Authors:  Dina W Al-Joburi, DO, Eric A Farabaugh, MD
Editor: by Tom Morrissey MD PhD

Vascular Access is the cornerstone of emergency medicine and part of every emergency medicine physician’s safety net.  With that said, not every patient that enters the ER will require vascular access. It is important to know when to obtain access and what type of access should be used. Furthermore, an emergency medicine physician must be comfortable placing all forms of access.

Peripheral Venous Access

Peripheral venous access is by far the most common form of vascular access. It is used to provide patients with fluids and medications and draw blood samples.

Indications

• Patient with multiple blood samples required
• Patient with suspected or definite admission into the hospital
• Patient unable to tolerate PO medications or liquids
• Patient requires IV fluids or blood products
• Patient require IV vs. PO medication because of its pharmacologic profile
• Patient requires IV contrast for radiologic imaging, e.g. CTA
  

Contraindications

• Extremity with an arteriovenous fistula
• Extremity with a history of mastectomy or lymph node dissection
• Cellulitis overlying the site
  

Technique

Size: The size of the peripheral vascular catheter is most commonly referred to as its gauge size. The gauge size is inverse to the diameter of the catheter; therefore a 24 gauge is the smallest practical size, while a 14 gauge is much larger.  The length is typically 2-3 cm, but can be 5-15 cm.

When choosing the appropriate catheter it is important to remember that flow rate is directly related to the inner radius of a catheter and inversely related to the length of a catheter. Therefore for rapid infusion, a short, large-bore catheter such as an 18-14 gauge is best.

Materials

Tourniquet, Cleanser, Venous Catheter, Connective Tubing, Flush, Dressing, Tape

Steps

1. Place a Tourniquet proximal to the intended insertion site
2. Cleanse the skin using an antiseptic solution-wipe from proximal to distal as to prevent emptying the vein’s blood
3. With the dominant hand, hold the catheter in between the thumb and forefinger with the bevel up. With the non-dominant hand, pull the skin taut while being careful to not compress the vein
4. Enter the vein at about 10-30 degrees until a flash of blood in the chamber is seen
5. Once the flash is obtained, continue advancing the catheter with the needle another 1-2mm
6. With the dominant index finger, advance the small tab on the hub of the catheter and continue to advance the catheter over the needle until it is completely in the vein
7. If resistance is felt while advancing the catheter it has not smoothly advanced into the lumen of the vein. Commonly, the needle has been advanced to far and out the back of the vain, or was not advanced far enough and never truly entered the vein. Intraluminal obstructions, such as valves or thrombus can also impede catheter advancement. DO NOT FORCE A CATHETER THAT IS NOT ADVANCING SMOOTHLY.
8. Once the catheter is inserted, push the button to retract the needle and venous blood should be coming out of the catheter
9. Remove the tourniquet
10. Connect the IV infusion tubing
11. IV catheter should flush without difficulty and with no pain to the patient, no swelling should be seen at the catheter site
12. Place a dressing and further secure it with tape or specialized IV securing device such as “Stat-lock”.

Complications

Hematoma, Phlebitis, Extravasation of IV fluid, Bleeding, Infection

The New England Journal of Medicine’s  Videos in Clinical Medicine series demonstrates peripheral IV placement PIV http://www.nejm.org/doi/full/10.1056/NEJMvcm0706789

Special consideration:

• Peripheral IV placement is not limited to the distal veins of the upper arm. They can be placed in the external jugular vein or in the leg/foot. Foot placement is discouraged because of the increased risk of infection and relatively poorer circulation.
• Ultrasound-guided peripheral IVs are typically placed in the proximal veins of the upper extremity.

The New England Journal of Medicine’s  Videos in Clinical Medicine series demonstrates US Guided PIV

http://www.nejm.org/doi/full/10.1056/NEJMvcm1005951

Central Venous Access

Central Venous lines offer multiple benefits over peripheral access. The can be maintained longer in hospitalized patients. Large bore central lines, or percutaneous introducer sheaths (such as Cordis-Johnson & Johnson) allow very rapid volume infusions and can accommodate passage of devices such as pacemakers. Multiple lumen lines can allow the infusion of several different medications that might not be compatible through a single IV site. These lines are commonplace in ICU level patients. Central Venous Catheters are typically placed in the central veins, typically the subclavian, internal jugular and femoral veins. Alternatively, a PICC line or Peripheral Inserted Central Catheter can be placed via the proximal arm veins. These can remain in place for weeks and are often used for long-term outpatient treatment with IV medications.

Indications

• Administration of vasopressors and sclerosing agents e.g. calcium chloride, and hypertonic solutions e.g. parental nutrition
• Hemodynamic monitoring
• Prolonged drug administration
• Inability to obtain peripheral access, e.g. IV drug abusers, obese patients
• Venous Interventions e.g. transvenous cardiac pacing, hemodialysis
  

Contraindications

• Infection overlying insertion site
• Superior Vena Cava Syndrome
• Thrombosis in vein
• Coagulopathy (relative)
  

Technique

Size: Catheter size is 16-18 gauge and 15 to 30 cm in length and there are typically 2-4 infusion ports. As the number of lumens increase, the overall diameter of the catheter increases, and the diameter of the individual luminal channels decreases. Multiple infusion ports are typically preferable as it allows administration of multiple fluids and medications from one point of access. Larger single lumen central catheters, or percutaneous introducers, generally range in size from 4F to 7F.

Materials

Universal precaution materials, Tape, Dressing, Central line kit: anesthetic needle, angio cath needle, steel needle, lidocaine, catheter, guidewire, scalpel, dilator, IV port caps, suture

Steps

• Informed consent obtained
• Wash hands
• Place the patient in slight Trendelenburg position
• Don sterile gown, gloves, hat and mask
• Test each port and flush the lines with sterile saline
• Clamp each port, keep distal port open to accommodate guidewire
• Cleanse area with chlorhexadine
• Drape area in usual sterile fashion
• The US probe is properly set up, draped and sonographic gel is used on inside and outside of sterile sheath
• The vein is localized using anatomical landmarks and/or with the ultrasound machine
• The skin is anesthetized with lidocaine in a small wheal
• Using the large needle syringe complex cannulate the vein while aspirating
• When in the vein, should feel decrease resistance when aspirating the syringe and visualize venous blood in the syringe, confirm with ultrasound
• Remove the syringe from the needle. (If pulsatile blood comes from needle, this may indicate arterial cannulation. Remove the needle and hold direct pressure for 5-10 minutes.)
• Advance the guidewire through the access needle and into the vein
• Remove the access needle by sliding backwards over the wire (leave wire in place)
• Make a knick with a scalpel in the skin adjacent to the guidewire to advance the dilator, being sure not to cut the guidewire
• Advance the dilator over the guidewire and dilate the tissue tract
• Remove dilator and advance the triple lumen over the wire, holding the guidewire steady
• Never let go of the guidewire
• Once the line is in placed remove the guidewire in its entirety
• Advance IJ or subclavian lines to approximately just above the right atrium (14-16cm on the right side or 16-18cm on the left side). Femoral lines can be fully advanced to the hub
• Aspirate and flush each access hub
• Suture the line in place
• Place antibiotic dressing (such as Biopatch disk- Johnson & Johnson) and sterile occlusive dressing
• Obtain CXR to confirm tip of catheter at SVC- RA junction and look for pneumo/hemothorax (in IJ or subclavian lines)
  

Complications

Pneumothorax, Hemothorax, Bleeding, Infection, Artery Puncture, Venous air embolism, Brachial Plexus injury, Arrhythmia, Thoracic duct injury, Catheter embolization

NEJM Video Series

The New England Journal of Medicine’s  Videos in Clinical Medicine series demonstrates Central Venous Catheterization http://www.nejm.org/doi/full/10.1056/NEJMvcm055053

The New England Journal of Medicine’s  Videos in Clinical Medicine series demonstrates Placement of a  Femoral Venous Catheter http://www.nejm.org/doi/full/10.1056/NEJMvcm0801006

The New England Journal of Medicine’s  Videos in Clinical Medicine series demonstrates Ultra Sound Guided Internal Jugular Line placement

http://www.nejm.org/doi/full/10.1056/NEJMvcm0810156

The New England Journal of Medicine’s  Videos in Clinical Medicine series demonstrates Subclavian Catheter placement http://www.nejm.org/doi/full/10.1056/NEJMvcm074357

Special Considerations

• Right internal jugular vein has a direct route to the SVC and is thus the preferred site for insertion of transvenous pacemaker wires, pulmonary artery catheters, and hemodialysis catheters.
• Avoid subclavian if patient may need the site as hemodialysis access in the future.
• Femoral vein is often considered least desirable site because it has been associated with a higher infection risk (although conflicting literature exists). This approach is often used in cardiopulmonary resuscitation scenarios because it does not interfere with chest compressions and resuscitative efforts.
• Internal Jugular veins is the preferred site for central venous access when ultrasound is available.
• Clavicles limit ultrasound guidance with the subclavian approach.
• Clavicles limit compressibility in the case of arterial puncture. This approach is less desirable than Internal Jugular in patients with coagulopathy.
• In the pediatric population, if unable to obtain adequate peripheral venous access, IO is preferred over central venous catheter during cardiac arrest and/or shock.
• Take into consideration patient’s clinical state. For example, if patient is presenting with left-sided pneumonia place the central line on the left side. If line placement results in a pneumothorax, the patient’s respiratory dysfunction will remain unilaterally dependent on the “good” lung.
• When removing the central line, place the patient in Trendelenberg position, ask the patient to exhale as the catheter is removed to prevent air embolism.
  

Intraosseous Access

Intraosseus (IO) lines function as form of vascular access because the bone marrow of long bones contain veins that ultimately drain into the vena cava. This form of access is particularly beneficial because in times of shock peripheral veins collapse and bone marrow functions as a non-collapsible venous access route.

Indications

• Venous access has failed
  

Contraindications

• Fractured bone
• Previously penetrated bone
• Osteogenesis Imperfecta, Osteopetrosis
• Cellulitis at the site
• Osteomyelitis at the site
• Previous orthopedic procedure e.g. prosthetic limb or hardware
  

Technique

Size: Battery-powered driver needles come in three lengths. The length that is selected is based upon the patient’s size and weight. If patient is 39 kg or less use the 15mm needle, 40 kg and up will require 25mm needle, if patient is 40 kg with excess subcutaneous tissue use a 45mm needle. After making a needle selection, take the driver-needle unit, position it 90 degrees to the bone surface and press the needle through the skin so that it is on top of the bone. Look at the needle to assure that at least one black line can be visualized above the surface of the skin. If a black line is not seen, the needle selected is too short to reach the medullary space.

Materials

Antiseptic cleanser, 10cc syringe, Flush, Lidocaine, IO needle + trocar or driver

Manual IO insertion of proximal tibia steps

• Place the patient in the supine position and place padding under the knee to get about 30-degrees of flexion
• Identify the puncture site of the anteromedial surface of the proximal tibia-approximately one fingerbreadth below the tubercle
• Cleanse the skin around the puncture site
• Use local anesthetic at the puncture site if the patient is awake
• At a 90-degree angle, introduce a short, large-caliber, bone-marrow aspiration needle into the skin and periosteum with the bevel up directed toward the feet and away from the epiphyseal plate
• After entering the bone, direct the needle slightly away from the epiphyseal plate, twist and advance the needle through the bone cortex and into the bone marrow. You will feel a decrease in resistance as the needle enters the marrow cavity.
• Remove the stylet and attach a 10cc syringe with 5cc of sterile saline
• Aspirate the syringe looking for bone marrow contents. Flush with 10 cc saline. Infusing 1-2% lidocaine can relieve the discomfort associated with flushing, if patient is awake.
• If the needle flushes easily and no evidence of swelling, needle is likely in the medullary cavity
• Connect the IV infusion tubing and secure the needle and tubing in place
  

 Battery-powered driver steps

• Identify site
• Attach the needle to the battery-powered driver
• Remove the needle safety cap
• Position the driver-needle unit at a 90 degree angle to the bone
• When stabilizing the tibia, be sure to not place the non-dominant hand directly behind were the needle is being driven
• Manually push the needle until the tip touches the bone
• Press the trigger and apply downward pressure until a sudden decrease in resistance is felt
• Remove the driver, unscrew the needle style counter-clockwise
• Aspirate bone marrow and flush (use lidocaine prior to flushing if patient is awake)
• Connect IV infusion tube and secure the needle in place

Complications

Infection, hematoma, through-and-through penetration of the bone, physeal plate injury, pressure necrosis of the skin, compartment syndrome, osteomyelitis, subcutaneous abscess

NEJM Video Series

The New England Journal of Medicine’s  Videos in Clinical Medicine series demonstrates Placement of IO Access In Adults http://www.nejm.org/doi/full/10.1056/NEJMvcm1211371

and IO Placement in children http://www.nejm.org/doi/full/10.1056/NEJMvcm0900916

Special Considerations

• If an IO needle is not readily accessible, a short 18-gauge spinal needle with stylet or bone marrow needle can be used as a substitute.
• While any drug given via a peripheral IV can be administered via the IO route at the same dosages, a limitation is that adenosine is not as effective when administered via the IO route.
• Although the proximal tibia is most common site for IO access secondary to its location and flat surface, the distal tibia, distal femur, sternum, and humerus are other site that can be used.
• IO blood can be sent to the lab for analysis, but discard the first 2cc of marrow aspirated to improve the accuracy of the lab results.
  

Arterial Line

Arterial line placement is less common than venous access, but it is important to know when and how to place one. Titrating vasoactive drugs or monitoring labile blood pressure is not a rarity and non-invasive blood pressure monitoring both slow and prone to inaccuracy. Such inaccuracy can be the result of malposition, inappropriate cuff size, profound hypotension and peripheral edema. The arterial line provides a more accurate and constant blood pressure monitoring at times where every millimeter of mercury makes a clinical difference.

Indications

• Frequent arterial blood gases will need to be obtained
• Inability to use indirect blood pressure monitoring i.e. obese or burn patients
• Continuous blood pressure monitoring, e.g. hypertensive emergency, shock, patient on multiple pressors
  

Contraindications

• Buerger Disease/Raynaud Syndrome
• Full thickness burns
• Absent pulse
  

Technique

Materials

Sterile gloves, sterile gauze, sterile dressing, antiseptic cleanser, lidocaine, scalpel, suture, three-way stopcock, pressure transducer kit, pressure tubing

Catheter over wire (modified Seldinger) steps

1. Palpate the radial pulse
2. Perform Allen test or modified Allen test to assess for collateral flow to the hand or foot
3. Position the wrist dorsiflexed by placing a towel roll underneath
4. Don sterile gown, gloves, hat and mask
5. Create a sterile field
6. If patient is awake, inject local anesthesia
7. Test guidewire to ensure it moves smoothly
8. Puncture the skin over the radial artery at a 30 to 45-degree angle (aiming proximally) with the needle bevel up
9. Advance the needle until a flash of blood is seen in the hub
10. Stabilize the needle and advance the guide wire into the artery
11. If resistance is felt, stop advancing, reposition and try again
12. Once the guidewire is place, advance the catheter over the guidewire
13. Remove the needle and guidewire as a single unit
14. You should observe bright red pulsatile blood flow from the catheter hub
15. Attach catheter to arterial line tubing
16. Suture line in place and place dressing
    

Complications

Infection, hematoma, bleeding, nerve damage, arteriovenous fistula, air embolism, thrombosis.

NEJM Video Series

The New England Journal of Medicine’s  Videos in Clinical Medicine series demonstrates Placement of an Arterial Line http://www.nejm.org/doi/full/10.1056/NEJMvcm044149

and Ultrasound-Guided Insertion of a Radial Arterial Catheter

http://www.nejm.org/doi/full/10.1056/NEJMvcm1213181

Special Considerations

• Femoral artery is a suitable alternative if radial artery cannot be cannulated, brachial, dorsalis pedis, or axillary arteries can also be used.
• Do not use modified Seldinger technique in neonates because the diameter of their artery is too small to allow the guidewire to advance. For neonates and infants, catheter-over-needle technique is preferred.
• Whereas a 20-gauge peripheral artery catheter kit is suitable for large children and adult patients, a 22- to 24-gauge angiocatheter is preferable for infants and neonates.
  

References

1. Advanced Trauma Life Support: Student Course Manual. 9th ed. Chicago, IL: American College of Surgeons, 2012. Print.
2. Bailey, Pamela, MD. “Intraosseous Infusion.” Intraosseous Infusion. UpToDate, 24 Mar. 2014. Web. 31 Dec. 2014.
3. Clermont, Gilles, MDCM, MSc, and Arthur C. Theodore, MD. “Arterial Catheterization Techniques for Invasive Monitoring.” Arterial Catheterization Techniques for Invasive Monitoring. UpToDate330, 30 July 2014. Web. 31 Dec. 2014.
4. Frank, Robert L., MD. “Peripheral Venous Access in Adults.” Peripheral Venous Access in Adults. UpToDate, 10 July 2013. Web. 31 Dec. 2014.
5. Heffner, Alan C., MD. “Overview of Central Venous Access.” Overview of Central Venous Access. UpToDate, 20 Oct. 2014. Web. 31 Dec. 2014.
6. Koyfman, Alex, MD. “Arterial Line Placement .” Arterial Line Placement. Medscape, 23 Dec. 2014. Web. 31 Dec. 2014.
7. Marino, Paul L., and Kenneth M. Sutin. The ICU Book. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007. Print.
8. The New England Journal of Medicine. Videos in Clinical Medicine series. http://www.nejm.org/mulitmedia/medical-videos.   Accessed 04-30-2015.