlebitis Interstitial Leakage

7. Placement a Peripheral IV Practice Universal Precautions – Always wear gloves – Consider face and eye protection Avoid needle sticks – Do not recap needles – Do not put needles back in the sheath – Dispose in proper sharps container Always start peripheral and move proximal if initially unsuccessful

8. Placement a Peripheral IV: Equipment Gloves and protective equipment Appropriate size IV catheter (14G – 25 G) Tourniquet Gauze Transparent Dressing (Tegaderm) IV bag with tubing

9. Placement a Peripheral IV Wear gloves Apply tourniquet proximal to insertion site Palpate vein Clean skin with alcohol prep Remove protective cover of catheter With left hand stabilize the vein while you insert catheter, bevel up, with your right hand Angle of insertion should be approximately 35 degrees

10. Placement a Peripheral IV As catheter is advanced, watch for blood “flash” Once “flash” is seen, slowly advance needle 1 cm, then stabilize needle and advance catheter into vein Remove tourniquet Attach catheter to saline lock Dispose of needle in sharps container

11. Indications for Central Line Placement Infusion of sclerosing or hyperosmolar medications – Pressors, chemotherapy, TPN, etc. Access for hemodynamic monitoring – Swan-Ganz Catheter Lack of peripheral access Transvenous pacing Aspiration of venous air (Intra-operative issue only)

12. Central Venous Access Locations Internal Jugular Vein Femoral Vein Subclavian Vein Uncommon – Arm (brachiocephalic vein) – External Jugular Vein Usually cannulate dwith a peripheral IV

13. General Concepts to Central Venous Catheter Placement Obtain informed consent Set up your equipment Position the patient Practice Universal precautions – Gown – Gloves – Eye protection

14. General Concepts to Central Venous Catheter Placement Clean the area with chlorhexidine or betadine Drape the area to reduce infection risk Use plenty of lidocaine superficially and deeper in the soft tissue

15. External Jugular Vein Advantages Easy to learn to perform Essentially peripheral venipuncture Pneumothorax is uncommon Arterial puncture is uncommon Disadvantages Inability to cannulate vein common (≈ 20 %) Practice required to use guide wire Wire or catheter may perforate veins May interrupt CPR during code

16. External Jugular Anatomy

17. Femoral Vein Advantages Does not interrupt CPR during a code Vein does not collapse Easy access to central circulation Useful for hypovolemic shock Disadvantages If pulse is absent, vein may be hard to locate Longer delivery time of drug to heart Risk of thrombosis (0.5 %), infection (1 to 2 %), colonization (25 to 30 %) and inadvertent puncture of the femoral artery (5 to 8 %) with vascular injury

18. Femoral Vein Anatomy

19. Femoral Vein Technique Position patient supine Measure halfway between Anterior Superior Iliac Spine and Pubs Symphysis along the inguinal ligament – Femoral Artery site Palpate Femoral Artery Target venopuncture 2 cm inferior to inguinal ligament and 2 cm medial to femoral artery Advance needle at 20-30 degrees while aspirating until venous flash is seen

20. Femoral Vein Technique After venous flash remove syringe Advance wire through needle Remove Needle holding pressure over puncture site – NEVER LET GO OF THE WIRE! Advance catheter over wire Remove wire

21. Femoral Vein Access Complications Infection Thrombophlebitis Retroperitoneal hemorrhage Inadvertent puncture of bladder Vasovagal reaction A-V fistula Hematoma Femoral artery thrombosis or embolism

22. Internal Jugular Advantages More sterile than femoral vein Can do hemodynamic monitoring with IJ – Swan-Ganz catheter Can do with ultrasound assistance Quick delivery of drug to the heart Disadvantages Risk of pneumothorax Risk of carotid artery puncture Cannot be done while CPR is being done

23. Internal Jugular Vein Superficial Anatomy

24. Internal Jugular Vein Venous Anatomy

25. Internal Jugular Vein Patient supine, 15-degree angle in Trendelenberg, head down 3 Different approaches – Central – Anterior – Posterior Right side IJ is preferred – Dome of pleura is lower – Straight line to right atrium – Thoracic duct not in the way

26. Internal Jugular Vein Technique Standing at head of patient Visualize triangle formed by heads of sternocleidomsatoid 5 cm superior to clavicle Palpate carotid pulse with left hand Use finder needle, insert at 30-45 degree angle aiming toward ipsilateral nipple If blood is not aspirated within 2.5 cm slowly withdrawal needle and reposition

27. Internal Jugular Vein Technique After venous flash remove syringe Advance wire through needle Remove Needle holding pressure over puncture site – NEVER LET GO OF THE WIRE! Advance catheter over wire Remove wire

28. Subclavian Vein Insertion Advantages Superficial vein Can remain in place for long time Can do central hemodynamic monitoring (IJ is preferred) Disadvantages Difficult to compress in bleeding situation High rate of pneumothorax Risk of subclavian artery injury

29. Subclavian Venous Access

30. Position patient in 15 degrees of Trendelenberg Abduct patient’s arm Insert Needle 2-3 cm inferior to the midpoint of clavicle Keep needle parallel to floor Advance needle under clavicle and towards sternal notch

31. Subclavian Vein Technique After venous flash remove syringe Advance wire through needle Remove Needle holding pressure over puncture site – NEVER LET GO OF THE WIRE! Advance catheter over wire Remove wire

32. Comparison of Central Access Sites

33. Central Venous Catheter Complications Local Complications Hematoma Cellulitis Thrombosis Phlebitis Serious Complications Embolism Vascular Erosions Pericardial Tamponade Pneumothorax Thrombosis Catheter Associated Infection Misinterpretation

34. Intraosseous (IO) Access Intraosseous infusion is possible because of large veins that drain medullary sinuses in the bone marrow of long bones

35. IO Indications Pediatrics in shock or cardiopulmonary arrest Acute life-threatening situations when standard venous access cannot be rapidly achieved Any situation when venous access cannot be achieved quickly

36. IO Access Advantages Easy accesses Can infuse all types of medication and fluid Easily done in a CPR or code scenario Disadvantages Painful Infusion comparable to a 21 gauge needle Temporary Access only – SHOULD NOT BE LEFT IN LONGER THAN 24 HOURS

37. Intraosseous Access Sites Proximal tibia (popliteal vein) Femur (branches of femoral vein) Distal tibia (great saphenous vein) Proximal humerus (axillary vein) Manubrium (internal mammary and azygos veins)

38. Intraosseous Contraindications Fractured bone Extremity with vascular interruption Cellulitis, burns, or osteomyelitis at cannulation site Patients with osteogenesis imperfecta or osteopetrosis Patients with right to left intracardiac shunts – Greater risk for bone-marrow emboli

39. IO Required Equipment Betadine or chlorhexidine solution Universal precautions – Gloves – Gown – Eye protection Syringe with saline flush Intraosseous needle

40. IO Technique Wear universal precautions Clean the insertion area Infiltrate the skin, subcutaneous tissue and periosteum with 1% lidocaine Palpate the landmarks and identify insertion site

41. IO Technique Direct needle perpendicular to entry site Apply pressure with a twisting motion As the needle passes through the cortex and into the marrow cavity a “release of resistance is felt Unscrew the needle cap and remove the stylet Confirm placement by aspiration of marrow Begin infusion

42. IO Technique: Tibia Clean the insertion site In children insertion is 2 cm distal and 1 cm medial to tibial plateau

43. IO Technique: Tibia In adults insertion site is the distal tibia 1-2 cm superior to malleolus Medial is preferred to the lateral malleolus

44. IO Complications Bone fracture Osteomyelitis Compartment syndrome Microscopic fate and bone marrow emboli

45. Conclusions Vascular access is an important part of treatment in all hospitalized patients Many options for vascular access exist – Peripheral IV – Central Line (multiple locations) – Intraosseous Access (multiple locations) Choice of option and location made based on patient characteristics – Always choose the least invasive option if possible