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I. Vascular Access
I. Introduction and Indications
Emergency physicians are often called upon to rapidly establish intravenous access for critically ill patients. Depending on the clinical scenario, cannulation of a peripheral vein is first attempted and if unsuccessful a more central vein is tried. Several factors including body habitus, volume depletion and history of intravenous drug abuse can make this an incredibly challenging task. Bedside ultrasound not only provides us with a window of the patient’s vascular anatomy but also gives us the ability to visualize the needle as it enters the body. If used correctly, the needle can be successfully guided into the desired vein. The use of ultrasound increases accuracy, limits complications and reduces the number of attempts of venous access.
Indications:
- Assist in real-time venous cannulation under direct ultrasound visualization
- Minimize vascular attempts
- Assist in alternate peripheral access
II. Anatomy
It is important to appreciate the sonographic difference between veins and arteries. Veins are thin walled, non-pulsatile, easily compressible, and in a patient with normal hydration status larger than arteries. This principle applies to both the central and peripheral vasculature. In this section we will discuss the basic anatomical landmarks required to perform a peripheral and central venous cannulation.
Central Venous Access
When deciding which central vein to cannulate, we usually think of either the subclavian or internal jugular vein.
As already hinted by its name, the subclavian vein runs for a significant distance under the clavicle. Ultrasound visualization in this area is extremely difficult, as the high acoustic impedance of the clavicle bone causes a large acoustic shadow in most areas of the image. Only in a very lateral or supraclavicular approach imaging can be obtained. This makes it a more difficult choice for cannulation under ultrasound guidance. In contrary the internal jugular vein traverses the neck virtually unopposed by bone making it an ideal vessel to evaluate using ultrasound. The internal jugular vein runs vertically in the neck lying at first lateral to the internal carotid artery, and then lateral to the common carotid as it eventually unites with the subclavian vein. The internal jugular vein lies underneath the bifurcation of the sternal and clavicular heads of the sternocleidomastoid muscle (SCM), which is used as an external landmark when trying to locate the vein.
Central line checklist:
- Central line kit
- Skin cleanser (Chloraprep)
- Line Flush
- Sterile gloves and other stuff
- Extra Lidocaine
- Large tegaderm/opsite (IV site dressing)
Dirty Central Line: Includes old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.
The checklist for such patients change due to less time option.
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