Difficult Vascular Access Alternative Approaches & Troubleshooting Tips
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1 Difficult Vascular Access Alternative Approaches & Troubleshooting Tips Michelle Lin, MD Associate Professor of Clinical Emergency Medicine UC San Francisco - San Francisco General Hospital Michelle.Lin@emergency.ucsf.edu
2 There are many pieces of the puzzle to achieve success in obtaining vascular access in difficult cases. Choosing the best vascular site Implementing ultrasound technology Troubleshooting tips
3 Case #1 40 y/o man c/o chest pain and peaked T waves on EKG. He is a known dialysis patient with poor vascular access. You are unable to obtain a peripheral IV in his arms or legs. V1 V4 Picture V2 V5 V3 V6 Where do you try next to get rapid vascular access?
4 External Jugular Vein External Jugular Sternocleidomastoid Muscle Adapted from Netter s Atlas of Human Anatomy, 1989
5 External Jugular Vein Positioning Trendelenburg Slight neck rotation to stretch the vein
6 External Jugular Vein Technique Valsalva maneuver Shallow angle needle (5-10 degrees)
7 External Jugular Vein Technique Reduce vein-rolling (bifurcation site or side-puncture)
8 External Jugular Vein Pearls May not have flashback of blood in catheter Floating the IV technique Secure the IV around the ear
9 External Jugular Vein Pearls May not have flashback of blood in catheter Floating the IV technique Secure the IV around the ear
10 Deep Peripheral Veins Deep Brachial Veins Medial and lateral to brachial artery Most superficial 1-2 cm superior to antecubital crease Not palpable or visible Basilic Vein Proximal extension of deep brachial veins Forms axillary vein more proximally Not palpable or visible
11 Deep Peripheral Veins Biceps Muscle Adapted from Netter s Atlas of Human Anatomy, 1989 Brachial Artery Brachial Veins
12 Deep Peripheral Veins Positioning Arm in relaxed extension Abduct shoulder to access ulnar elbow. Technique Tourniquet arm proximally. Use linear ultrasound transducer to find veins in transverse view. Use a 2-inch angiocatheter. Aim needle at 45 o (not shallow angle). 2-in angiocath 1.25-in angiocath
13 Ultrasound 101 Use a high-frequency ( MHZ) linear probe Basic tenets: 1. Blood vessels are black (anechoic) 2. Veins are compressible and arteries are not 3. Marker on probe correlates with marker on screen 4. Hashmarks on screen are at 1 cm intervals.
14 Ultrasound 101 Use a high-frequency ( MHZ) linear probe Basic tenets: 1. Blood vessels are black (anechoic) 2. Veins are compressible and arteries are not 3. Marker on probe correlates with marker on screen 4. Hashmarks on screen are at 1 cm intervals.
15 Deep Peripheral Veins Pearls Best if vein is 0.4 cm and within cm depth. 1 Needle may puncture through anterior and posterior wall. Withdraw needle slowly may give you a flashback of blood. 1. Witting, J Emerg Med, 2010
16 Deep Peripheral Veins Pearls Complications with deep veins: studies without using U/S Paresthesias (18%) Brachial artery puncture (8%) Hematoma formation (1.6%) IV decannulation (8%) 2-in angiocath 1.25-in angiocath
17 Deep Peripheral Veins Pearls Complications with deep veins: studies without using U/S Paresthesias (18%) Brachial artery puncture (8%) Hematoma formation (1.6%) IV decannulation (8%) Consider using a single-lumen central line for added stability.
18 Case #2 35 y/o woman presents with necrotizing fasciitis and hypotension. You can t get a peripheral IV because of her long IVDU history. Left antecubital fossa Right neck Where do you try next for vascular access?
19 Central Venous Access Femoral, Internal Jugular, Subclavian What s the best site?
20 Central Venous Access Merrer et al. JAMA study in 2001 Prospective study with 289 patients in 8 French ICU s randomized to get a femoral or subclavian line. Femoral Subclavian Thrombotic 21.5% 1.9% Complications Catheter 19.8% 4.5% Colonization Catheter-Related 4.4% 1.5% Clinical Sepsis
21 Central Venous Access Thrombotic risks Mian et al. Acad Emerg Med study in 1997 Prospective study with 42 patients Patients underwent bilateral lower extremity ultrasounds within 7 days of femoral line placement. Result: 26.2% had a DVT in that same extremity (versus 0% in the other leg without a femoral line)
22 Central Venous Access Infectious risks Parienti et al. JAMA study in 2008 Randomized study with 750 patients receiving either a femoral or IJ dialysis vascular catheter. Femoral IJ Catheter Colonization 25% 26% Catheter-Rel Bloodstream Infxn 1% 2% Subgroup analysis: Femoral lines had a greater colonization rate compared to IJ lines for obese patients (BMI >28.4). Study limitation: IJ lines were NOT placed under ultrasound guidance (known higher infection rate).
23 Central Venous Access Infectious risks Gowardman et al. Intensive Care Med study in 2008 Prospective, non-randomized study of 605 central lines placed in single ICU. Femoral IJ Subclavian Catheter 12% 13% 7% Colonization Catheter-Related 0.5% 2% 2% (p>0.05) Bloodstream Infxn
24 Central Venous Access Bottom line about choosing a site Subclavian lines are best. IJ lines are ok for short-term (<7 days) despite higher catheter colonization rate, because of higher risk of acute complications with subclavian lines. Femoral lines should be avoided if possible. Exceptions: - Severe coagulopathy - Patient in extremis - Failed neck line attempt - Patient likely to need dialysis catheter long term
25 Central Venous Access Femoral line
26 Central Venous Access: Femoral line troubleshooting V-Technique Locate the vein without a pulse
27 Central Venous Access: Femoral line troubleshooting Difficulty feeding the guidewire Re-aspirate for blood Flatten needle angle Twirl guidewire
28 Central Venous Access: Femoral line troubleshooting Difficulty feeding the guidewire
29 Central Venous Access: Femoral line troubleshooting Central line kit with guidewire hole in plunger Guidewire Difficulty feeding the guidewire
30 Central Venous Access: Femoral line troubleshooting Find the true inguinal ligament Difficulty feeding the guidewire
31 Central Venous Access: Femoral line troubleshooting Find the true inguinal ligament: Do not cannulate the greater saphenous vein Difficulty feeding the guidewire
32 Central Venous Access: Internal jugular line
33 Central Venous Access: Internal jugular line Use ultrasound imaging for all IJ central lines, if time allows. Anatomical variation: High incidence of unexpected IJ vein location based on external landmarks
34 Central Venous Access: Internal jugular line Use ultrasound imaging for all IJ central lines, if time allows. It makes things faster and safer. 1. Meta-analysis: Lower failure rate (RR 0.14) 1 U/S Landmark Time from skin puncture to blood flash 115 sec 512 sec # of attempts Time to placement ( difficulty sticks ) 93 sec 463 sec Arterial puncture 1.7% 8.3% Hematoma formation 0.2% 3.3% 1. Hind D et al, BMJ, Miller et al, Acad Emerg Med, Denys et al, Circulation, 1993
35 Central Venous Access: Internal jugular line Ultrasonography of the IJ vein
36 Central Venous Access: Internal jugular line Ultrasonography of the IJ vein
37 Central Venous Access: Internal jugular line troubleshooting Problem: Vein has a small diameter on ultrasound Trendelenburg patient over 15 o If unable to Trendelenburg, have patient Valsalva or hum 1 If still small diameter <0.7 mm, try a different site. An independent predictor of failed procedure Lewin et al, Annals EM, Mey, Support Care Center, 2003
38 Central Venous Access: Subclavian line
39 Central Venous Access: Subclavian line
40 Central Venous Access: Subclavian line Tip #1: Positioning No need to position in Trendelenburg Basic tip: Place small towel roll between scapulas Advanced tip: Abduct arm to flatten deltoid bulge
41 Central Venous Access: Subclavian line
42 Central Venous Access: Subclavian line Tip #2: Prevent IJ Tip Placement Most common malpositioning of subclavian catheter (2-9%) Technique: 1 - Using the needle-stabilizing hand, place finger in supraclavicular fossa. Feed guidewire with other hand - Malpositioned tip in IJ: 6% (control) vs 0% (test case) - Patients with malpositioned catheter in IJ had ear pain or tickling throat sensation. 1. Ambesh et al, 2002
43 Central Venous Access: Subclavian line Tip #3: Supraclavicular line ( pocket shot ) Landmark: 1 cm lateral to SCM and posterior to clavicle Aim anteriorly and for contralateral nipple Can use small linear or endocavitary ultrasound probe.
44 Central Venous Access: Subclavian line Advantages of supraclavicular line: No need for Trendelenburg No need for head turn Most successfully positioned neck line
45 Case #3 75 y/o man arrives in your ED with severe full-thickness burns to his body above the waist, including the neck, chest, and arms. Peripheral IV s are unsuccessful. You are having difficulty getting the central lines at various sites. Where else can you try to get access?
46 Intraosseous Line EZ-IO Drill BIG Cross-section of sternum and FAST-1 Commercially available kits EZ-IO Drill Bone Injection Gun (BIG) Fast Access in Shock and Trauma (FAST) - sternal Sites Sternum Proximal tibia Proximal humerus Distal tibia (just superior to medial malleolus)
47 Intraosseous Line
48 How do you interpret IO blood? Discard first 2 ml blood return Correlates well with peripheral blood draw: Albumen, total protein BUN, creatinine Glucose Hematocrit, hemoglobin IO blood may result in lower numbers: CO2, Platelets IO blood may result in higher numbers: WBC Miller et al, Arch Pathol Lab Med, 2010.
49 Summary 1. Use ultrasound to improve your success in finding and cannulating the vein. 2. Central line site choice is important: Subclavian > internal jugular >>> femoral 3. Remember your backup plans for vascular access. External jugular vein Deep brachial and basilic vein Central venous access Intraosseous line
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