Venous Access

INTRAOSSEOUS CANNULATION (IO)

Introduction:

An intraosseous cannula is placed through cortical bone into the medullary cavity and allows for infusion of fluids, blood, and most medications. This is a temporary and useful alternative to peripheral or central venous cannulation when placement of either is difficult, especially in emergency situations. In adults, the most common sites for placement are the proximal humerus and proximal anteromedial tibia.

Indications: Emergency venous access when intravenous line or central venous line cannot be placed

Contraindications: Bone fracture, infection or burns at insertion site, osteoporosis

Equipment: Antiseptic, intraosseous needles and insertion drill, 10cc syringe, intravenous line tubing

Preparation: Assemble the needle and the drill, clean the skin around the intended cannulation site, and select the correct needle for the selected insertion site (45mm needle for adult tibia and humerus). If placing the IO in the tibia, it should be placed on the medial flat surface 2cm below the tibial tuberosity. If placing the IO in the humerus, position the patient’s palm on their abdomen with the elbow flexed and shoulder internally rotated. It should be placed in the greater tubercle 2cm below the acromion process.

Steps:

1. Hold the drill with the dominant hand and stabilize the intended insertion site with the nondominant hand
2. Using a moderate amount of pressure, place the needle tip perpendicular to the long axis of the bone
3. Squeeze the trigger and continue to apply moderate pressure while the drill is penetrating the cortex of the bone (figure)
4. Once there is a sudden loss of resistance, stop drilling
5. Detach the needle from the drill and subsequently remove the stylet from the cannula (figure)
6. Secure the cannula with a dressing (figure)
7. Attach extension tubing to the cannula and aspirate; return of bone marrow confirms correct placement. Make sure that a flush of fluid from a syringe easily flushes through the cannula. (If there is immediate local swelling, the cannula is not well positioned and needs to be removed. The cannula can be removed by attaching a syringe to act as a handle then gently placing in-line traction to pull out the cannula)
8. Begin infusing the medication or fluid
9. The intraosseous cannula should be removed as soon as possible (maximum 24 hours) once other intravenous access has been obtained

Complications: Extravasation of fluid into soft tissue, compartment syndrome, infection, fat embolism

 CENTRAL VENOUS LINE (CVL) PLACEMENT

Introduction: Central venous line placement can provide large bore or multi-lumen access. Caustic medications including vasoactive medications can be given through CVLs. Acute dialysis can be performed through a hemodialysis catheter placed in a central vein. There are three sites for CVL placement: the subclavian vein (SC; most sterile, not compressible), the internal jugular vein (IJ; compressible), and the femoral vein (FV; least sterile, compressible).

Indications: Need for large bore, rapid infusion of blood or fluids, multi-lumen access, access for caustic medications, central venous pressure monitoring, dialysis access, total parenteral nutrition administration

Contraindications: Coagulopathy (consider placing in internal jugular vein or femoral vein because the vein can be compressed), infected skin site, injury to area, ipsilateral pneumothorax (for SC and IJ access)

Equipment: Antiseptic, sterile gloves, sterile surgical towels or drapes, ultrasound (if available) central line kit (local anesthetic, syringe, 14-18 gauge introducer needle, scalpel, J-tip guidewire, tissue dilator, desired central line, suture and needle, sterile dressing, saline)

Preparation: If performing a SC or IJ CVL, place patient in Trendelenburg position, clean site with antiseptic, steriley drape the patient, flush and close all ports with sterile saline

Steps:

1. Inject local anesthetic if the patient is awake
2. Use the introducer needle while constantly applying negative pressure by pulling back on the plunger of the syringe to puncture the target central vein 
   
   

Subclavian vein landmarks:

• Insert the introducer needle 1-2 cm lateral to the bend of the clavicle
• “Walk” the needle down under the clavicle
• Redirect the needle in the direction of the sternal notch
• Advance the needle parallel to clavicle until the SCV is punctured

Internal jugular vein landmarks:

• Insert the introducer needle at the apex of the angle formed by the two heads of the sternocleidomastoid, lateral to the carotid artery pulsation at an angle approximately 30 degrees from the skin
• Direct the needle towards the ipsilateral nipple
• Advance the needle until the IJV is punctured; prevent a pneumothorax and/or carotid artery cannulation by avoiding passage of the needle beyond a depth of 1-2 cm
• Assure that the carotid artery is not punctured by assessing for pulsatility and bright red color of the blood that returns into the syringe

Femoral vein landmarks:

• Palpate the femoral artery
• Puncture the skin holding the introducer needle at a 30-45 degree angle 1-2 cm below the inguinal ligament and just medial to the femoral artery
• Assure that the femoral artery is not punctured by assessing for pulsatility and bright red color of the blood that returns into the syringe

• Once a blood flash obtained, stabilize the needle and remove the syringe
• Thread the wire; always hold onto the wire
• Remove the introducer needle over the wire
• Nick the skin with the scalpel at the wire entry site
• Pass the skin dilator over the wire once and then remove the dilator
• Pass the central line over wire
• Remove the wire
• Draw back all air, flush all the ports with sterile saline
• Suture the central line in place
• Place a sterile dressing
• Obtain a post-placement chest x-ray to confirm proper placement (the tip should be at the cavo-atrial junction) and check for complications (such as pneumothorax)
• Try to remove central venous lines as soon as possible

Complications: Air embolization, arrhythmia, arterial puncture, bleeding, pneumothorax, hemothorax, malposition, central line associated bloodstream infection, myocardial perforation, venous thrombosis

SAPHENOUS VEIN (SV) CUTDOWN

Introduction: Saphenous vein cutdown is a procedure that is utilized when attempts at percutaneous venous access are unsuccessful especially, in the setting of hypovolemic shock leading to collapsed veins. The SV’s superficial location allows it to be accessed quickly.  This procedure should be considered in emergency patient scenarios.

Indications: Inability to obtain percutaneous venous access

Contraindications: Saphenous vein is in an area of injury or infection, or there is more proximal injury to the saphenous or deep venous system

Equipment: Antiseptic, tourniquet, scalpel, 3-0 silk ties, curved hemostat, IV cannula, local anesthetic, suture, tape

Preparation: Identify the saphenous vein on the medial aspect of the proximal ankle anterior to the medial malleolus (approximately 1 cm anterior and 1 cm superior to the medial malleolus), place a tourniquet proximal to the area of intended cutdown, clean the area of intended cutdown with antiseptic, inject local anesthetic if the patient is awake

Steps:

1. Make a 3cm transverse skin incision very superficially over the vein
2. Use the hemostat to bluntly dissect out the vein
3. Pass two silk ties under the vein. Tie down the distal silk tie to ligate the vein. Keep the tie in place to use for traction
4. Make a venotomy by transversely dividing approximately 40% of the diameter (figure)
5. Insert the IV catheter into the venotomy and tie down the proximal silk tie around the vein and cannula (figure)
6. Connect the IV tubing
7. Secure the catheter with a suture and/or tape

Complications: Transection of vein, injury to saphenous nerve, phlebitis, thrombosis

FEMORAL VEIN CUTDOWN

Introduction: Femoral vein cutdown is a procedure that should be used only when the patient is in extremis and percutaneous access cannot be obtained.

Indications:No other access can be obtained

Contraindications: Injury to the area or suspected pelvic fracture, injury to the ipsilateral iliac vein, IVC injury

Equipment: Antiseptic, central venous line kit (described above), electrocautery (if available)

Preparation: Clean the groin with antiseptic

Steps:

1. Palpate the femoral artery. Make an approximately 7cm longitudinal incision just medial to the arterial pulsation. If no pulse can be felt, the longitudinal incision should be made 2 fingerbreadths lateral to the pubic tubercle
2. Continue the incision through the subcutaneous tissue
3. Sharply open the femoral sheath to identify the femoral vein
4. Place the central line using the Seldinger technique (described above)
5. Suture the central venous line to the surrounding tissue and temporarily close the incision until the line can be removed

Complications:

Arterial cannulation, injury to artery or nerve, hematoma, infection, lymphatic leak, thrombosis