Venous axis: Methods of obtaining peripheral venous access in difficult situations

11.02.201912.04.2021 by alexxlab

Содержание

Venous access

Authors: Bradley A. Wallace, MD; Todd Taylor, MD, Emory University School of Medicine, Department of Emergency Medicine
Editor: Matthew Tews, DO, MS; Medical College of Wisconsin

Introduction

Both vascular access and bedside ultrasound are vitally important aspects of Emergency Medicine and can often be used in conjunction with one another. Whenever there is difficulty in obtaining peripheral intravenous access by traditional means (i.e., sight or palpation), bedside ultrasound can be a useful adjunct to the procedure and can often succeed when other methods fail. Additionally, using ultrasound at the bedside when obtaining central venous access has become commonplace within Emergency Medicine and throughout the medical field. As vascular access as a whole has been described elsewhere on this site (https://cdemcurriculum.com/vascular-access/), this chapter will focus almost exclusively on using bedside ultrasound as an adjunct when obtaining vascular access.

Ultrasound-Guided Peripheral Intravenous Access

A vast majority of patients in the emergency department will ultimately require peripheral venous access. While venipuncture can be performed on many patients with ease, there are times when obtaining peripheral venous access on patients by traditional means can prove difficult. In situations such as these, the ultrasound machine is a very useful tool with a high success rate.1 Additionally, studies have shown that, when compared to traditional blind venipuncture techniques, ultrasound guided peripheral IV access is frequently more successful on first attempt, requires less time, reduces the number of needle punctures, and improves patient satisfaction.2

Patients on which to consider ultrasound-guided IV access

Self-proclaimed “hard sticks”
Patients with end-stage renal disease
Patients with a history of IV drug abuse
Obese patients
Patients with significant edema
Patients with sickle cell anemia or other blood dyscrasias
Severely dehydrated patients with poor landmarks

Selecting a Vessel

Location: Sites that are specifically good for ultrasound guided access include:

Antecubital fossa
Basilic vein of the medial upper arm
External jugular vein

Identifying the Vessel

After placing a tourniquet on the patient’s upper arm, use the linear ultrasound probe to evaluate for an appropriate vein making sure to differentiate between vein and artery. The characteristic differentiation between veins and arteries on ultrasound is collapsibility. When applying direct downward pressure with the ultrasound probe, veins should collapse easily while arteries will keep their cross-sectional circular shape.

Clip 1. When gentle downward pressure is applied with the ultrasound probe, veins will easily collapse while arteries will remain patent and often exhibit pulsatility.

Additionally, arteries will have thicker, hyperechoic walls as well as pulsatility when compared to veins.

Image 1. An artery (A) will have thicker, hyperechoic walls (arrows) when compared to veins (V).

If you have identified a vessel that you believe to be a vein but are still uncertain, it can be useful to turn on the ultrasound machine’s color flow. When color flow is turned on, a vein will have a low flow continuous color (or may sometimes be anechoic) while an artery will exhibit a higher velocity pulsatile flow.

Clip 2. The vessel at the center of the clip exhibits pulsatile color flow, indicating that it is an artery. The other vessels in the clip remain anechoic when color flow is turned on, indicating that they are veins.

Once you have identified a vein, it is important to evaluate its depth and size.

According to a 2010 study by Witting et al., ultrasound-guided IV access is more likely to be successful when the vein is:

Less than 1.5 cm below the skin
Greater than 0.4 cm in diameter3

When attempting to locate an appropriately sized vein, it can be useful to adjust the depth on the ultrasound machine to 2.0 cm or less. The advantages of this are twofold: it decreases attempts at IV placement on veins that are too deep as well as making superficial veins appear larger on the screen and therefore easier to successfully puncture.

In addition to evaluating the vessel’s depth and size it is a good idea to scan along the vessel lengthwise to determine its degree of tortuosity. If the vein is exceedingly tortuous it can be difficult to thread the IV catheter. Be sure to scan proximally and distally to your proposed puncture site to evaluate the trajectory of the vein.

Technique

Once you have identified an appropriate vessel as above, there are two views that can be used on the ultrasound machine for peripheral IV placement: short axis (cross-sectional) or long axis (longitudinal). Each method has its individual advantages and disadvantages, which will be discussed shortly. The supplies needed are the same for either method.

Supplies

High frequency linear ultrasound probe
Sterile gel/lubricant
Adhesive dressing (e.g., Tegaderm®)
IV catheter (ideally longer than 1.16 inches)
Tourniquet
Antiseptic solution

Image 2. Supplies needed for an ultrasound guided IV insertion.

Short Axis (Cross-Sectional) Approach

Apply tourniquet to upper arm
Cleanse the skin with antiseptic solution
Place adhesive dressing over ultrasound probe
Apply sterile gel/lubricant to ultrasound probe over adhesive dressing
Place ultrasound probe on skin perpendicular to the previously identified vein making sure to keep the cross-section of the vein at the center of the screen

Ensure that the ultrasound probe indicator is pointing to the patient’s right—i.e., the ultrasound operator’s left—so that the left side of the ultrasound screen corresponds to the ultrasound indicator

Image 3. Orientation of ultrasound probe for short-axis approach. Note the probe indicator pointing to the patient’s right (the operator’s left).

6. Pierce the skin at a 45O angle with the catheter at the center of the probe

7. Identify the hyperechoic needle tip on the screen

It may be useful to push the catheter up-and-down or fan the probe back-and-forth to help identify the needle tip on the screen

Clip 3. The hyperechoic needle tip is visualized proximal/superficial to the blood vessel. Note that when the needle is gently moved back-and-forth it can be more easily identified.

8. Pierce the vein looking for the “target sign” or “bull’s eye sign” (the hyperechoic needle tip in the center of the anechoic vessel)— you should see a corresponding flash of blood in the catheter once the needle tip has pierced the vessel

Image 4. Hyperechoic needle tip localized in blood vessel in short axis. This is called the “target sign” or “bull’s eye sign.”

9. Once the target sign is visualized, thread the catheter in the usual manner and secure the catheter to the skin with an adhesive dressing

10. The IV should now flush easily and painlessly if placed correctly

Long Axis (Longitudinal) Approach

Use the same technique as described in steps 1-4 of the short axis approach above
Place the ultrasound probe on the skin parallel to the axis of the previously identified vein with the probe indicator facing towards the patient’s head

Image 5. Orientation of ultrasound probe for long-axis approach. Note that the probe indicator is pointing towards the patient’s head.

3. Pierce the skin at a 45O angle just distal to the ultrasound probe with the needle at the center of the probe

4. Identify the hyperechoic needle tip on the right side of the screen

5. Advance the needle tip until you visualize it piercing the wall of the vessel on the screen— you will see a corresponding flash of blood in the catheter once the needle has pierced the vessel

Image 6. Hyperechoic needle tip localized in blood vessel in long axis.

6. Thread the catheter in the usual fashion and secure the catheter to the skin with adhesive

7. The IV should now flush easily and painlessly if placed correctly

Comparison of Methods

Both the short axis and long axis approaches have advantages and disadvantages. The main advantage of the short axis method is better lateral resolution (i.e., after piercing the skin, one is able to tell if the needle tip is lateral to the vein). The main drawback to the short axis technique is the requirement of moving the ultrasound probe dynamically to keep the needle tip on the screen.

Image 7. In a short axis view, the location of the ultrasound probe can result in the needle appearing to be in multiple different positions. Though the needle in the image above has gone entirely through the vessel, the needle appears to be proximal to the vessel using position 1, within the vessel using position 2, or through the back wall of the vessel using position 3.

Compared to the short axis method, the long axis technique allows the operator to visualize the entirety of the needle and see in real time as it enters the vein in profile, as illustrated in Image 6 above.

While the short axis method has good lateral resolution, the long axis method can be more technically challenging due to its poor lateral resolution (i.e., the needle can appear to be in the same plane as the vessel despite being just lateral to the vessel). Furthermore, with the long axis approach it can be easy to lose sight of the vein and accidentally re-focus the probe onto an adjacent artery with very small moves of the ultrasound probe.

If one is learning the technique for ultrasound-guided IV access for the first time, the short axis approach has been shown to be easier to learn than the long-axis approach for novice operators.4 Furthermore, a 2011 study demonstrated that the short axis method both resulted in a higher success rate and took less time than the long axis approach.5

The Videos in Clinical Medicine series by The New England Journal of Medicine provides a review of ultrasound-guided IV placement: http://www.nejm.org/doi/full/10.1056/NEJMvcm1005951

Ultrasound-Guided Central Venous Catheter Placement

While many patients in the emergency department can be successfully resuscitated with only peripheral access, some patients will require central venous access. Though central venous catheters have been associated with certain complications (e.g., pneumothorax, arterial puncture, bleeding, and infection), there have been multiple prospective, randomized controlled trials and several meta-analyses that have shown that the use of real-time ultrasound guidance during catheter placement has reduced the number of complications as well as reducing the number of cannulation attempts when compared to using landmarks alone.6-9

Note: Central venous access is discussed in depth elsewhere on this site; as such, this chapter will focus on using ultrasound to locate and cannulate central veins. For further information on central venous catheter placement, including indications, contraindications, and the individual steps required for the entirety of the procedure, please refer to the Vascular Access chapter (https://cdemcurriculum.com/vascular-access/).

Location Selection

The three traditional locations for central venous line placement are the internal jugular vein, the femoral vein, and the subclavian vein. The technique for ultrasound-guided central line placement into the internal jugular vein and femoral vein is nearly identical; as such, the discussion here will focus mainly on placement into the internal jugular vein as it tends to be the favored location for central line placement. While the use of ultrasound for subclavian central line placement is becoming more popular, this is a more advanced technique and will not be discussed in this chapter.

Anatomy

Image 8. Anatomy of major neck vasculature. Both the internal jugular vein and common carotid artery are located in an anatomic triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle. (Image courtesy of Sierra Beck, MD.)

Technique

As discussed in the ultrasound-guided peripheral IV access section above, the ultrasound machine can be used to visualize blood vessels in both short axis and long axis. The materials needed are the same for both, though the technique varies slightly. The short axis approach will be discussed first.

Supplies

Central line kit (including drape)
Sterile gown/gloves/cap
Probe cover kit (with sterile gel)
Ultrasound machine with linear probe

Image 9. Supplies needed for ultrasound guided central line insertion.

Short Axis Approach—Internal Jugular Vein

Standing at the head of the bed, place the ultrasound machine to patient’s right or left depending on which internal jugular vein you plan to cannulate. Some operators prefer the machine on the ipsilateral side to the internal jugular vein that is being accessed while others prefer the ultrasound machine on the contralateral side— this is largely a matter of personal preference
Place patient in Trendelenberg position
Have patient turn head contralaterally to the desired puncture site
Apply gel to linear ultrasound probe
Place probe on patient’s neck just above the clavicle, making sure to have the indicator pointing to the patient’s (and the operator’s) left side so that the left side of the probe corresponds to the left side of the ultrasound machine
Walk probe proximally and distally in an attempt to find a site where the internal jugular vein is largest and relatively remote from the carotid artery. Keep in mind that movements of the patient’s head may alter vascular anatomy greatly
Remember that arteries are typically thick-walled, pulsatile, and non-collapsible when applying pressure with the ultrasound probe while veins are thin-walled, non-pulsatile, and collapse easily when applying pressure with the probe (see Clip 1 and Clip 2 above for how to better differentiate arteries and veins).After locating an appropriate puncture site, remove gel from patient’s neck and apply appropriate sterilizing solution (e.g., Chlorhexadine, betadine, etc.)
Open central line kit, don sterile gown, hat, mask and gloves, and open ultrasound probe cover
While you hold the ultrasound probe cover, have an assistant apply ultrasound gel to ultrasound probe and drop probe into cover making sure to keep probe cover sterile

Image 10. Sterile gloved hand holding sterile probe cover open while an assistant places the ultrasound probe into the probe cover.

10. Place sterile ultrasound gel on outside of probe cover

11. Anesthetize skin overlying the puncture site

12. Place ultrasound on patient’s neck perpendicular to orientation of vasculature

13. Pierce skin at 45o angle at the center of the ultrasound probe (keeping the vessel in the middle of the screen) making sure to continuously aspirate immediately after piercing skin

Image 11. Ultrasound operator in foreground with sterile gloves piercing skin at 45o angle to the skin at center of the ultrasound probe. Note that the operator is continuously aspirating given that the needle tip has pierced the patient’s skin. In the background of the image, note that the ultrasound image is centered on the hypoechoic internal jugular vein in short axis as the operator is advancing the needle towards the vessel.

14. Identify the hyperechoic needle tip in relation to the internal jugular vein. It may be useful to fan the probe back-and-forth or gently bounce the needle up-and-down in the soft tissue when attempting to locate the needle tip. Be sure to keep the needle tip on the screen by advancing the ultrasound probe along the skin as you advance the needle—this will ensure the you do not inadvertently cannulate the wrong vessel (viz., the artery)

15. Once you note the bull’s eye or target sign (see Image 4 above) you should have aspiration of blood into the syringe

16. When aspiration of blood is confirmed, place the ultrasound probe on the sterile drape, remove the syringe from the needle, and advance the guidewire

17. Remove the needle from the skin

18. Grab the ultrasound probe and place it on the patient’s neck to obtain a longitudinal view of the internal jugular vein. If the wire is appropriately positioned, you will be able to visualize a hyperechoic structure (the wire) in long axis on the ultrasound machine

Image 12. Hyperechoic guidewire localized in internal jugular vein.

19. Complete placement of the central venous catheter using the Seldinger technique and secure the catheter to the skin

20. Obtain chest X-ray to confirm appropriate positioning of central venous catheter

Long Axis Approach—Internal Jugular Vein

Carry out the same steps as above (steps 1-13)
Place ultrasound probe on skin parallel to venous structures when surveying vascular anatomy. Ensure that the probe indicator is oriented towards the patient’s head, corresponding to the left side of the ultrasound screen
When piercing the skin at 45o angle, be sure that the entire vessel is visualized on the screen
With the probe indicator oriented towards the patient’s head, you should see the needle tip enter the left side of the screen after piercing the skin
Once you visualize the needle tip enter the vessel (see Image 6 above), you should note aspiration of blood into the syringe
Place probe onto sterile drape, remove syringe, and thread guidewire
Place ultrasound probe back onto skin in long axis, attempting to visualize the guidewire within the vessel in long axis— it is critical to verify the location of the guidewire prior to dilation (see Image 12 above)
Complete placement of the central venous catheter using the Seldinger technique and secure the catheter to the skin
Obtain chest X-ray to confirm appropriate positioning of central venous catheter and ensure that there is no iatrogenic pneumothorax

Note: The femoral vein can be accessed using the same steps as above. When surveying femoral anatomy, keep in mind that the femoral vein is located medially to the femoral artery.

Conclusion

While both peripheral venous access and central venous access were traditionally performed using palpation or anatomic landmarks, the use of ultrasound for both procedures has become more prevalent in Emergency Medicine. Using ultrasound guidance while performing peripheral IV placement has been shown to be a robust alternative to traditional approaches on patients whom venipuncture has proven difficult while also helping to improve patient satisfaction. Similarly, ultrasound guided central line placement has been shown to decrease both number of attempts at cannulation and complications of the procedure. As such, the ultrasound machine should be a consideration whenever contemplating venous access strategies in the emergency department.

References

Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med. 1999 Dec. 34(6):711-4.
Costantino TG, Parikh AK, Satz WA, Fojtik JP. Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med. 2005 Nov. 46(5):456-61.
Witting MD, Schenkel SM, Lawner BJ, Euerle BD. Effects of vein width and depth on ultrasound-guided peripheral intravenous success rates. J Emerg Med. 2010 Jul. 39(1):70-5.
Blaivas M, Brannam L, Fernandez E. Short-axis versus long-axis approaches for teaching ultrasound-guided vascular access on a new inanimate model. Acad Emerg Med. 2003 Dec. 10(12):1307-11.
Mahler SA, Wang H, Lester C, Skinner J, Arnold TC, Conrad SA. Short- vs long-axis approach to ultrasound-guided peripheral intravenous access: a prospective randomized study. Am J Emerg Med. 2011 Nov. 29(9):1194-7.
Leung J, Duffy M, Finckh A. Real-time ultrasonographically guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications:a randomized, prospective study. Ann Emerg Med. 2006;48:540-547.
Karakitsos D, Labropoulos N, De Groot E, et al. Real-time ultrasound guided catheterization of the internal jugular vein: A prospective comparison to the landmark technique in critical care patients. Crit Care. 2006;10:R162.
Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: A meta-analysis of the literature. Crit Care Med. 1996;24:2053-2058.
Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, Thomas S. Ultrasonic locating devices for central venous cannulation: Meta-analysis. BMJ. 2003;327:361.

Methods of obtaining peripheral venous access in difficult situations

The placement of peripheral intravenous lines forms a significant part of the workload of junior medical1
2and, increasingly, nursing staff3-6 in a hospital environment. However, peripheral venous line placement can be difficult, especially at the extremes of age or if the patient is obese, dark skinned, an intravenous drug abuser, is hypotensive or has multiple injuries limiting the number of limbs available for use.

Central venous line placement is not to be undertaken lightly as a substitute for difficult peripheral venous access. The procedures involved usually require a high level of operator skill, as well as conferring a risk of morbidity and mortality.7-9 Central venous lines can, in any case, be inserted via peripheral veins if required.10
11

We therefore decided to review methods of obtaining peripheral venous access, with emphasis on difficult situations. We believe that proper selection of site and optimal technique will minimise the need for repeated attempts at venous access. We have devised an algorithmic approach to help in this situation.

We carried out a Medline search for the years from 1980 to 1998 using the keywords ‘peripheral venous access’ and ‘venous cannulation’. We chose 35 articles for the purposes of the review. This includes a 1975 reference obtained by cross-referencing the articles initially generated. We also manually searched current textbooks on anaesthetics, intensive care, emergency medicine, phlebotomy and acute paediatrics. All the articles chosen were in the English language.

Methods of improving venous prominence and/or locating peripheral veins

In general, the upper limb is the preferred site for placing an intravenous cannula. This is because of the increased incidence of thrombophlebitis and thrombosis with lower limb infusions,12
13 as well as the need to often immobilise the patient if a drip is sited in the lower limb. The non-dominant upper limb is preferred as an initial option.

An attempt should initially be made to locate visible veins with the limb dependent, that is, below the level of the heart. A visible vein should also be easily compressible in order to qualify for use. The vein should be palpated by the operator’s index finger to determine the relative size of the vessel and the direction in which it runs. A firm to hard non-compressible vein is indicative of thrombosis and not suitable for further efforts at venous access.

If the peripheral veins are not prominent and need to be made more prominent, gentle slapping of the skin overlying the vein may make it more prominent. The mechanism by which this occurs is unclear. This slapping must not be too firm as pain may cause reflex vasoconstriction. Milking the vein from proximal to distal may also increase venous prominence. Venous prominence is further augmented by the use of a proximal venous tourniquet. This can be either a purpose-made tourniquet or the tourniquet effect can be achieved by manual proximal circumferential compression of the limb by an assistant. The tourniquet should be applied 5–10 cm proximal to the selected site. This compression must be sufficient to permit arterial inflow whilst restricting venous outflow. In order to get accurate control of outflow occlusion, a sphygmomanometer cuff may be used. There are various views on what inflation pressure is best for this purpose but consensus opinion appears to indicate a choice of at or just below diastolic pressure.14-16 Manual limb compression by an assistant is difficult to control and, in our experience, a purpose-made tourniquet is preferable. Prolonged application of a venous tourniquet, for more than 5 minutes, increases venous tortuosity and fragility and should thus be avoided.

If venous prominence is not improved by these measures, asking the patient to grip and relax their hands repeatedly, and application of a warm compress (pads soaked in lukewarm water) for at least 2–3 minutes will improve venous visibility. This is achieved by increased local blood flow which increases venous distension. Immersing the limb in warm water may achieve the same effect. The use of betadine swabs is reportedly helpful in dark skinned patients.17 Gently wiping the skin with an alcohol swab may help visualisation of the vein as the reflection of the light off the skin changes.18

Transillumination may help at this stage. The lights in the treatment room need to be turned off and a torch can be placed under the limb to visualise the veins. Venous visualisation may also be possible, even with haematoma formation and with previously punctured veins. The Landry light is a portable battery-operated device which uses a halogen light source delivered through dual fibre-optic arms which rotate 360°. Veins can be identified between the fibre-optic arms as dark lines in the pinker subcutaneous tissue. Surface veins appear darker and more defined than the diffuse lines of deep veins. It does, however, require experience in interpreting visual cues, which is not difficult to acquire.19-21 Topical venodilatation may be achieved by the application of 4% nitroglycerine ointment, smeared onto the skin and left for 2–3 minutes.22-24

A venous distension device has been evaluated in adults in whom non-emergent intravenous cannulation was found to be difficult. This essentially relies on the production of a vacuum around the limb distal to a tourniquet.25
26 The device is a plastic film-covered cardboard mailing tube that can be placed over the forearm. A rubber sleeve attached to the distal end forms a seal after a blood pressure cuff is wrapped around the sleeve and the upper arm. A rubber squeeze bulb is attached to the distal end of the device and is used to generate a vacuum within the device. The cuff is used as a tourniquet. Although initial results were promising, the method does not seem to have gained widespread acceptance.

Infusion of small veins beyond a proximal tourniquet with a bolus of warm crystalloid may help in improving visualisation of larger veins, when large bore access is required.27
28

Ultrasound-guided venepuncture has been described for placement of central venous lines via peripheral veins.29-33 This is operator dependent, with a long learning curve, but with increasing availability of ultrasound facilities in accident and emergency departments and perhaps on general wards and in clinics, may become an option for the near future. The use of a transversely oriented 7.5 MHz linear transducer is helpful to locate superficial veins (see figure 1) which can be identified even in the presence of oedema. In one study, a hand-held Doppler was felt to accurately identify forearm veins larger than 2 mm in diameter in patients with invisible and impalpable veins, in the presence of a venous tourniquet.34

Figure 1

Transverse scan of right antecubital region, without tourniquet, using 10 MHz linear array probe. A = artery; V = vein; NS = shadow of needle/cannula assembly

Peripheral venous cut-down is suggested as an option for securing venous access in an emergency situation, especially in multiple trauma victims.35 A skin incision can be made directly over either the long saphenous vein in the ankle or the median basilic vein in the elbow. The vein is exposed by blunt dissection and cannulated under direct vision after making a small incision in the wall and ligating the distal end. The cannula is secured with another ligature to the proximal end_. Even if the operator is not familiar with this procedure, a catheter over needle assembly can be introduced into the vein under direct vision.

There are a variety of methods described to improve peripheral venous access. The use of a sequential algorithmic approach (see figures 2 and3) and the employment of adjunctive measures should make venepuncture less of an ordeal than it can be. A view has been expressed that structured venepuncture training is essential and we would concur with this view.36

Figure 2

Algorithm for peripheral venous access in adults

Figure 3

Algorithm for peripheral venous access in children

Safe Central Venous Access in an Overburdened Health System | Critical Care Medicine | JAMA

A previously healthy man, intubated in the intensive care unit (ICU) for respiratory failure due to coronavirus disease 2019 (COVID-19), required central venous access for vasopressor infusion. The intensivists were occupied managing other critically ill patients, so an available intern attempted to place a triple-lumen catheter in the right internal jugular vein using only anatomic landmarks for guidance. When the access needle was inserted, pulsatile return of blood was noted.

What Should Be Done Next?

Remove the needle and hold pressure.
Place a small single-lumen catheter to prevent bleeding.
Use a percutaneous closure device to close the puncture site.
Surgically expose the artery to remove the needle and repair the artery.

With immediate recognition of the arterial puncture and only the access needle in place, the needle can safely be removed and prolonged pressure held over the site for 10 to 30 minutes.¹ The risk of hematoma or pseudoaneurysm formation is low and can be further reduced by using a small 22-gauge or 25-gauge micropuncture needle for the access.¹ The tract should not be dilated by placement of a single-lumen catheter. Percutaneous arterial closure devices have been effectively used off label for repair of iatrogenic carotid artery injuries associated with central venous access when a large-bore catheter has been placed.² However, given that the artery was not dilated and the catheter was not yet placed, neither percutaneous closure nor surgical repair is indicated. In the unlikely event that despite prolonged pressure a hematoma or pseudoaneurysm results, surgical repair may be required.

This iatrogenic arterial injury associated with a central venous access procedure may have resulted from several factors, including failure to use ultrasound guidance, which is the contemporary standard practice, and central line placement attempt by an inexperienced and likely inadequately trained operator.³

Placement of central venous access, a routine occurrence in critical care units and emergency departments, poses a unique challenge during health care crises when experienced clinicians are overburdened with acutely ill patients. To better utilize the specialized skills of the available workforce and maximize patient safety during the COVID-19 pandemic, central venous access line teams have been developed to address the venous access needs of hospitalized patients.⁴^,5 The teams typically include vascular surgeons, general surgeons, interventional radiologists, and anesthesiologists, all specialists with training and experience in central venous access. During the height of the COVID-19 pandemic and other health care emergencies, elective operations and procedures were deferred, freeing up personnel and resources that could serve on line insertion teams. These specialists also have experience identifying and managing the complications associated with these procedures. Some line insertion teams also placed arterial lines, orogastric and nasogastric tubes, and Foley catheters to further assist other overburdened clinicians.⁵

To evaluate the implementation and outcomes of these central venous access line teams, a cross-sectional, self-reported multi-institutional study was performed.⁵ Sixty hospitals in 13 countries and 37 US states contributed data regarding their experiences of creating and implementing line insertion teams. They also reported on technical aspects of the central venous access procedures in the pandemic setting and the management of associated iatrogenic complications. Of the 60 hospitals, 58 had designated teams of clinicians available for central line placement. Most of these hospitals did not have line insertion teams prior to the pandemic. Line insertion team protocols were rapidly developed to address urgent and unique venous access requirements during the pandemic. Most of the participating hospitals were urban, academic, university-affiliated hospitals with more than 400 beds. Data were collected between April 22 and May 4, 2020. Most line insertion teams provided services for ICU patients with positive or pending COVID-19 test results. Some teams also placed lines in COVID-19–negative patients to assist the overburdened ICU teams, and some also placed lines for patients in the medical/surgical units or in the emergency department. All centers continued to adhere to standard practice and use ultrasound guidance for central venous access procedures whenever possible, including confirming wire position in the long-axis ultrasound view.

There were 2657 lines placed in patients with positive, pending, and negative COVID-19 test results in the 20 participating sites that were able to report the total number of lines placed. Of these, 11 (0.41%) line placements were associated with iatrogenic complications, less than the expected complication rate of 4% to 9%.⁶^-9 There were 2 inadvertent arterial catheter placements, 7 puncture-site bleeding episodes (hematoma or active bleeding), 1 pneumothorax, and 1 air embolism. The air embolism was in a patient with COVID-19 who was not intubated, and the patient died shortly thereafter. This was the only death reported from these sites that was directly related to an iatrogenic venous access complication. The lower-than-expected complication rate might have been attributable to the greater level of experience and expertise of the vascular access teams.

Line insertion teams managed a total of 48 iatrogenic complications in COVID-19–positive patients at 23 of the 60 participating sites. Most (39/48) complications were associated with line placement procedures performed by clinicians who were not part of the line insertion team. In 20 of the 48 complications, the participating site reported that the complications were attributable to insufficient operator experience and inadequate use of ultrasound or wire control during the procedures. Every line insertion team reported using ultrasound guidance for all procedures, but this was not the case for lines placed by clinicians who were not associated with the line insertion teams.

When initiating a central venous access line team, an appropriate schedule for the team’s activation should be established based on available resources and institutional needs. Ideally, the team should be available at all times and be able to provide service throughout the hospital; any limitations of hours or sites served should be communicated clearly to all relevant hospital personnel. The activation and conclusion of line insertion team services should be tailored to the needs of the institution and the requirement of the line insertion team members’ expertise in other clinical areas. Understanding variations in individual institutional resource allocation and having open communication between relevant stakeholders is key to providing appropriate, high-quality service to all hospitalized patients at the optimal time and place. In preparation for future surges of the COVID-19 pandemic and other health care emergencies, protocols should be developed that include central venous access line teams composed of physicians with percutaneous vascular access expertise, development of standardized protocols, and a method to track procedural outcomes.

An adequately stocked line cart increases the efficiency of line placements. This cart should have all the supplies and personal protective equipment (PPE) necessary to safely perform the procedures. An appropriately stocked cart minimizes potential clinician exposure to infectious agents and allows for a more streamlined performance. Further increases in the efficiency of clinician utilization can be realized by limiting the number of clinicians in the room performing the procedure to 2, with a runner outside the room to retrieve additional supplies as needed. This likewise can preserve PPE and minimize personnel exposed to infectious agents.

The internal jugular vein was the preferred anatomic location for central venous access used in this study of 60 hospitals during the COVID-19 pandemic due to ease of accessibility by ultrasound. Subclavian lines were discouraged, given the known increased incidence of pneumothorax compared with internal jugular lines. Due to the frequent use of prone positioning in patients with COVID-19, study participants reported successfully placing a triple-lumen catheter in the popliteal vein under ultrasound guidance with techniques commonly used in the lysis of iliofemoral deep vein thrombosis (Video).¹⁰ This demonstrates the ability of clinicians with appropriate specialized technical expertise to adapt to unusual challenges that may be imposed by a health care crisis. A caveat of placing central lines in the popliteal vein is a potential increase in the risk of deep vein thrombosis. Thus, each case should be carefully considered and executed with caution.

The needle was removed and pressure was held for 20 minutes. The patient did not develop any clinical signs of a hematoma or pseudoaneurysm during the hospitalization, which was confirmed by ultrasound.

Box Section Ref ID

Bottom Line

Even during a health care emergency, standard practices including use of ultrasound guidance for central venous access and prioritization of standard anatomic locations should be maintained to minimize procedural complications.
Dedicated central venous access line teams composed of physicians trained in percutaneous central venous access can ease a stressed health care system during a health care crisis.
Appropriately staffed dedicated central venous access line teams can perform high volumes of procedures with low procedural complication rates.
Planning for future health care emergencies should include protocols for central venous access line teams that describe staffing, a dedicated line cart, recommendations on the optimal anatomic site and technique, and a method to evaluate outcomes.

Corresponding Author: Karen Woo, MD, MS, Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, 200 UCLA Medical Plaza, Ste 526, Los Angeles, CA 90095 ([email protected]).

Conflict of Interest Disclosures: None reported.

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D, Mathews
BK,
et al. Recommendations on the use of ultrasound guidance for central and peripheral vascular access in adults. J Hosp Med. 2019;14:E1-E22. doi:10.12788/jhm.3287PubMedGoogle ScholarCrossref

Approach to Difficult Vascular Access

Intravenous (IV) access is a basic and invaluable skill for emergency physicians. For patients requiring rapid fluid resuscitation, airway management, or medication administration, the placement of one or more IV lines is absolutely essential. Most patients do well with a simple, landmark-based, blind placement of a superficial peripheral IV. However, we often encounter situations where this may be difficult or impossible to achieve, and so we all should have a repertoire of other sites and techniques to employ.

[su_tabs vertical=”yes”][su_tab title=”US-Guided Deep Peripheral IVs”]

Ultrasound (US)-guided IV placement has been shown to be safe, quick, and patient-friendly in adults and children [1, 2]. In at least 10% of patients, we encounter in the ED, blind insertion of a peripheral IV may be complicated by obesity, edema, IV drug use, surgical scars, dialysis, burns, etc. Obtaining peripheral IV access rapidly can avoid the time and risk associated with central venous catheterization or the discomfort of intraosseous access.

Deep veins of the upper arm are generally larger and are the best targets, especially the basilic and cephalic veins.

Ideal in these situations: Peripheral IV candidates complicated by obesity, IV drug use, or inability to lie flat for procedures

Not ideal in these situations: Central access needed, cardiac arrest

Optimal positioning: Ideally, position patient with shoulder slightly abducted, elbow completely extended, forearm completely supinated. The ultrasound machine should be placed next to the patient’s head or on the opposite side of the bed, so that you turn your neck as little as possible.

Method:

Use a long (1.8 or 2.5 inch) catheter because it typically needs to traverse through more tissue to a deep vein.
Clean the ultrasound transducer should be cleaned and apply sterile lubricant.
Apply a tourniquet proximal to the site.
Use universal precautions.
Clean the skin just distal to the probe with an antiseptic swab.
Use the linear ultrasound transducer and adjust the position/depth so that the vessel is in the center of the image.Veins will be thin-walled and easily compressible, compared with arteries that will be thick-walled and non-compressible.
Insert the needle at a 30-45 degree angle, just distal to the ultrasound probe.
Slowly sweep the probe proximally as the needle tip moves proximally.
Once a flash is seen in the IV chamber, the rest of the procedure proceeds similar to the blind technique.
Drop the angle of the needle about 15 degrees and advance it another 1-2 mm to ensure that both the tip of the catheter and the needle are in the vein.
Hold the needle in place as the catheter is completely advanced.

Complications: Paresthesias, brachial artery puncture, hematoma formation, IV decannulation

Pearls:

The best target will be the vein that is the largest and most superficial.
For deep veins, angle your catheter at a steeper angle than you would for a superficial vein (35-45 degrees).
You can use the ultrasound to confirm catheter placement afterwards by visualizing tiny bubbles within the vessel during saline flush. Anechoic fluid in the soft tissue suggests extraluminal placement.

Resources:

[/su_tab] [su_tab title=”External Jugular Vein (EJ)”]

The EJ vein is a great site for rapid IV access. It can often be accessed without ultrasound guidance and is a large vein that can often be used for medication/fluid administration and phlebotomy. Vasoactive medications and radiographic contrast should not be administered due to potential complications such as extravasation and airway compromise. The EJ vein courses over the sternocleidomastoid (SCM) before joining the subclavian vein under the clavicular head of the SCM.

Ideal in these situations: Ultrasound not readily available, EJ vein easily seen on exam

Not ideal in these situations: Unable to visualize landmarks on neck, patient unable to tolerate laying flat

Optimal positioning: Position the patient in Trendelenburg about 10-15 degrees. Turn head slightly away from side of EJ cannulation.

Method:

With the patient positioned properly, cleanse the site and use a finger to provide slight traction next to the vein to anchor it.
Approach the vein at a 5-10 degrees angle, about midway between the angle of the jaw and the clavicle.
After a blood flash return in the IV catheter, advance the catheter until the hub is secure against the skin.

Complications: Hematoma, laceration of the deeper internal jugular vein, air embolism, infection, airway compromise

Pearls:

Resources:

Start at the 1-minute mark for the actual procedure.

[/su_tab] [su_tab title=”Intraosseous (IO) Line”]

Intraosseus (IO) Line

An intraosseus line is used for emergent vascular access when one is unable to obtain peripheral venous access. It allows you to draw almost any lab, including blood cultures and lactate, as well as administer large volumes of fluid, blood, inotropes, and vasopressors. While historically used in pediatric cardiac arrest, IO access is also used in adult resuscitation for rapid vascular access. The most common site for IO access in the anteromedial tibia, 1-2 cm distal to the tibial tuberosity. Alternative sites include the humeral head and the distal femur in the anterior midline above the external epicondyles, 1-3 cm proximal to the femoral plateau.

Ideal in these situations: Cardiac arrest or profound cardiogenic shock, when peripheral or central access have failed or are difficult

Not ideal in these situations: Previous IO attempts in the same bone, osteogenesis imperfecta, osteoporosis, proximal fractures, overlying infection or skin damage

Method: This assumes use of a powered device, such as the EZ-IO.

Sterilize the insertion site with povidone-iodine, chlorhexidine, or alcohol.
Use your nondominant hand to stabilize the arm or leg.
Insert the IO needle perpendicular to the bone. The resistance suddenly decreases once the marrow cavity is entered.
Remove the trocar.
Use a 5- to 10-mL syringe to aspirate blood for confirmation.
Slowly instill lidocaine into the intraosseous space to anesthetize the visceral pain fibers.
Observe the area for signs of extravasation.
Secure the needle and immobilize the extremity.

Pearls:

For humeral IO insertion, be sure the patient’s shoulder is internally rotated (patient’s hand on his/her abdomen).
Monitor the extremity continuously for compartment syndrome.
IOs should be removed within 24 hours.
For removal, connect a Luer lock syringe to the hub of the catheter, and twist clockwise while pulling the needle straight out. Do not rock back and forth which could cause bone cracks.
Infusion is still going to be painful despite lidocaine.
EZ-IO drills are not to be used for the sternum like they do in the military. They use a different apparatus.

Complications: Extravasation

Resources:

[/su_tab][/su_tabs]

Central Venous Access

Central venous access is indicated for infusions that require larger, less fragile veins, such as vasopressors, hyperosmolar solutions, and hyperalimentation (Note: vasopressors can be infused peripherally in certain circumstances per EMCrit.) Central access could also be considered when peripheral IV access is very difficult, such as with extensive burns to the body, or if multiple medications need to be infused, or blood draws need to happen frequently. A 2012 Critical Care Medicine systematic review suggests that there is no difference in catheter-related bloodstream infections between the three typical sites: internal jugular, subclavian, and femoral veins. The best site to place a central line can depend on several factors detailed below. Ultimately, line selection is a complex clinical judgment rather than a ‘one size fits all’ strategy. It is driven by setting (level of hemodynamic instability, risks for abrupt crash), patient factors (anxiety, cooperativeness, sedation levels or safety for sedation, airway sustainability/adequacy/patency), operator experience and flexibility, and probable need for multiple drug infusions and therapies.

Pearls:

[su_tabs vertical=”yes”][su_tab title=”Internal Jugular (IJ) Vein”]

The IJ vein is often the ideal site to place a central line. An IJ central line will allow placement of a pulmonary artery catheter or a transvenous pacing wire, as well as for measurement of CVP. The IJ vein typically lies anterolaterally to the carotid artery at the apex of the triangle formed by the clavicle and the two heads of the sternocleidomastoid muscle.

Ideal in these situations: Most central venous access needs

Not ideal in these situations: Patients who cannot lay flat or have respiratory distress, distorted anatomy or trauma at site, suspected cervical spine fracture

Optimal positioning: Place patient in 15 degree Trendelenburg position and rotate patient’s head opposite the site of cannulation.

Method: The standard basic technique on the placement of a central line will not be reviewed here. Please consult your preferred textbook, or watch the videos below to review the procedure.

Pearls:

Complications: Airway compromise from hematoma, pneumothorax, carotid artery puncture, thrombosis, infection

Resources:

[/su_tab] [su_tab title=”Femoral Vein”]

The femoral vein is a useful site for code/crash situations, where the neck is inaccessible due to active airway management and/or the chest is occupied with ongoing CPR. It it often the easiest site to perform blind central vein cannulation based on landmarks alone, and thus quickest if very rapid central access must be achieved, e.g. in patients in extremis. It is also the site to use if patients cannot lay flat for a subclavian or IJ central line. The femoral vein is classically located medial to the femoral artery, best remembered by the mnemonic NAVEL (from lateral to medial- Nerve, Artery, Vein, Empty space, Lymphatics).

Ideal in these situations: Patients in extremis, code situations, coagulopathic patients, patients who cannot lay flat

Not ideal in these situations: Distorted anatomy or trauma to region, suspected proximal vascular injury (e.g. the IVC)

Optimal positioning: Patient can be sitting about 45 degrees to supine. Externally rotate leg and bend the knee to expose the groin.

Method: Basic technique on the placement of a central line will not be reviewed here. Please consult your preferred textbook, or watch the videos below to review the procedure.

Pearls:

During chest compressions, pulses may be felt in either the artery or vein. Some would argue that it is safer to always choose intraosseus access in cardiac arrest.
If you inadvertently start too inferiorly, your needle may be cannulating the greater saphenous vein, in which it is difficult to introduce the guidewire due to its valves and smaller diameter.

Complications: Retroperitoneal hematoma, thrombosis, infection

Resources:

Placing a femoral central line in a pulseless patient:

NEJM video on femoral central line placement

[/su_tab] [su_tab title=”Subclavian Vein”]

The subclavian vein is another common site, especially when an ultrasound is not available. The subclavian vein is classically located just over the 1st rib. It lies immediately posterior to the medial 1/3 of the clavicle. It is separated from the deeper subclavian artery by the anterior scalene muscle, and is 1-2 cm in diameter.

Ideal in these situations: For any central venous access needs, ultrasound not readily available

Not ideal in these situations: Coagulopathic patients, distorted anatomy or trauma, pneumothorax on opposite site of cannulation, fracture of the clavicle or proximal ribs

Optimal positioning: Place the patient in Trendelenburg position. The vein is kept patent by surrounding costoclavicular ligaments but Trendelenburg position will help prevent air embolism. Place a small towel between the scapulae to reduce deltoid muscle bulge. Abduct arm slightly.

Method: Basic technique on the placement of a central line will not be reviewed here. Please consult your preferred textbook, or watch the videos below to review the procedure.

Pearls:

Most patients with a malpositioned catheter were into the IJ. Apply external pressure over the base of the IJ vein using a sterile finger during guidewire insertion to prevent the guidewire from going into the IJ. [Ambesh et al 2002]
Patients with ear pain or a tickling throat sensation during guidewire insertion typically means that the guidewire is in the IJ. [Ambesh et al 2002]
Avoid placing a subclavian line opposite to a known or suspected pneumothorax, due to the risk of creating bilateral pneumothoraces.
Try using ultrasound to guide your placement if anatomy is difficult or with patients who have high risk of pneumothorax.

Complications: Pneumothorax, thrombosis, infection

Resources:

[/su_tab][/su_tabs]

References

Costantino TG, Parikh AK, Satz WA, Fojtik JP. Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med. 2005 Nov;46(5):456-61. PMID 16271677
Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med. 1999 Dec;34(6):711-4. PMID 10577399
Shah, Kaushal, and Chilembwe Mason, eds. Essential emergency procedures. Lippincott Williams & Wilkins, 2007.

Additional Reading: Lin, M. (2012). Difficult Vascular Access: Alternative Approaches & Troubleshooting Tips [Powerpoint slides]. Retrieved from UCSF CME Department.

Ultrasound-guided central venous access – The British Journal of Cardiology

Ultrasound guidance is a useful technique to aid central venous access. Alignment of the ultrasound probe and visualisation of the needle is a skill that takes some practice. This article describes how to perform ultrasound guidance to gain central venous access via the internal jugular, femoral and axillary/subclavian veins.

For UK healthcare professionals only

Introduction

Central venous catheterisation is ubiquitous in hospital practice. Complications may occur in 10% of cases using surface landmark techniques.^1,2 When used to locate vessels and give real-time guidance, ultrasound limits these complications.³ The UK National Institute for Health and Clinical Excellence (NICE) suggests ultrasound guidance is used for elective cannulation of the internal jugular vein. However, similar advantages are seen for cannulation of veins and arteries at other sites in elective and acute situations.

Preparation

Monitor the patient with pulse oximetry, electrocardiography and non-invasive blood pressure measurement. Establish peripheral intravenous access and offer conscious sedation. Place the patient 15^o head down with arms supported by their sides. Ensure the field is aseptic, image the vein at the chosen site with the ultrasound and infiltrate the skin and subcutaneous tissues with local anaesthetic.

Ultrasound

Ultrasound probes of 7–10 MHz are suitable. Arteries are identifiable as they pulsate and are difficult to compress. Veins are non-pulsatile, easily compressible, have respiratory variation, and distend when the patient is tilted or performs the Valsalva manoeuvre.^4,5 Real-time images are easier to interpret because of these dynamic findings. Doppler verification may also be used.

Position the ultrasound display at eye level on the opposite side of the patient to the operator. Place the probe lightly on the skin (the vein will collapse easily). Choose a site where the vein lies side-by- side with the artery (rather than anterior to it) as the vein will often need to be transfixed to puncture its anterior wall. If the vein is transfixed, successful aspiration then occurs on gentle withdrawal of the needle.

Transducer and display set-up

Touch one side of the probe and observe the image to allow orientation. A palpable marker is often present on the side of the transducer corresponding to the marker on the display. Adjust the depth to ensure structures are visualised in the centre of the screen. Alter the gain to create a dark image that allows discrimination of the white dot generated by the needle. Use sterile ultrasound gel inside and outside the protective sterile sheath.

Guidance techniques

Needles can be guided through tissues directly and indirectly.⁶

Indirect ultrasound guidance

This involves the identification of a patent non-diseased vessel prior to puncture. Mark the skin and estimate the angle and depth of the needle course. Collateral structures may still be hit if the approach of the needle is not correct.

Direct ultrasound guidance

Table 1. Factors influencing needle visualisation

This involves the use of ultrasound to visualise the needle in real time. There are two techniques – the use of needle guides and freehand puncture. An appreciation of appearances of needles crossing the ultrasound beam in transverse (short axis) and longitudinal (long axis) is required. Other factors affecting needle visualisation are summarised in table 1.

Needle guides direct the needle in a pre-determined direction to various depths from the transducer surface, depending on the selected angle of the guide.⁷ Guides vary and may be fixed or detachable from the transducer. Guidance lines generated on the display show the projected path of the needle. Adjust the probe so the target vessel lies within the guidance lines and assess the depth. With the probe held still, clamp the needle in the guide and pass it through the tissues either to a pre-determined depth or until the needle tip is positioned in the vessel.

For freehand puncture, hold the needle with one hand and the transducer with the other. This approach provides greater flexibility without having to use secondary instruments and allows for subtle compensatory adjustments.

Short- and long-axis approaches

Short axis

Insert the needle at a shallow angle until the tip (a white dot) enters the ultrasound beam. Withdraw slightly, realign more steeply and advance until seen again in a deeper position. Repeat, correcting the insertion direction to approach and puncture the vessel centrally. Because this approach gives poorer visualisation of the needle (the needle tip may be mistaken for the needle shaft), the position of the needle tip may need to be re-established by either rocking the transducer or realigning the needle in a more vertical plane. A needle passing through the ultrasound beam in short axis produces an acoustic shadow, seen as a black line passing to the base of the image.

Long axis

Though this allows better needle visualisation, practice is required to keep the needle precisely within the image plane and the target vessel within the beam. Novices may find this method more difficult.⁸

Verification of needle-tip placement

Irrespective of the technique used, verify the needle-tip placement by either aspirating blood or noting the vein to re-open following collapse due to the pressure of the advancing needle. The vein wall may occlude the needle tip, which appears to lie within the vessel lumen.

Internal jugular vein cannulation

Figure 2. Cross-sectional images of the right axillary vein (AV), with the cephalic vein (CV) lying anteriorly. The axillary artery (AA) is seen deeper and more cranial. The pleura (P) and chest wall are easily visualised. The ultrasound probe is placed just lateral to medial clavicle with the image orientated to be as seen from patient’s right sideFigure 1. Cross-sectional images of the right internal jugular vein (IJV), partially overlying the right carotid artery (CA) next to the thyroid gland (TG). The centre of the IJV is only 1.5 cm deep to the skin. The images are orientated as seen from the patient’s head

The vein lies surprisingly superficial (1–2 cm) and is close to the carotid artery (figure 1). The thyroid is easily visible with a characteristic grey appearance. Lymph nodes may be mistaken for vessels but are non-compressible and moving the probe up and down shows their outline.

Axillary/subclavian vein cannulation

The conventional flat approach to the subclavian vein is not possible with ultrasound as the clavicle obscures visualisation. Instead, move laterally over the deltopectoral triangle to visualise the axillary artery and vein and branches, in particular the cephalic vein (figure 2). The axillary vein is the continuation of the basilic vein and extends from the outer border of teres major to the outer border of the first rib. On moving laterally to the axillary vein, the artery and vein are further apart, and the rib cage and pleura fall away (a misplaced needle transfixing the vein does not hit vital structures). The brachial plexus is just cephalad to the artery.

Femoral vein cannulation

Figure 4. Cross-sectional images of the right common femoral vessels just below the inguinal ligament, showing the ‘Mickey Mouse sign’. The femoral artery (FA) is depicted on the left and the femoral vein (FV) on the right. The sapheno-femoral junction (SFJ) comprises the long saphenous vein (LSV) and the FVFigure 3. Cross-sectional images of the right femoral vessels approximately 3 cm below the inguinal ligament, orientated to be as seen from patient’s feet. The superficial femoral artery (SFA) partially overlaps the femoral vein (FV). The profunda femoris artery (PFA) is deeper

The side-by-side orientation of the femoral vein, artery and nerve as depicted in anatomy texts is an oversimplification, and only true at the level of the inguinal ligament, which is difficult to palpate in most subjects. Below this level lies the saphenofemoral vein junction, and the arterial bifurcation into deep and superficial femoral branches. The superficial artery overlies the femoral vein, making access difficult. The use of ultrasound allows differentiation of these structures and accurate first pass puncture of the common femoral vein immediately below the inguinal ligament (figures 3 and 4). For arterial access, ultrasound guidance allows the choice of the most appropriate site for puncture in the common femoral artery with avoidance of heavily diseased areas.

Conclusion

Ultrasound guidance is a useful technique to aid central venous access. It is effective in difficult cases,⁹ allows easy cannulation of the veins^10,11 and reduces complications. Similar advantages should apply for arterial access. Though alignment of the ultrasound probe and visualisation of the needle is a skill that takes some practice, the time spent understanding and practising the technique will be repaid many times over when performing invasive procedures.

Conflict of interest

Andrew Bodenham has recieved honoraria from Sonosite for teaching in this area of practice.

Key messages

Routine use of ultrasound guidance significantly reduces the risk of procedural complications during central venous access. Practice is required to use it to best effect
The National Institute for Health and Clinical Excellence (NICE) has recommended its use in central venous access and is auditing compliance in this area
It can potentially be used at all sites of vascular access including the axillary/subclavian vein and peripheral arteries
It is particularly useful in the more difficult case

References

Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331:1735–8.
Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med 1986;146:259–61.
Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996;24:2053–8.
Armstrong PJ, Sutherland R, Scott DH. The effect of position and different manoeuvres on internal jugular vein diameter size. Acta Anaesthesiol Scand 1994;38:229–31.
Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study. Anesth Analg 1991;72:823–6.
Chapman GA, Johnson D, Bodenham AR. Visualisation of needle position using ultrasonography. Anaesthesia 2006;61:148–58.
Reid MH. Real-time sonographic needle biopsy guide. Am J Roentgenol 1983;140:162–3.
Blaivas M, Brannam L, Fernandez E. Short-axis versus long-axis approaches for teaching ultrasound-guided vascular access on a new inanimate model. Acad Emerg Med 2003;10:1307–11.
Hatfield A, Bodenham A. Portable ultrasound for difficult central venous access. Br J Anaesth 1999;82:822–6.
Galloway S, Bodenham A. Ultrasound imaging of the axillary vein–anatomical basis for central venous access. Br J Anaesth 2003;90:589–95.
Sharma A, Bodenham AR, Mallick A. Ultrasound-guided infraclavicular axillary vein cannulation for central venous access. Br J Anaesth 2004;93:188–92.

Integrating Long-Axis and Short-Axis Views with a Twist for Ultrasound-Guided Vascular Access, Part I: Femoral Approach

Jonathan Salcedo, MD, FACC, FHRS

Cardiac Electrophysiology; Palo Alto Medical Foundation – Sutter Health; Silicon Valley Cardiology; Sequoia Hospital, Redwood City, California

Introduction

Ultrasound-guided vascular access has emerged as a ubiquitous tool used by a variety of specialties, including cardiologists, vascular surgeons, emergency room physicians, and critical care specialists. Studies have shown that femoral artery access guided by ultrasound results in safer outcomes.¹In addition, femoral ultrasound guidance for common electrophysiology procedures has proven to be superior than landmark-guided access to reduce adverse events.^2,3 The most common approach to ultrasound-guided access involves using short-axis (ie, transverse axis) views to guide the needle puncture. This article will describe a hybrid approach using both short-axis and long-axis (ie, longitudinal axis) techniques to enhance visualization of the needle tip into the femoral vessel with a twisting motion to further reduce the chance of inadvertent posterior wall puncture.⁴

Equipment

A standard linear array probe (5-15 MHz) made by most ultrasound equipment companies (Sonosite, Philips, etc.) provides the best resolution and depth for femoral vessel access. To enhance visualization, an 18-gauge echo-visible needle should be used with every access attempt. A 21-gauge needle can also be used, and there are echo-visible versions available as well. In my experience, an 18-gauge echo-visible needle has a modest advantage over a 21-gauge needle due to enhanced visualization (and thus, confidence of needle tip position), one less step for wire/sheath introduction, and a better bevel-cutting function with a twisting motion. Ideally, the lab staff should prepare the access needle, J-wires, sheaths, and ultrasound probe in a sterile sleeve near the groin site to minimize the amount that the operator has to move or reach while obtaining access (Figure 1).

Technique

The first step involves a short-axis survey of the femoral artery and vein anatomy, including the bifurcations of each into the superficial femoral and deep branches, the location of posterior bony structures (femoral head and ischial tuberosity), and identification of any superficial crossing vessels to avoid on the path down to the target vessel (Figure 2). The goal is to puncture the femoral vein or artery in the common femoral portion above the bifurcation of the branches and below the inguinal ligament to avoid the inferior epigastric branch of the artery or vein. Given the 3- to 4-centimeter distance of travel from the surface of the skin to the surface of the vessel, it is best to start just superior or at the bifurcation of the intended femoral vessel. Frequently, the femoral vein branches inferiorly to the femoral artery. If the vein is the target, starting at this level (ie, the arterial bifurcation and not the venous bifurcation) is usually necessary, since the superficial femoral artery branch will frequently travel anterior to the vein as the vessels are scanned down inferiorly.

Next, with the target vessel in the middle of the field of view, an echo-visible needle is also inserted into the middle of the field of view. In Figure 3, Video 1 and Video 2, the right common femoral vein is the target for three separate puncture attempts. Fanning of the ultrasound view in an inferior-to-superior motion as the needle is inserted facilitates visualization of the tip of the needle at all times. The short-axis view is not as optimal for visualizing the needle tip versus the long-axis view; however, given the importance of landing the needle in the center of the target vessel to avoid a glancing injury to any neighboring structures, the short-axis view is preferred for the initial approach of the needle toward the vessel. Using a fine jiggling motion and slow insertion of the needle, the needle tip can be approximated visually as the ultrasound view is fanned superiorly.

When the needle is at the anterior surface of the vessel, the ultrasound probe is then rotated clockwise 90 degrees to visualize the vessel and needle in long-axis view. Here, maximal tenting is obtained by further slow advancement of the needle. Fine adjustments of the probe and/or tilt of the needle will aid in finding the optimal visualization. After maximal tenting is confirmed, a rapid twisting motion of the needle with consistent forward pressure allows the sharp beveled edge of the needle to cut through the anterior wall of the vessel. This technique avoids the frequently taught jabbing motion, which could inadvertently puncture too far and cause a “through-and-through” injury to the vessel. Once blood flow is confirmed, then the introducer guidewire is inserted under ultrasound guidance by holding the probe in place with the left hand and using the right hand to remove the syringe (slip-tip preferably if one is used), let go of the needle, and insert the wire (Figure 3, Videos 1 and 2). Alternatively, since visualizing the wire enter on ultrasound is not completely necessary for safety, the operator can choose to set down the ultrasound probe and hold the needle in place with the left hand while removing the syringe and inserting the guidewire with the right hand.

If multiple venous access sites are needed — such as the protocol in our lab, which uses three puncture sites into the right femoral vein for all atrial fibrillation and supraventricular tachycardia ablations — the subsequent entry site is attempted about 2-3 millimeters below (inferior to) the prior puncture site (Figure 4). The prior wire is seen on ultrasound but does not usually interfere with seeing the second or third puncture needle tip, especially once switching to the long-axis view. After all punctures have been achieved, a quick ultrasound surveillance in long-axis view can show all three wires cleanly entering the target vessel.

For femoral artery punctures, the same approach applies with identifying the bifurcation, using short axis for the initial needle approach, and then utilizing the long-axis view to see the maximal tenting while twisting the needle to pop through the anterior wall of the artery (Figure 5). However, it is even more crucial to stay as centered as possible on the artery. With its muscular (and thus, more rigid) vessel wall and higher intravascular pressures, any off-center attempts may result in the needle glancing off the side of the vessel or the tip of the needle only inserting obliquely through the muscular wall and not into or partially into the lumen of the vessel. Trying to insert a wire in this situation could result in dissection of the arterial wall. Therefore, slow advancement, jiggling of the needle, and meticulous fanning of the probe during the approach of the needle will pay dividends in a perfectly centered needle tent before rotating over to long axis. After that, the twisting motion of the needle and continued forward pressure will easily result in quick cannulation into the lumen and brisk pulsatile bright red blood flow back.

Limitations/Challenges

There is a learning curve of approximately 5-10 cases with rotating the probe and finding the best angle to view the anterior wall of the target vessel and the needle tip in long axis. This takes some coordination between both hands, with fine adjustments of both until the needle tip and ultrasound plane are in phase with each other. Therefore, it is best to begin learning with femoral vessel puncture (versus axillary vein or artery puncture), given the wider field to move the probe and the lower serious risk of posterior structure injury (such as pneumothorax). Also, roughly 5-10% of ultrasound-guided femoral access will not have perfect visualization of the anterior vessel wall due to a variety of factors, including body habitus (and thus, deeper vessels, although not necessarily a perfect correlation), presence of renal disease, scar tissue from prior procedures, or poor tissue visualization quality (unclear contributing factors in otherwise normal habitus individuals). Once an operator has performed an adequate number of “normal” attempts (25-50) using this hybrid technique, then safe and successful puncture is still possible due to prior experience, despite suboptimal visualization of the vessel wall and needle tip. Another function that is not used on every case but is valuable to keep in mind is the color Doppler function, which aids in keeping the needle centered and knowing the approximate depth to the vessel when adequate visualization of the vessel is not possible due to superficial tissue characteristics of the patient.

Conclusion

With the availability of ultrasound technology in nearly every procedure lab, ultrasound-guided vascular access should be the first-choice approach for all proceduralists needing to gain femoral artery or vein access. Combining short-axis and long-axis views during needle advancement and using a twisting, cutting motion during maximal tent further optimizes the safety of this approach, and can be easily adopted by all operators at no or minimal additional cost. Future enhancements will involve the integration of a biplane view in all vascular probes to avoid needing to manually rotate the probe.

Acknowledgments: I would like to thank John Crowell (Abbott EP territory manager) for his superb video and photography skills using my Apple iPhone 11 Pro.

Disclosure: Dr. Salcedo has no conflicts of interest to report regarding the content herein.

Contact the author on Twitter: @50wattdoc

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Watch Dr. Salcedo discuss the article in a video overview:

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Central Venous Access via Posterior Approach to Internal Jugular Vein: Background, Indications, Contraindications

Author

Bradford L Walters, MD, FACEP Assistant Residency Director, Emergency Medicine Residency Program, Department of Emergency Medicine, Lead Physician of Keystone Sepsis Project, William Beaumont Hospital; Assistant Clinical Professor, Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Receiving Hospital

Bradford L Walters, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Michigan College of Emergency Physicians