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Central Venous Access Procedures
42 Central Venous Access Procedures Thomas M. Przybysz, Alan C. Heffner
OUTLINE Peripheral Intravenous Cannulation, 447 Equipment, 447 Technique, 447 Clinical Pearls, 448 Complications, 448 Central Venous Access General Principles and Preparation, 449 Seldinger Technique, 449 Clinical Pearls, 449 Internal Jugular Vein, 449 Relevant Anatomy, 449 Landmark Technique, 450 Ultrasound-Guided Technique, 450 Clinical Pearls, 450 Complications, 450 Subclavian Venous Cannulation, 450 Technique, 450 Complications, 450 Clinical Pearls, 450
Femoral Venous Cannulation, 450 Complications, 452 Clinical Pearls, 452 Radial Arterial Cannulation, 453 Equipment, 453 Technique, 453 Clinical Pearls, 454 Complications, 454 Femoral Arterial Cannulation, 454 Indications and Contraindications, 454 Equipment, 454 Technique, 454 Clinical Pearls, 455 Complications, 455
PERIPHERAL INTRAVENOUS CANNULATION
at the antecubital fossa requires the arm to maintain a straight position. When present, Y-shaped venous confluences are preferred targets. The dorsal hand, wrist, and forearm are common access sites. Use of a proximal tourniquet or blood pressure cuff accentuates the venous targets. Avoid tying the tourniquet in a tight knot. Focused manual pressure may be applied to distend a superficial jugular vein. Actively pumping the fist hastens venous engorgement at upper extremity sites. Steps for inserting a peripheral intravenous line are shown in Fig. 42.1. Always wear clean gloves. When targeting a venous Y-confluence, aim for the branch point. Local anesthesia may be infiltrated prior to cannulation but is not required. Apply traction with the nondominant hand to anchor the vein and keep the skin taut. Advance the catheter-over-needle assembly through the skin and into the vein while monitoring for a blood flash at the needle hub. The initial flash represents needle-tip penetration. Advance 1 to 2 mm to ensure that the entire needle tip is within the vessel before advancing the catheter into the vein. Maintain the needle in position and release the tourniquet. Next, remove the needle and discard it. Connect the intravenous
Patients in the cardiac intensive care unit (CICU) require reliable intravenous access.1–3 Dependable peripheral vein cannulation technique is an essential tool to establish intravenous access in critically ill patients.
Equipment Equipment for peripheral venous access includes the following: (1) 16-, 18-, and 20-gauge intravenous (IV) catheter over needle units with backup supplies, (2) alcohol swabs, (3) tourniquet, (4) TB or 3-mL syringe with 1% lidocaine, (5) 25-gauge needle, (6) short connector IV tubing flushed with sterile crystalloid, and (7) Steri-Drape and tape to secure the access.
Technique Although any vein may be utilized for emergency access, distal upper extremity veins and superficial jugular veins are prime peripheral cannulation targets. Note that highly mobile sites may limit reliability following insertion. For example, cannulation
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J Fig. 42.1 Peripheral intravenous line placement. (A) Lay out all the equipment in an organized way. (B) Look for a good vein, ideally one shaped like an inverted Y. (C) Make sure that the tourniquet can be undone with one hand. (D) Try to get the vein to stand out. (E) Apply alcohol wipe and administer lidocaine. (F) Pull the skin taut and keep it taut. (G) Approach at a shallow angle to get the needle and catheter tip in. (H) Without letting go of the taut skin, advance the catheter. (I) Undo the tourniquet. (J) Hold down above the catheter.
connector tubing and secure the catheter. Monitor for subcutaneous infiltration while gently flushing the catheter with sterile crystalloid.
Clinical Pearls • Prepare all equipment, including backup supplies, prior to the first venipuncture attempt. • Long intravenous tubing represents the greatest resistance to flow. For rapid large-volume resuscitation, a 16-gauge catheter is equally efficient to larger catheters. • Y-shaped venous confluences are easily anchored and represent high-yield targets for peripheral venous cannulation.
• Advancing 1 to 2 mm after the initial blood flash ensures that the needle tip is within the vein. Failure to advance the needle following initial blood flash is a common mistake. • Adequately secure the IV access immediately after insertion.
Complications Known complications of peripheral venous access are phlebitis, infection, and extravasation. Adequate skin preparation, limited punctures, and diligent site monitoring are recommended to reduce complications. Poorly functioning access sites should be removed immediately once alternative access is obtained.
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CENTRAL VENOUS ACCESS GENERAL PRINCIPLES AND PREPARATION Central venous access is indicated in CICU patients who require reliable intravenous access, vasopressor administration, hemodynamic monitoring, temporary transvenous pacing, and hemodialysis access.4 Contraindications to central access are relative, depending on alternative vascular access options and the urgency of the situation. Anatomic distortion, local infection, and existing hardware justify avoiding specific sites when possible. Coagulopathy is not a contraindication to central access placement, but the procedural risk and patient benefits should be carefully weighed.4–6 Central access is often required emergently and obtaining consent may not be practical. In nonemergent circumstances, consent should be obtained prior to cannulation and should highlight the benefits and risks of the procedure. Infection, bleeding, arterial injury, venous thrombosis, and pneumothorax are all important risks to discuss.7,8 After consent is obtained, dedicate several minutes to optimal site selection and preparation. Most nonemergent central venous catheters in the CICU are placed in the internal jugular or subclavian vein. If ultrasound is available, the site should be investigated prior to skin preparation and draping. Abnormal vascular anatomy or visible clots may prohibit a preferred site. The Trendelenburg position is recommended for subclavian and jugular access if the patient can safely tolerate repositioning. A patient in severe respiratory distress may require intubation prior to obtaining central access. The neutral body position is ideal for most central lines with a few modifications. Patients may need to have breast tissue or an abdominal pannus retracted by an assistant or secured with tape to access a site. Once the site is selected and the patient is positioned, the skin should be cleaned. Chlorhexidine-based solutions reduce central line–associated blood stream infection (CLABSI) compared with povidone iodine-alcohol solutions.9–11 Full sterile precautions consisting of hat, face mask, eye shield, sterile gown, sterile gloves, and large sterile drape should be used for all central access procedures.12 A table large enough to accommodate the central line kit should be ergonomically positioned within the provider’s arm reach. Supplies should not be placed on the sterile drape as patients can unexpectedly move during the procedure. The insertion site should be anesthetized with 1% lidocaine. Ultrasound guidance is recommended for access procedures when available. It may be used to confirm appropriate anatomy and landmarks prior to instrumentation or provide dynamic real-time imaging to track needle penetration.
SELDINGER TECHNIQUE The modified Seldinger guidewire technique is standard for central venous and arterial access procedures. Initial vessel puncture is obtained with a large-bore, 18-gauge introducer needle or catheter-over-needle assembly. Needle trajectory and depth should be monitored closely throughout the procedure. Continuous negative pressure is applied to the aspirating syringe
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during needle advancement and withdrawal. Initial blood flash may be first recognized during needle withdrawal. The ability to continuously aspirate while maintaining strict control of the needle requires practice. Novice providers should be closely supervised. Venous puncture confirmation is important for central venous access procedures to avoid inadvertent arterial cannulation. Blood color, pulsatility, and ultrasound visualization may be misleading in certain circumstances.13 A 30-cm length of intravenous or pressure tubing can be used to gauge or transduce pressure prior to vessel dilation.14 The pressure tubing may be connected directly to the introducer needle or angiocath inserted over the needle or via guidewire. The guidewire is next advanced through the introducer needle to approximately 20 cm. The needle must remain stationary before the wire is inserted. Bracing the hand against the patient to steady the needle and avoid accidental needle movement is a common technique. The guidewire should pass easily with minimal resistance. If resistance is encountered, remove the wire, reconfirm blood aspiration, or reposition the needle trajectory or guidewire J-tip orientation prior to readvancing the guidewire. With the wire stabilized at 20 cm, the needle is removed and a small stab incision at the guidewire exit site is completed with a No. 11 scalpel. While stabilizing the guidewire, the tissue tract dilator is advanced over the guidewire through the skin and connective tissue to reach the vessel. Care must be taken to avoid advancing the wire and dilator together, as this can bend the wire and damage the vessel. The wire should always slide easily within the dilator during proper technique. Next, the dilator is removed while keeping the wire stationary and maintaining hemostasis at the site with firm pressure. The vascular catheter is then advanced into position over the guidewire using the same technique. Finally, the guidewire is removed, the catheter lumens are flushed, and the catheter is secured to the skin at the appropriate depth (usually 15 to 20 cm depending on access site and patient size).
Clinical Pearls • Arrange all supplies on a bedside table prior to starting the procedure. • Place the guidewire on the field in close proximity and brace the needle during syringe removal and guidewire insertion to avoid losing the target vessel during these steps. • Stabilizing the guidewire while advancing the dilator helps prevent guidewire kinking and vessel injury. • Hold the dilator close to the skin while advancing in small increments. • Novice operators focus heavily on procedural mechanics and may not identify patient deterioration during the procedure. Bedside assistance or supervision is highly recommended.
INTERNAL JUGULAR VEIN Relevant Anatomy The internal jugular vein originates at the jugular foramen and descends to join the subclavian vein. In the mid to lower neck, it lies lateral and then anterolateral to the carotid artery. At the level of the thyroid cartilage, the vein lies deep to the
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sternocleidomastoid muscle. The vessel emerges from behind the muscle into the triangle created by the sternal and clavicular insertions of the sternocleidomastoid muscle, just above the clavicle. Right-sided jugular cannulation is preferred owing to the direct path to the superior vena cava and to avoid risk to the left-sided thoracic duct.
Landmark Technique Steps for internal jugular central venous line placement are shown in Fig. 42.2. Turn the patient’s head 15 to 30 degrees to gain exposure to the access site. Turning the neck farther will compress and flatten the vessel. It is useful to mark the surface landmarks before starting the procedure. The apex of the sternocleidomastoid triangle or medial border of the posterior sternocleidomastoid muscle is a common needle insertion point. The carotid artery can be palpated medial to this point. A 22-gauge finder needle is inserted 30 degrees to the skin and aimed toward the ipsilateral nipple. After the internal jugular vein is located, the finder needle is kept in place, and the larger 18-gauge introducer needle mounted on a 5-mL slip tip syringe is inserted adjacent to the needle finder and along the same trajectory. Typical jugular vein depth is less than 2 cm from the skin surface but needle trajectory and patient variation may require deeper needle insertion. Following needle puncture, insert the catheter using the Seldinger technique as described earlier.
Ultrasound-Guided Technique Ultrasound-guided central line placement aids in identifying anatomic variations and is associated with improved success and reduced complications.15,16 Real-time dynamic ultrasound allows the provider to visualize the needle tip during insertion. It is important to recognize that the needle shaft and tip have a similar appearance. Vigilantly monitor needle insertion depth during the procedure.
Clinical Pearls • The sternocleidomastoid triangle and carotid artery pulsation are important surface landmarks. • Insert the needle at the apex of sternocleidomastoid triangle to maximize distance from the lung and avoid pneumothorax. • Orient the ultrasound screen to minimize head turning during the procedure. • An angiocatheter and pressure tubing allow accurate confirmation of venous access and can prevent inadvertent arterial dilation or catheter placement, which are associated with arterial occlusion and stroke.
Complications It is important to know how to manage pitfalls and complications associated with internal jugular cannulation. The most critical complications arise from carotid artery puncture or cannulation. Recognized puncture of the artery with immediate needle withdrawal and application of firm but nonocclusive pressure is usually uncomplicated. Major bleeding can lead to neck hematoma and airway compromise. Arterial cannulation can result in cerebrovascular insufficiency, vessel thrombosis, or pseudoaneurysm formation. If this occurs, leave the catheter
in place and consult a vascular surgeon for assistance with removal. Advancing the guidewire too deeply can induce dysrhythmias that are usually relieved by withdrawing the guidewire.
SUBCLAVIAN VENOUS CANNULATION Subclavian venous access is a common and often preferred access site based on the low risk of mechanical and infectious complications.17 Site-specific contraindications include clavicle distortion or indwelling local hardware (i.e., pacemakers or implantable cardioverter-defibrillators) and severe coagulopathy that may promote bleeding at this noncompressible site.
Technique Steps for subclavian central venous line placement are shown in Fig. 42.3. The left subclavian vein is the preferred site owing to low incidence of catheter malposition and direct insertion trajectory for emergency transvenous pacemaker or pulmonary artery catheter placement. Consider prioritizing cannulation ipsilateral to severe unilateral lung disease or an indwelling chest drain to minimize patient decompensation in the event of a procedure-related pneumothorax. Set up for the central line as described earlier with proper position and full sterile equipment. Consider having an assistant apply gentle caudal traction to the ipsilateral arm.18 Ultrasound guidance for subclavian cannulation is not standard but is described.19 Inject 1% lidocaine at the injection site for anesthesia. The introducer needle is inserted 2 cm lateral and inferior to the midclavicular point. Aim for the suprasternal notch and pass beneath the clavicle. Intentionally contacting the clavicle to “walk” the needle down the clavicle helps to maintain the needle in a plane parallel to the floor to reduce the risk of pneumothorax.20 Following vessel puncture, insert the catheter via the Seldinger technique as described earlier.
Complications Pneumothorax and subclavian arterial puncture are common concerns with the subclavian access approach but the rate of mechanical complication remains low.
Clinical Pearls • To avoid pneumothorax, the needle should be maintained parallel to the floor during insertion. • The subclavian vein is the preferred venous access site to reduce mechanical and infectious complications.
FEMORAL VENOUS CANNULATION Femoral venous catheters are generally avoided in favor of internal jugular or subclavian venous access but still have a role in certain scenarios, such as emergency situations and for hemodialysis access when the right internal jugular vein is not an option.21 The femoral site has historically been associated with an increased risk of infection, but more recent literature suggests only minor increased risk.22,23 Venous thrombosis is more common compared with jugular and subclavian vein access.24
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N Fig. 42.2 Internal jugular central venous line placement. (A) Get lined up and then palpate the sternal notch (lower finger) and mastoid process (upper finger) to identify the sternocleidomastoid muscle. (B) Without any imaging guidance, go in at about the halfway point. (C) Palpate the carotid artery but do not press down on it to avoid compressing and flattening the internal jugular vein, making it hard to hit. (D) Use local anesthetic judiciously. (E) It is crucial to be close to the carotid artery but aiming away from it (at the ipsilateral nipple). If this is performed under ultrasound guidance, the carotid artery and internal jugular vein are adjacent to each other. (F) Proceed until dark venous blood is observed, usually 1 to 2 cm deep. (G) Once the finder is in, place the needle directly on top of the finder to exactly reproduce the approach angle. (H) If the blood is bright and squirts out in pulsatile fashion, the attempt has missed and hit the artery. (I) Assuming that did not happen, advance the wire, keeping an eye out for ectopy. (J) Once the wire is in, again check that it is in the right place. Slide the 18-gauge catheter down the wire, pull the wire out, and connect the catheter to the extension tubing. (K) Hold the tubing up, make sure that the blood goes up to central venous pressure height and not to arterial height (it would climb all the way to the top and squirt out). This is a quick and effective way of ensuring the correct location. Proceed with the standard Seldinger technique. (L) Nick, dilate, flush, sew, and dress. (M) If a cordis is being placed, the dilator and cordis should be placed as a unit. (N) Aspirate and flush, without leaving anything open to air, which could lead to an air embolus.
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E Fig. 42.3 Subclavian central venous line placement. (A) The needle should target the sternal notch, but always angle away from the lungs. If the needle needs to be depressed, press down on top with three fingers so that the whole needle goes down flat as a single unit rather than just pointing the tip down. (B) The needle is in the clavicle and the upper fingers are pressing the needle down as a unit so that it goes down but is still inclined away from the lung. (C) Once the needle is in, the subclavian area has a distinct advantage over the internal jugular vein area, as the needle is held between the clavicle and the first rib and is better secured. (D) Wire, nick, dilate, and flush. Do not go too medially to avoid getting stuck between the first rib and the clavicle. (E) Aspirate, flush, sew, and dress.
Steps for inserting a femoral central venous line are shown in Fig. 42.4. The ipsilateral leg should be slightly abducted and externally rotated for access site exposure. The anatomic structures can be recalled by the mnemonic NAVEL (nerve, artery, vein, empty space, lymphatics-oriented lateral to medial). Use of ultrasound is recommended if available. The introducer needle is inserted 1 to 2 cm below the inguinal crease with the aim of puncturing the femoral vein as it emerges beneath the inguinal ligament. Vessel puncture and instrumentation above the inguinal ligament risks procedure-related hemorrhage that may be concealed in the retroperitoneum and is not easily compressible. The needle is advanced at a 20- to 30-degree angle to the skin toward the arterial pulsation. Preparation and Seldinger technique have been described earlier.
Complications Retroperitoneal hemorrhage can occur from posterior vessel injury without any evidence of superficial bleeding or hematoma formation and may go unrecognized.
Clinical Pearls • It is ergonomically easier for right-handed operators to target the right femoral vein. • Avoidance of this site or modified technique with a straight guidewire may be required in patients with indwelling inferior vena cava filters. • Any clinical consideration of a retroperitoneal hemorrhage must be ruled out immediately with a CT scan.
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Fig. 42.4 Femoral central venous line placement. (A) The mnemonic NAVEL is very useful for reviewing the anatomic landmarks (nerve, artery, vein, empty space, lymphatics). (B) Apply local anesthesia generously. (C) Using the hollow needle, advance until dark venous blood is observed. (D) Hold the needle steady, wire it up, and proceed using the standard Seldinger technique. (E) Nick the skin, dilate, and pass the line. (F) Aspirate, flush, sew in place, and apply dressing.
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RADIAL ARTERIAL CANNULATION Continuous invasive arterial access is indicated for close blood pressure monitoring and for reliable serial blood gas sampling. The radial artery is the most commonly selected site.25–29 This site is contraindicated following radial artery harvest as a bypass conduit and in cases of preexisting arterial insufficiency to the hand.
Equipment Equipment for radial arterial line placement includes the following: (1) antiseptic skin preparation, (2) a wrist board to hold the position once completed, (3) tape, (4) 1% lidocaine in a small syringe with a 25-gauge needle, (5) 20-gauge vascular cannula—a prefabricated arterial catheter-over-needle assembly with attached guidewire and sheath is common, with peripheral intravenous cannulas being an alternative option, and (6) transducer and pressure tubing.
Technique Steps for inserting a radial arterial line are shown in Fig. 42.5. First, as with all procedures, explain the procedure and obtain consent. Consider real-time ultrasound guidance, which may be associated with greater first-pass success.30 Set up all equipment prior to starting the procedure. Sitting in a comfortable position
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at the bedside is recommended over standing and bending over the target. Extend the target site wrist 20 degrees to flatten the thenar eminence and gain exposure to the site. Extending the wrist over a towel roll may help. Tape the hand to maintain this position. Apply chlorhexidine-based antiseptic skin preparation solution and allow it to dry followed by infiltration of local anesthetic at the intended puncture site. Target the distal vessel just proximal to the flexor crease. This allows a more proximal artery target in case of vasospasm or hematoma following a failed first attempt. Puncture the skin and slowly advance the needle or catheterover-needle assembly at a 15- to 30-degree angle along the long axis of the target vessel. The vessel lies less than 0.5 cm deep in most situations, which is more superficial than commonly recognized. Once inserted beyond the anticipated target depth, slowly withdraw the needle under close guidance while monitoring for blood flash. Some operators prefer a throughand-through technique in which the needle is intentionally inserted through and beyond the artery, with flash monitored during needle withdrawal. Once punctured, pressurized arterial blood should flow from the catheter or up the attached sheath. A flexible, straight guidewire is advanced over the wire to maintain access to the vessel. A 20-gauge catheter is then advanced in place over the guidewire and the needle and guidewire are removed.
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Fig. 42.5 Radial arterial line placement. (A) To approach the radial artery, one needs to go over the thenar eminence. (B) Extending the wrist allows a straight shot to the radial artery. (C) Approach at a shallow angle to get the needle in, then slide up a little more to get the catheter in as well. (D) Make sure that the blood keeps flowing as you advance. (E) Slide the catheter in, then hold down above the line so that the blood does not squirt out. (F) It is recommended to use a Luer-Lok to avoid disconnecting the line.
Following confirmation of arterial blood withdrawal, connect the pressure tubing to the catheter. Check the arterial tracing to ensure an appropriate waveform. Secure the catheter and wrist position with an arm board. If the first attempt fails, apply pressure to maintain hemostasis and reinsert at the same site or just proximal.
Clinical Pearls • Prepare all equipment and orient yourself in a comfortable position prior to attempting insertion. • Apply chlorhexidine skin preparation and ensure sterile insertion technique as in central venous access procedures. • Approach the artery via a shallow 15- to 30-degree angle. • Recognize the superficial position of the target vessel. • The wire should pass easily and smoothly without resistance. • Remove the catheter and consider vascular surgery consultation for signs of distal extremity ischemia.
Complications Distal arterial ischemia is the most feared complication, but is uncommon. Despite tradition, the Allen test is not a good screening test for arterial collateralization of the hand. The arterial catheter should be removed for evidence of distal ischemia. Other important complications include infection, dissection, vasospasm, arterial aneurysm, and vascular sclerosis.
FEMORAL ARTERIAL CANNULATION Indications and Contraindications Femoral arterial access31–33 is indicated for close blood pressure monitoring and arterial access for frequent blood sampling. The
femoral site is often selected for patients in shock or with absent or diminished radial pulses. This site is contraindicated in patients with recent femoral or iliac artery surgery, infection at the site, and severe aortoiliac disease, as monitoring will be inaccurate.
Equipment The equipment for femoral arterial line placement includes the following: (1) antiseptic skin preparation and sterile barrier equipment, (2) 1% lidocaine in a small syringe with a 25-gauge needle, (3) 18- or 16-gauge single-lumen cannula—often contained in prefabricated arterial or venous access kits, and (4) transducer and pressure tubing.
Technique Steps for inserting a femoral arterial line are shown in Fig. 42.6. If the operator is right-handed, the right femoral artery is easier to approach. Prep and drape in sterile fashion and have an assistant nearby. Apply local anesthetic. The ipsilateral leg should be slightly abducted and externally rotated for access site exposure. The lateral to medial anatomic landmarks can be recalled by using the mnemonic NAVEL. The needle is inserted 1 to 2 cm below the inguinal crease in anticipation of puncturing the femoral artery as it emerges beneath the inguinal ligament. Needle puncture above the inguinal ligament risks procedure-related hemorrhage that may be concealed in the retroperitoneum and is not easily compressible. The needle is inserted at a 20- to 30-degree angle to the skin toward the arterial pulsation. Ultrasound guidance should be used if available. Following arterial puncture, the arterial cannula is inserted via the Seldinger technique as described earlier, with the exception that guidewire-assisted insertion of the thin-walled arterial cannula does not require a tissue tract dilator or skin incision.
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Fig. 42.6 Femoral arterial line placement. (A) Shown is a good kit for a femoral arterial line. The needle is soft-tipped so that it does not erode and cause retroperitoneal bleeding. (B) Palpate the femoral pulse and remember the mnemonic NAVEL for anatomic structures going lateral-to-medial (nerve, artery, vein, empty space, lymphatics). (C) Apply local anesthetic generously. (D) Using the big hollow needle, advance until bright blood is observed. (E) Once the needle is in, proceed with the Seldinger technique, making sure that the wire goes in easily. (F) A small nick is enough for the 16-gauge catheter to go in easily. (G) Dilate with caution to avoid a major bleed. (H) Slide the catheter up, check the location again, connect the tubing, sew in place, and apply dressing.
Clinical Pearls • Optimize patient and provider positioning prior to starting the procedure. • The femoral artery is smaller than most central venous access targets. Pre-position the guidewire for rapid insertion through the needle to avoid losing access to the vessel. • Any clinical consideration of a retroperitoneal hemorrhage must be ruled out immediately with a computed tomographic scan.
Complications Vascular complications—including hemorrhage, arterial thrombosis with malperfusion, pseudoaneurysm, dissection, and
arteriovenous fistula—are rare but well recognized. Appropriate technique and monitoring following placement are important. Occult bleeding deep to the vessel and in the retroperitoneum may occur with puncture superior to the inguinal ligament. The absence of superficial hematoma formation does not exclude the presence of a retroperitoneal hemorrhage. Arterial cannulas are associated with catheter-associated bloodstream infection and deserve vigilant sterile technique and maintenance.34 The full reference list for this chapter is available at ExpertConsult.com.
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17. Parienti JJ, du Cheyron D, TImsit JF, et al. Meta-analysis of subclavian insertion and nontunneled central venous catheterassociated infection risk reduction in critically ill adults. Crit Care Med. 2012;40(5):1627–1634. 18. Kitigawa N, Oda M. Proper shoulder position for subclavian venipuncture. Anesthesiology. 2004;101:1306–1312. 19. Fragou M, Gravvanis A, Dimitriou V, et al. Real-time ultrasoundguided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med. 2011;39(7):1607–1612. 20. Thompson ED, Calver LE. Safe subclavian vein cannulation. Am Surg. 2005;71:180–183. 21. Ge X, Cavallazzi R, Li C, et al. Central venous access sites for the prevention of venous thrombosis, stenosis and infection. Cochrane Database Syst Rev. 2012;(3):CD004084. 22. Marik PE, FLemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012;40(8):2479–2485. 23. Parienti JJ, Thirion M, Megarbane B, et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA. 2008;299(20):2413–2422. 24. Parienti JJ, Morgardon N, Megarbane B, et al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015;373(13):1220–1229. 25. Lovenstein E. Prevention of cerebral embolization from flushing radial artery cannulas. New Engl J Med. 1971;25:1414–1415. 26. Levin PD. Use of ultrasound guidance in the insertion of radial artery catheters. Crit Care Med. 2003;31:481–484. 27. Franklin C. The technique of radial artery cannulation. J Crit Illness. 1995;10:424–432. 28. McEllistrem RF, O’Toole DP, Keane P. Post-cannulation radial artery aneurysm: A rare complication. Can J Anaesth. 1990;37:907–909. 29. Slogoff S, Keats AS, Arlund C. On the safety of radial artery cannulation??? Anesthesiology. 1983;59:42–47. Mandel MA, Dauchot PJ. ???Radial artery cannulation in 1000 patients: Precautions and complications. J Hand Surg Am. 1977;2:482–485. 30. White L, Halpin A, Turner M, Wallace L. Ultrasound-guided radial artery cannulation in adult and paediatric populations: a systematic review and meta-analysis. Br J Anaesth. 2016;116(5):610–617. 31. Fowler GC. Arterial puncture. In: Pfenninger JL, Fowler GC, eds. Procedures for Primary Care Physicians. St. Louis: Mosby; 1994:340–347. 32. Bowdle TA. Complications of invasive monitoring. Anesth Clin North Am. 2002;20:571–588. 33. Cutler TD, Weidemann HP. Complications of hemodynamic monitoring. Clin Chest Med. 1999;20:249–267. 34. Lorente L, Santacreu R, Martin MM, et al. Arterial catheterrelated infection of 2,949 catheters. Crit Care. 2006;10(3):R83.
OUTLINE Peripheral Intravenous Cannulation, 447 Equipment, 447 Technique, 447 Clinical Pearls, 448 Complications, 448 Central Venous Access General Principles and Preparation, 449 Seldinger Technique, 449 Clinical Pearls, 449 Internal Jugular Vein, 449 Relevant Anatomy, 449 Landmark Technique, 450 Ultrasound-Guided Technique, 450 Clinical Pearls, 450 Complications, 450 Subclavian Venous Cannulation, 450 Technique, 450 Complications, 450 Clinical Pearls, 450
Femoral Venous Cannulation, 450 Complications, 452 Clinical Pearls, 452 Radial Arterial Cannulation, 453 Equipment, 453 Technique, 453 Clinical Pearls, 454 Complications, 454 Femoral Arterial Cannulation, 454 Indications and Contraindications, 454 Equipment, 454 Technique, 454 Clinical Pearls, 455 Complications, 455
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at the antecubital fossa requires the arm to maintain a straight position. When present, Y-shaped venous confluences are preferred targets. The dorsal hand, wrist, and forearm are common access sites. Use of a proximal tourniquet or blood pressure cuff accentuates the venous targets. Avoid tying the tourniquet in a tight knot. Focused manual pressure may be applied to distend a superficial jugular vein. Actively pumping the fist hastens venous engorgement at upper extremity sites. Steps for inserting a peripheral intravenous line are shown in Fig. 42.1. Always wear clean gloves. When targeting a venous Y-confluence, aim for the branch point. Local anesthesia may be infiltrated prior to cannulation but is not required. Apply traction with the nondominant hand to anchor the vein and keep the skin taut. Advance the catheter-over-needle assembly through the skin and into the vein while monitoring for a blood flash at the needle hub. The initial flash represents needle-tip penetration. Advance 1 to 2 mm to ensure that the entire needle tip is within the vessel before advancing the catheter into the vein. Maintain the needle in position and release the tourniquet. Next, remove the needle and discard it. Connect the intravenous
Patients in the cardiac intensive care unit (CICU) require reliable intravenous access.1–3 Dependable peripheral vein cannulation technique is an essential tool to establish intravenous access in critically ill patients.
Equipment Equipment for peripheral venous access includes the following: (1) 16-, 18-, and 20-gauge intravenous (IV) catheter over needle units with backup supplies, (2) alcohol swabs, (3) tourniquet, (4) TB or 3-mL syringe with 1% lidocaine, (5) 25-gauge needle, (6) short connector IV tubing flushed with sterile crystalloid, and (7) Steri-Drape and tape to secure the access.
Technique Although any vein may be utilized for emergency access, distal upper extremity veins and superficial jugular veins are prime peripheral cannulation targets. Note that highly mobile sites may limit reliability following insertion. For example, cannulation
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J Fig. 42.1 Peripheral intravenous line placement. (A) Lay out all the equipment in an organized way. (B) Look for a good vein, ideally one shaped like an inverted Y. (C) Make sure that the tourniquet can be undone with one hand. (D) Try to get the vein to stand out. (E) Apply alcohol wipe and administer lidocaine. (F) Pull the skin taut and keep it taut. (G) Approach at a shallow angle to get the needle and catheter tip in. (H) Without letting go of the taut skin, advance the catheter. (I) Undo the tourniquet. (J) Hold down above the catheter.
connector tubing and secure the catheter. Monitor for subcutaneous infiltration while gently flushing the catheter with sterile crystalloid.
Clinical Pearls • Prepare all equipment, including backup supplies, prior to the first venipuncture attempt. • Long intravenous tubing represents the greatest resistance to flow. For rapid large-volume resuscitation, a 16-gauge catheter is equally efficient to larger catheters. • Y-shaped venous confluences are easily anchored and represent high-yield targets for peripheral venous cannulation.
• Advancing 1 to 2 mm after the initial blood flash ensures that the needle tip is within the vein. Failure to advance the needle following initial blood flash is a common mistake. • Adequately secure the IV access immediately after insertion.
Complications Known complications of peripheral venous access are phlebitis, infection, and extravasation. Adequate skin preparation, limited punctures, and diligent site monitoring are recommended to reduce complications. Poorly functioning access sites should be removed immediately once alternative access is obtained.
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CENTRAL VENOUS ACCESS GENERAL PRINCIPLES AND PREPARATION Central venous access is indicated in CICU patients who require reliable intravenous access, vasopressor administration, hemodynamic monitoring, temporary transvenous pacing, and hemodialysis access.4 Contraindications to central access are relative, depending on alternative vascular access options and the urgency of the situation. Anatomic distortion, local infection, and existing hardware justify avoiding specific sites when possible. Coagulopathy is not a contraindication to central access placement, but the procedural risk and patient benefits should be carefully weighed.4–6 Central access is often required emergently and obtaining consent may not be practical. In nonemergent circumstances, consent should be obtained prior to cannulation and should highlight the benefits and risks of the procedure. Infection, bleeding, arterial injury, venous thrombosis, and pneumothorax are all important risks to discuss.7,8 After consent is obtained, dedicate several minutes to optimal site selection and preparation. Most nonemergent central venous catheters in the CICU are placed in the internal jugular or subclavian vein. If ultrasound is available, the site should be investigated prior to skin preparation and draping. Abnormal vascular anatomy or visible clots may prohibit a preferred site. The Trendelenburg position is recommended for subclavian and jugular access if the patient can safely tolerate repositioning. A patient in severe respiratory distress may require intubation prior to obtaining central access. The neutral body position is ideal for most central lines with a few modifications. Patients may need to have breast tissue or an abdominal pannus retracted by an assistant or secured with tape to access a site. Once the site is selected and the patient is positioned, the skin should be cleaned. Chlorhexidine-based solutions reduce central line–associated blood stream infection (CLABSI) compared with povidone iodine-alcohol solutions.9–11 Full sterile precautions consisting of hat, face mask, eye shield, sterile gown, sterile gloves, and large sterile drape should be used for all central access procedures.12 A table large enough to accommodate the central line kit should be ergonomically positioned within the provider’s arm reach. Supplies should not be placed on the sterile drape as patients can unexpectedly move during the procedure. The insertion site should be anesthetized with 1% lidocaine. Ultrasound guidance is recommended for access procedures when available. It may be used to confirm appropriate anatomy and landmarks prior to instrumentation or provide dynamic real-time imaging to track needle penetration.
SELDINGER TECHNIQUE The modified Seldinger guidewire technique is standard for central venous and arterial access procedures. Initial vessel puncture is obtained with a large-bore, 18-gauge introducer needle or catheter-over-needle assembly. Needle trajectory and depth should be monitored closely throughout the procedure. Continuous negative pressure is applied to the aspirating syringe
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during needle advancement and withdrawal. Initial blood flash may be first recognized during needle withdrawal. The ability to continuously aspirate while maintaining strict control of the needle requires practice. Novice providers should be closely supervised. Venous puncture confirmation is important for central venous access procedures to avoid inadvertent arterial cannulation. Blood color, pulsatility, and ultrasound visualization may be misleading in certain circumstances.13 A 30-cm length of intravenous or pressure tubing can be used to gauge or transduce pressure prior to vessel dilation.14 The pressure tubing may be connected directly to the introducer needle or angiocath inserted over the needle or via guidewire. The guidewire is next advanced through the introducer needle to approximately 20 cm. The needle must remain stationary before the wire is inserted. Bracing the hand against the patient to steady the needle and avoid accidental needle movement is a common technique. The guidewire should pass easily with minimal resistance. If resistance is encountered, remove the wire, reconfirm blood aspiration, or reposition the needle trajectory or guidewire J-tip orientation prior to readvancing the guidewire. With the wire stabilized at 20 cm, the needle is removed and a small stab incision at the guidewire exit site is completed with a No. 11 scalpel. While stabilizing the guidewire, the tissue tract dilator is advanced over the guidewire through the skin and connective tissue to reach the vessel. Care must be taken to avoid advancing the wire and dilator together, as this can bend the wire and damage the vessel. The wire should always slide easily within the dilator during proper technique. Next, the dilator is removed while keeping the wire stationary and maintaining hemostasis at the site with firm pressure. The vascular catheter is then advanced into position over the guidewire using the same technique. Finally, the guidewire is removed, the catheter lumens are flushed, and the catheter is secured to the skin at the appropriate depth (usually 15 to 20 cm depending on access site and patient size).
Clinical Pearls • Arrange all supplies on a bedside table prior to starting the procedure. • Place the guidewire on the field in close proximity and brace the needle during syringe removal and guidewire insertion to avoid losing the target vessel during these steps. • Stabilizing the guidewire while advancing the dilator helps prevent guidewire kinking and vessel injury. • Hold the dilator close to the skin while advancing in small increments. • Novice operators focus heavily on procedural mechanics and may not identify patient deterioration during the procedure. Bedside assistance or supervision is highly recommended.
INTERNAL JUGULAR VEIN Relevant Anatomy The internal jugular vein originates at the jugular foramen and descends to join the subclavian vein. In the mid to lower neck, it lies lateral and then anterolateral to the carotid artery. At the level of the thyroid cartilage, the vein lies deep to the
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sternocleidomastoid muscle. The vessel emerges from behind the muscle into the triangle created by the sternal and clavicular insertions of the sternocleidomastoid muscle, just above the clavicle. Right-sided jugular cannulation is preferred owing to the direct path to the superior vena cava and to avoid risk to the left-sided thoracic duct.
Landmark Technique Steps for internal jugular central venous line placement are shown in Fig. 42.2. Turn the patient’s head 15 to 30 degrees to gain exposure to the access site. Turning the neck farther will compress and flatten the vessel. It is useful to mark the surface landmarks before starting the procedure. The apex of the sternocleidomastoid triangle or medial border of the posterior sternocleidomastoid muscle is a common needle insertion point. The carotid artery can be palpated medial to this point. A 22-gauge finder needle is inserted 30 degrees to the skin and aimed toward the ipsilateral nipple. After the internal jugular vein is located, the finder needle is kept in place, and the larger 18-gauge introducer needle mounted on a 5-mL slip tip syringe is inserted adjacent to the needle finder and along the same trajectory. Typical jugular vein depth is less than 2 cm from the skin surface but needle trajectory and patient variation may require deeper needle insertion. Following needle puncture, insert the catheter using the Seldinger technique as described earlier.
Ultrasound-Guided Technique Ultrasound-guided central line placement aids in identifying anatomic variations and is associated with improved success and reduced complications.15,16 Real-time dynamic ultrasound allows the provider to visualize the needle tip during insertion. It is important to recognize that the needle shaft and tip have a similar appearance. Vigilantly monitor needle insertion depth during the procedure.
Clinical Pearls • The sternocleidomastoid triangle and carotid artery pulsation are important surface landmarks. • Insert the needle at the apex of sternocleidomastoid triangle to maximize distance from the lung and avoid pneumothorax. • Orient the ultrasound screen to minimize head turning during the procedure. • An angiocatheter and pressure tubing allow accurate confirmation of venous access and can prevent inadvertent arterial dilation or catheter placement, which are associated with arterial occlusion and stroke.
Complications It is important to know how to manage pitfalls and complications associated with internal jugular cannulation. The most critical complications arise from carotid artery puncture or cannulation. Recognized puncture of the artery with immediate needle withdrawal and application of firm but nonocclusive pressure is usually uncomplicated. Major bleeding can lead to neck hematoma and airway compromise. Arterial cannulation can result in cerebrovascular insufficiency, vessel thrombosis, or pseudoaneurysm formation. If this occurs, leave the catheter
in place and consult a vascular surgeon for assistance with removal. Advancing the guidewire too deeply can induce dysrhythmias that are usually relieved by withdrawing the guidewire.
SUBCLAVIAN VENOUS CANNULATION Subclavian venous access is a common and often preferred access site based on the low risk of mechanical and infectious complications.17 Site-specific contraindications include clavicle distortion or indwelling local hardware (i.e., pacemakers or implantable cardioverter-defibrillators) and severe coagulopathy that may promote bleeding at this noncompressible site.
Technique Steps for subclavian central venous line placement are shown in Fig. 42.3. The left subclavian vein is the preferred site owing to low incidence of catheter malposition and direct insertion trajectory for emergency transvenous pacemaker or pulmonary artery catheter placement. Consider prioritizing cannulation ipsilateral to severe unilateral lung disease or an indwelling chest drain to minimize patient decompensation in the event of a procedure-related pneumothorax. Set up for the central line as described earlier with proper position and full sterile equipment. Consider having an assistant apply gentle caudal traction to the ipsilateral arm.18 Ultrasound guidance for subclavian cannulation is not standard but is described.19 Inject 1% lidocaine at the injection site for anesthesia. The introducer needle is inserted 2 cm lateral and inferior to the midclavicular point. Aim for the suprasternal notch and pass beneath the clavicle. Intentionally contacting the clavicle to “walk” the needle down the clavicle helps to maintain the needle in a plane parallel to the floor to reduce the risk of pneumothorax.20 Following vessel puncture, insert the catheter via the Seldinger technique as described earlier.
Complications Pneumothorax and subclavian arterial puncture are common concerns with the subclavian access approach but the rate of mechanical complication remains low.
Clinical Pearls • To avoid pneumothorax, the needle should be maintained parallel to the floor during insertion. • The subclavian vein is the preferred venous access site to reduce mechanical and infectious complications.
FEMORAL VENOUS CANNULATION Femoral venous catheters are generally avoided in favor of internal jugular or subclavian venous access but still have a role in certain scenarios, such as emergency situations and for hemodialysis access when the right internal jugular vein is not an option.21 The femoral site has historically been associated with an increased risk of infection, but more recent literature suggests only minor increased risk.22,23 Venous thrombosis is more common compared with jugular and subclavian vein access.24
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Steps for inserting a femoral central venous line are shown in Fig. 42.4. The ipsilateral leg should be slightly abducted and externally rotated for access site exposure. The anatomic structures can be recalled by the mnemonic NAVEL (nerve, artery, vein, empty space, lymphatics-oriented lateral to medial). Use of ultrasound is recommended if available. The introducer needle is inserted 1 to 2 cm below the inguinal crease with the aim of puncturing the femoral vein as it emerges beneath the inguinal ligament. Vessel puncture and instrumentation above the inguinal ligament risks procedure-related hemorrhage that may be concealed in the retroperitoneum and is not easily compressible. The needle is advanced at a 20- to 30-degree angle to the skin toward the arterial pulsation. Preparation and Seldinger technique have been described earlier.
Complications Retroperitoneal hemorrhage can occur from posterior vessel injury without any evidence of superficial bleeding or hematoma formation and may go unrecognized.
Clinical Pearls • It is ergonomically easier for right-handed operators to target the right femoral vein. • Avoidance of this site or modified technique with a straight guidewire may be required in patients with indwelling inferior vena cava filters. • Any clinical consideration of a retroperitoneal hemorrhage must be ruled out immediately with a CT scan.
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Fig. 42.4 Femoral central venous line placement. (A) The mnemonic NAVEL is very useful for reviewing the anatomic landmarks (nerve, artery, vein, empty space, lymphatics). (B) Apply local anesthesia generously. (C) Using the hollow needle, advance until dark venous blood is observed. (D) Hold the needle steady, wire it up, and proceed using the standard Seldinger technique. (E) Nick the skin, dilate, and pass the line. (F) Aspirate, flush, sew in place, and apply dressing.
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RADIAL ARTERIAL CANNULATION Continuous invasive arterial access is indicated for close blood pressure monitoring and for reliable serial blood gas sampling. The radial artery is the most commonly selected site.25–29 This site is contraindicated following radial artery harvest as a bypass conduit and in cases of preexisting arterial insufficiency to the hand.
Equipment Equipment for radial arterial line placement includes the following: (1) antiseptic skin preparation, (2) a wrist board to hold the position once completed, (3) tape, (4) 1% lidocaine in a small syringe with a 25-gauge needle, (5) 20-gauge vascular cannula—a prefabricated arterial catheter-over-needle assembly with attached guidewire and sheath is common, with peripheral intravenous cannulas being an alternative option, and (6) transducer and pressure tubing.
Technique Steps for inserting a radial arterial line are shown in Fig. 42.5. First, as with all procedures, explain the procedure and obtain consent. Consider real-time ultrasound guidance, which may be associated with greater first-pass success.30 Set up all equipment prior to starting the procedure. Sitting in a comfortable position
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at the bedside is recommended over standing and bending over the target. Extend the target site wrist 20 degrees to flatten the thenar eminence and gain exposure to the site. Extending the wrist over a towel roll may help. Tape the hand to maintain this position. Apply chlorhexidine-based antiseptic skin preparation solution and allow it to dry followed by infiltration of local anesthetic at the intended puncture site. Target the distal vessel just proximal to the flexor crease. This allows a more proximal artery target in case of vasospasm or hematoma following a failed first attempt. Puncture the skin and slowly advance the needle or catheterover-needle assembly at a 15- to 30-degree angle along the long axis of the target vessel. The vessel lies less than 0.5 cm deep in most situations, which is more superficial than commonly recognized. Once inserted beyond the anticipated target depth, slowly withdraw the needle under close guidance while monitoring for blood flash. Some operators prefer a throughand-through technique in which the needle is intentionally inserted through and beyond the artery, with flash monitored during needle withdrawal. Once punctured, pressurized arterial blood should flow from the catheter or up the attached sheath. A flexible, straight guidewire is advanced over the wire to maintain access to the vessel. A 20-gauge catheter is then advanced in place over the guidewire and the needle and guidewire are removed.
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Fig. 42.5 Radial arterial line placement. (A) To approach the radial artery, one needs to go over the thenar eminence. (B) Extending the wrist allows a straight shot to the radial artery. (C) Approach at a shallow angle to get the needle in, then slide up a little more to get the catheter in as well. (D) Make sure that the blood keeps flowing as you advance. (E) Slide the catheter in, then hold down above the line so that the blood does not squirt out. (F) It is recommended to use a Luer-Lok to avoid disconnecting the line.
Following confirmation of arterial blood withdrawal, connect the pressure tubing to the catheter. Check the arterial tracing to ensure an appropriate waveform. Secure the catheter and wrist position with an arm board. If the first attempt fails, apply pressure to maintain hemostasis and reinsert at the same site or just proximal.
Clinical Pearls • Prepare all equipment and orient yourself in a comfortable position prior to attempting insertion. • Apply chlorhexidine skin preparation and ensure sterile insertion technique as in central venous access procedures. • Approach the artery via a shallow 15- to 30-degree angle. • Recognize the superficial position of the target vessel. • The wire should pass easily and smoothly without resistance. • Remove the catheter and consider vascular surgery consultation for signs of distal extremity ischemia.
Complications Distal arterial ischemia is the most feared complication, but is uncommon. Despite tradition, the Allen test is not a good screening test for arterial collateralization of the hand. The arterial catheter should be removed for evidence of distal ischemia. Other important complications include infection, dissection, vasospasm, arterial aneurysm, and vascular sclerosis.
FEMORAL ARTERIAL CANNULATION Indications and Contraindications Femoral arterial access31–33 is indicated for close blood pressure monitoring and arterial access for frequent blood sampling. The
femoral site is often selected for patients in shock or with absent or diminished radial pulses. This site is contraindicated in patients with recent femoral or iliac artery surgery, infection at the site, and severe aortoiliac disease, as monitoring will be inaccurate.
Equipment The equipment for femoral arterial line placement includes the following: (1) antiseptic skin preparation and sterile barrier equipment, (2) 1% lidocaine in a small syringe with a 25-gauge needle, (3) 18- or 16-gauge single-lumen cannula—often contained in prefabricated arterial or venous access kits, and (4) transducer and pressure tubing.
Technique Steps for inserting a femoral arterial line are shown in Fig. 42.6. If the operator is right-handed, the right femoral artery is easier to approach. Prep and drape in sterile fashion and have an assistant nearby. Apply local anesthetic. The ipsilateral leg should be slightly abducted and externally rotated for access site exposure. The lateral to medial anatomic landmarks can be recalled by using the mnemonic NAVEL. The needle is inserted 1 to 2 cm below the inguinal crease in anticipation of puncturing the femoral artery as it emerges beneath the inguinal ligament. Needle puncture above the inguinal ligament risks procedure-related hemorrhage that may be concealed in the retroperitoneum and is not easily compressible. The needle is inserted at a 20- to 30-degree angle to the skin toward the arterial pulsation. Ultrasound guidance should be used if available. Following arterial puncture, the arterial cannula is inserted via the Seldinger technique as described earlier, with the exception that guidewire-assisted insertion of the thin-walled arterial cannula does not require a tissue tract dilator or skin incision.
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Fig. 42.6 Femoral arterial line placement. (A) Shown is a good kit for a femoral arterial line. The needle is soft-tipped so that it does not erode and cause retroperitoneal bleeding. (B) Palpate the femoral pulse and remember the mnemonic NAVEL for anatomic structures going lateral-to-medial (nerve, artery, vein, empty space, lymphatics). (C) Apply local anesthetic generously. (D) Using the big hollow needle, advance until bright blood is observed. (E) Once the needle is in, proceed with the Seldinger technique, making sure that the wire goes in easily. (F) A small nick is enough for the 16-gauge catheter to go in easily. (G) Dilate with caution to avoid a major bleed. (H) Slide the catheter up, check the location again, connect the tubing, sew in place, and apply dressing.
Clinical Pearls • Optimize patient and provider positioning prior to starting the procedure. • The femoral artery is smaller than most central venous access targets. Pre-position the guidewire for rapid insertion through the needle to avoid losing access to the vessel. • Any clinical consideration of a retroperitoneal hemorrhage must be ruled out immediately with a computed tomographic scan.
Complications Vascular complications—including hemorrhage, arterial thrombosis with malperfusion, pseudoaneurysm, dissection, and
arteriovenous fistula—are rare but well recognized. Appropriate technique and monitoring following placement are important. Occult bleeding deep to the vessel and in the retroperitoneum may occur with puncture superior to the inguinal ligament. The absence of superficial hematoma formation does not exclude the presence of a retroperitoneal hemorrhage. Arterial cannulas are associated with catheter-associated bloodstream infection and deserve vigilant sterile technique and maintenance.34 The full reference list for this chapter is available at ExpertConsult.com.
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