Use of intravenous access in resuscitation. Sites, Techniques, Potential complications FOS presentation 2 September 2009 Template

• Routine IV access in resucitation • Subclavian, Internal Jugular, Femoral central line technique • Complications of IV access • U/S guided IV access • Quick note on intraosseus and ETT access • 1) Basic IV access in resuscitation (see ATLS or ACLS guidelines). Choice of puncture location, choice of catheter size and length, single vs. • multilumen devices, etc. • 2) Complications of basic IV access • 3) Central IV access (femoral, subclavian, internal jugular) with emphasis on choice of IV site, indications and contraindications to each technique, as well as comparison of complications for each technique. • 4) I will touch on the use of Ultrasound in both peripheral and central intravenous access. • 5) I will touch briefly on alternate routes of access in resucitation (intraosseus, endotracheal, venous cut down) - again you can reference the current ACLS or ATLS guidelines. Decision algorithm Indications

• Select appropriate site for rapid fluid administration • Antecubital, forearm, saphenous vein, femoral puncture • 2 large calibre (minimum 16 gauge) IV • Rate of flow is proportional to the 4th power of the radius of the cannula and inversely related to the length (law of Poiseuille) • Short, large-calibre peripheral IVs are preferred for rapid infusion of large volumes of fluid. • The calibre of cannula is commonly indicated in gauge, with 14 being a very large cannula (used in resuscitation settings) and 24-26 the smallest Techniques

• Standard technique ‘blind’ • Tourniquet • Seldinger • U/S guided • cutdown Sites

• Radial branch of cephalic • Cephalic • Basilic • Median • Median cubital • Hand • External Jugular • Dorsal Pedal vein • Venous cutdown - saphenous

complications

• Phlebitis • Thrombophlebitis • Septic thrombophlebitis • Local infection/abcess • Infiltration • Hematoma • Nerve dammage complications

• Signs and symptoms of infiltration include: • swelling • pain • coolness of skin • leakage at site • erythema • blistering • lack of blood return Ultrasound guided peripheral IVs

• 51 patients that medics or ED RN could not get IV on • 46/51 successfully cannulated using ultrasound, 43 on first attempt – 4 were in brachial vein – Remainder in basilic, cephalic, antecubital, or forearm veins – Average time 2.5 minutes – Remaining 5 patients received central lines – One brachial artery puncture

Constantino TG, Fojtik JP. Success rate of peripheral IV catheter insertion by emergency physicians using ultrasound guidance (abstract). Academic Emergency Medicine 2003;10(5):487 Central catheters - indications

• Failed peripheral IV • Need for medications that can only be delivered centrally (certain pressors for example) • Use a sideport! • Femoral CVP – least sterile • Subclavian CVP – avoid in pts that are coagulopathic! Attention to lung injuries. • Internal Jugular CVP Vessel specifics

• IJ • Subclavian • Femoral techniques

• Blind • Seldinger • U/S guided Complications

• Femoral complications – DVT – Arterial or neurologic injury – Infection – AV fistula • Subclavian/Internal jugular complications – Pneumothorax – Venous thrombosis – Arterial or neurological injury – AV fistula – Chylothorax – Infection – Air embolis complications

– Increased # sticks directly correlated with increased complication

U/S guided access

– “In hospitals where US equipment is available and physicians have adequate training, the use of US guidance should be routinely considered for cases in which IJ venous catheterization will be attempted”

McGee DC, Gould MK. Preventing Complications of Central Venous Catheterization. NEJM 2003;348:1123-33 Vascular access options

• Peripheral IV • External jugular IV • US guided peripheral/basilic vein IV • Midline/PICC – US guided • Central line – landmark or US guided Adult IJ

• Denys et al “randomized” patients to IJ- US guided=928, Landmark=302 • Overall success 100% vs 88.1% • First attempt success 78% vs 38%

• Skin to vein time 9.8 (2-68) vs 44.5 (2-1000) sec • Carotid puncture 1.7% vs 8.3%

Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the internal jugular vein – a prospective comparison to the external landmark-guided technique. Circulation 1993;87:1557-62 Ultrasound access techniques

• “Static” – mapping technique – no sterile technique required for US • “Dynamic” – views needle entering vein • freehand • needle guide – requires sterile technique Static technique

• Position patient as you will for procedure • Look at vessels and confirm landmark- predicted anatomy • Mark location, note depths and angles • Remove ultrasound, prep patient without moving • Vein cannulated as usual Dynamic technique

• Place gel in palm of sterile glove • Place vascular probe in palm, avoid trapped air bubbles, and wrap free fingers out of way • Sterile KY jelly for glove-skin interface Dynamic technique

• Two potential approaches: – Transverse – Longitudinal Internal jugular

Medial Lateral

IJ

Carotid Internal jugular

Medial Lateral Internal jugular

Medial Lateral Vascular Access Intraosseus access

• Failure of IV access • Need for rapid fluid administration Intraosseus access

• Complications – Infection – Through and through penetration of bone – Subcutaneous or subperiosteal infiltration – Pressure necrosis of skin – Physeal plate injury – hematoma ETT drug administration

• Epinephrine • Nalaxone • Lidocaine • Atropine References

ATLS/ACLS guidelines • http://www.med.uottawa.ca/procedures/iv/ • Sabiston textbook of surgery, 18th edition – Chapter 5 – central venous catheters • http://www.pubmedcentral.nih.gov/articlerender.f cgi?artid=374364 – CVP preference • US – see article printouts • Intraosseus - http://www.allacademic.com/meta/p_mla_apa_re search_citation/0/6/4/8/9/p64896_index.html