3: Vascular Access


CHAPTER 3
Vascular Access


Jennifer Wang and John M. Oropello


Icahn School of Medicine at Mount Sinai, New York, NY, USA


Central venous access


Indications



  • Difficult venous access, frequent blood sampling.
  • Rapid administration of fluids and blood products (resuscitation).
  • Administration of fluids and medication caustic to small veins (e.g. vasopressors, chemotherapy, total parenteral nutrition).
  • Renal replacement therapy, plasmapheresis.
  • Transvenous pacemaker, pulmonary artery catheter.

Venous access sites



  • Internal jugular (IJ), subclavian medial (SM) or lateral (SL), and femoral (F) veins.

Catheter types (Figure 3.1)



  • Multilumen or single lumen (central venous access catheters).
  • Dialysis (large bore, double, or multilumen catheters).
  • Introducer (large bore for rapid resuscitation access, temporary pacemaker, or pulmonary artery catheter insertion).

Procedure



  • Prior to procedure, ensure that the patient’s name, procedure, and site of insertion are confirmed with the patient’s nurse.
  • Pre‐procedure US: the vein is visualized under US when using the IJ, SL, or F veins for access. (Note: the SM vein approach places the needle tip under the clavicle, hence it is not possible to visualize cannulation of the subclavian vein under US when using this approach.) Scan above, at, and below site of planned insertion (or lateral to medial with SL approach) with compression to check for thrombosis (Figure 3.2) or stenosis. Video 3.1 demonstrates the appearance of the vessels when performing the SL approach. On the viewer’s left, cephalad (towards the head, i.e. closer to the clavicle) is the subclavian artery (SA); to the viewer’s right, caudad (towards the feet, i.e. closer to the lung) is the subclavian vein (SV) (since the vessel has not yet passed the first rib, technically speaking it may be called the axillary vein). Note that the SV is compressible and non‐pulsating. Also note the twinkling horizontal line about 0.5 cm below the SV coming in from the right side with respiration: this is the pleural line.
  • For any neck line insertion (IJ or SM/SL sites) pre‐scan (US) the pleura on the side of planned insertion for the presence and degree of lung sliding. (See Chapter 4, Videos 4.1 and Video 4.2.) This can improve the accuracy of post‐procedure US to assess for pneumothorax.
  • Optimize site of insertion by selecting a plane where the artery is not directly beneath the vein (IJ insertion) or directly overlying the vein (F insertion) if possible. For IJ lines, turning the patient’s head toward the side of insertion may move the IJ to a more lateral position relative to the carotid artery. For F lines, moving the US superiorly toward the inguinal ligament will locate the vein medial to the artery. Moving the US down the leg (away from the inguinal ligament in the direction of the knee) will locate a position where the artery is overlying the vein, making access more difficult. Also, flexion of the lower extremity at the knee with lateral rotation may also help to move the femoral vein more medially from under the femoral artery. US will demonstrate whether this maneuver is effective or not.
  • Select the depth on the US machine (Figure 3.3) where both vein and artery can be easily visualized at their largest on the screen, i.e. minimum depth needed (a rough guide is approximately 2–3 cm for IJ, 4–5 cm for SL [for SL this includes visualization of the pleural line], and 3–5 cm for F). (Note: this requires a transverse orientation of the US probe. A longitudinal orientation will only show the vein, not the artery, unless the artery is directly beneath the vein. The transverse approach is preferred to prevent inadvertent arterial puncture, especially in less experienced or in‐training practitioners.)
  • Clean site of insertion plus a diameter of approximately 15 cm with chlorhexidine gluconate and isopropyl alcohol (e.g. Chloroprep).
  • Wash hands and put on cap, mask, sterile gown, and sterile gloves.
  • Prepare sterile field: drape patient with sterile sheets and drapes so that only prepped area is exposed.
  • Place sterile US gel into sterile US probe cover, then insert US into sterile covering; fasten covering with rubber bands.
  • Place sterile US gel onto insertion site.
  • Draw up 5–10 mL 1% lidocaine and label syringe.
  • Flush all ports of the catheter with sterile saline; for triple lumen catheters, clamp blue and white ports, but leave brown port unclamped; for dialysis catheters, clamp red port, but leave blue port unclamped (guidewire exits this port).
  • Remove and gently but firmly replace the introducer (i.e. insertion) needle onto the syringe ensuring the needle is not jammed onto the syringe.
  • Remove cap off guidewire (GW) and retract GW into plastic sheath until 2 mm is exposed.
  • Place gauze on sterile field near insertion site.
  • Draw sterile saline into syringe in preparation to flush all ports post‐insertion.
  • Set up tools on sterile table in the order in which they will be used: lidocaine, insertion needle and syringe, GW, skin dilator, scalpel, catheter, needle holder, suture.
  • Hold US probe in the non‐dominant hand, select insertion site, inject 3–10 mL lidocaine with dominant hand, and place lidocaine syringe into sharps sponge.
  • Hold US with non‐dominant hand; hold insertion needle and syringe with dominant hand (Video 3.2).
  • As soon as insertion needle pierces the skin, introduce negative pressure by pulling the plunger on the syringe.
  • Slowly advance syringe at a 70–80° angle under US guidance (Figure 3.4).
  • As soon as blood is aspirated into the syringe and introducer needle tip is visualized inside the vein near the center (Video 3.3: see at 30–31 seconds), place US down and stabilize the introducer needle with the non‐dominant hand. Twist syringe off with dominant hand.
  • Advance GW into insertion needle until 20 cm mark is just before the entry point into the introducer needle; the 20 cm mark is visualized as two parallel gray lines on the GW. Look at the ECG monitor; if new atrial or ventricular ectopy or arrhythmias are present, immediately withdraw the GW and then reinsert to a shallower depth, e.g. 15 cm.

    • If any difficulty is encountered during GW insertion (wire not advancing, e.g. bouncing back), withdraw GW, reattach introducer syringe and apply negative pressure while visualizing the vein under US. Never force GW into vein as this can cause damage to vessel walls, vein perforation, and artery cannulation. Excessive force placed on GW will result in a bent wire.
    • If insertion needle is noted to be centrally located inside vein (e.g. not buried into the posterior wall) and GW cannot be advanced, turn insertion needle 90° and attempt to advance GW.
    • If friction or bounce is still encountered after several attempts, remove insertion needle and attempt procedure again at a different site.

  • Remove insertion needle and place in sharps sponge.
  • Visualize GW in vein and not in artery with US (both criteria must be met) (Figure 3.5).
  • Load skin dilator onto GW, leaving a gap of 2 cm from the skin.
  • Using the scalpel, make a small skin nick at point of insertion. Withdraw scalpel into protective sheath before placing on sterile table. Note: in cases of thin skin tissue, it may be possible to advance the dilator without making a scalpel nick. This can help to reduce post‐procedure insertion site bleeding and should be considered especially in coagulopathic patients or patients who will be started on therapeutic anticoagulation post‐procedure.
  • Advance skin dilator approximately 3–4 cm, then remove dilator. Use the other hand to hold point pressure at insertion site to prevent bleeding.
  • Advance catheter over the GW, ensuring that contact with the GW is maintained at all times (i.e. there must always be one hand holding the GW when placing the GW and when placing the catheter over the GW).
  • As the catheter approaches the skin, pull GW out until it exits (brown port of triple lumen catheter or blue port of dialysis catheter). Hold this end of the GW with one hand as the other hand advances the catheter into the vessel.
  • Remove GW. After GW is completely removed, verbalize to nurse ‘wire out.’
  • Apply gentle negative pressure until blood is seen in the port tubing, then flush port with sterile saline. Ensure port tubing is free from blood, then clamp. Repeat for all ports. Apply caps onto all ports.
  • Instill 1 mL of lidocaine near each suture site.
  • Suture catheter to skin, ensuring sutures are snug, but not overly tight or loose.
  • Clean insertion site with chlorhexidine gluconate and isopropyl alcohol and allow to dry (1–2 minutes).
  • Apply dressing, e.g. Biopatch (hydrophilic polyurethane absorptive foam with chlorhexidine gluconate) then Tegaderm (transparent film dressing), or Tegaderm with impregnated chlorhexidine alone (Biopatch not needed).
  • Jugular and subclavian catheters usually require CXR to confirm position prior to use unless in an emergency; femoral catheters can be immediately used.
  • If there are signs or symptoms suggestive of pneumothorax at any point in the procedure after vein cannulation, perform pleural US on the side of the procedure. Lung sliding rules out pneumothorax. (See Chapter 4, Videos 4.1 and 4.2.)

Management of complications



  • Thrombosis: catheter removal, evaluate need for anticoagulation.
  • Bleeding at insertion site: point pressure (hydrophilic polymer and potassium ferrate powder (e.g. StatSeal) to stop bleeding), suturing.
  • Inadvertent arterial insertion: call vascular surgery for removal; do not attempt to remove the catheter yourself.

Follow‐up



  • Catheter site should be examined daily to ensure that insertion site is clean, dry, and without erythema or discharge.
  • Dressing should be changed when soiled and at least once weekly.
  • Catheters should be left in place no longer than necessary and should be removed as soon as indications resolve.

Arterial access


Indications



  • Continuous blood pressure monitoring (e.g. on vasoactive therapy, shock).
  • Frequent arterial blood sampling (e.g. respiratory failure, shock).

Arterial sites



  • Radial, axillary, femoral.

Catheter types



  • Radial, axillary, femoral (Figure 3.6).
  • Angiocatheter, assembly needle (angiocath and GW incorporated into a single unit), separate GW and needle (Figure 3.7).

Procedure



  • Prior to procedure, perform time out where the patient’s name, procedure, and site of insertion are confirmed with the patient’s nurse.
  • Pre‐procedure US: artery (radial, axillary, femoral) is visualized under US at and proximal to insertion site for stenosis.
  • Optimize site of insertion. For radial, supinate hand and tape hand down. For axillary, place a soft wrist restraint to help pull arm above patient’s head.
  • Select the depth on the US machine where artery can be easily visualized, i.e. minimum depth needed (a rough guide is approximately 2 cm for radial, 2–3 cm for axillary, and 4–5 cm for femoral). (Note: this requires a transverse orientation of the US probe.)
  • Clean site of insertion plus a diameter of approximately 15 cm with chlorhexidine gluconate and isopropyl alcohol (Chloroprep).
  • Wash hands and put on cap, mask, sterile gown, and sterile gloves.
  • Prepare sterile field: drape patient with sterile sheets and drapes so that only prepped area is exposed.
  • Place sterile US gel into sterile US probe cover, then insert US into sterile covering; fasten covering with rubber bands.
  • Place sterile US gel onto insertion site.
  • Draw up 5–10 mL 1% lidocaine and label syringe.
  • Remove and gently but firmly twist the introducer (i.e. insertion) needle onto syringe.
  • Remove GW from paper covering and retract GW into plastic sheath until 2 mm is exposed.
  • Place gauze on sterile field near insertion site.
  • Set up tools on sterile table in the order in which they will be used: lidocaine, insertion needle and syringe, GW, catheter, needle holder, suture.
  • Hold US in the non‐dominant hand, select insertion site, inject 3–4 mL lidocaine with dominant hand, and place lidocaine syringe into sharps sponge.
  • Hold US with non‐dominant hand; hold insertion needle and syringe with dominant hand.
  • As soon as insertion needle pierces the skin, introduce negative pressure by pulling the plunger on the syringe.
  • Slowly advance syringe at a steep, 70–80° angle for axillary (Figure 3.8A) or femoral arterial cannulation; use a more shallow angle (e.g. 45° or less) for radial arterial cannulation (Figure 3.8B), all under US guidance.
  • As soon as blood is aspirated into syringe and introducer needle tip is visualized inside the artery, near its center, place US probe down and stabilize introducer needle with non‐dominant hand. Twist syringe off with dominant hand. (Optionally the needle may be inserted without an attached syringe depending on operator preference.)
  • Advance half the length of GW into insertion needle:

    • If any difficulty is encountered during GW insertion (wire not advancing, e.g. bouncing back), withdraw GW, reattach introducer syringe, and apply negative pressure while visualizing artery under US. Never force GW into artery as this can cause damage to vessel walls and arterial perforation. Excessive force placed on GW will result in a bent wire.
    • If insertion needle is noted to be centrally located (e.g. not buried into the posterior wall) inside the artery and GW cannot be advanced, turn insertion needle 90° and attempt to advance GW.
    • If resistance or bounce is still encountered, remove insertion needle and place point pressure until hemostasis is confirmed; after hemostasis is achieved, procedure can be attempted again at a different site.

  • Remove insertion needle and place in sharps sponge.
  • Visualize GW in artery with US.
  • Advance catheter over GW, ensuring that contact with the GW is maintained at all times (i.e. there must always be one hand holding the GW when placing it and when placing the catheter over the GW).
  • As the catheter approaches the skin, pull GW out until it exits the arterial catheter. Hold this end of the GW with one hand as the other hand advances the catheter into the vessel.
  • Remove GW and immediately cover end of catheter to prevent bleeding. After GW is completely removed, verbalize ‘wire out.’
  • Apply connective tubing to the arterial catheter in sterile fashion.
  • Have the nurse forward flush the arterial catheter, then check for a good waveform on the monitor (Figure 3.9) before securing the catheter.
  • Instill 1 mL of lidocaine at the intended suture sites.
  • Suture catheter to skin: place suture through skin, then wrap suture around arterial catheter three times before tying knot. Ensure sutures are snug, but not overly tight or loose.
  • Clean insertion site with chlorhexidine gluconate and isopropyl alcohol and allow to dry (1–2 minutes).
  • Apply dressing, e.g. Tegaderm (transparent film dressing) or Tegaderm with impregnated chlorhexidine.
  • Note: the description above describes using a free GW with a separate needle and catheter. Some kits have the GW integrated into the needle and catheter assembly (Figure 3.7B); in this case after gaining access to the artery the GW is advanced through the assembly into the artery, followed by catheter insertion over the GW and removal of the entire assembly. Alternatively, radial artery access can also be performed without a GW, using an angiocatheter over a needle assembly in a fashion similar to inserting an intravenous catheter (Figure 3.7A), advancing the catheter over the needle after cannulating the artery.

Management of complications



  • Thrombosis: catheter removal, vascular surgery consultation, anticoagulation as indicated.
  • Hematoma: point pressure (hydrophilic polymer and potassium ferrate powder (StatSeal) to stop bleeding), suturing, vascular surgery consultation.
  • Nerve compression (e.g. axillary artery pseudo‐aneurysm): catheter removal, vascular surgery/neurology consultation.

Follow‐up



  • Catheter site should be examined daily to ensure that insertion site is clean, dry, and without erythema or discharge.
  • Dressing should be changed when soiled and at least once weekly.
  • Catheters should be removed as soon as indications resolve.
  • After arterial catheter removal: nurse should monitor insertion site for bleeding/hematoma for 2 hours.

Reading list



  1. Killu K, et al. Utility of ultrasound versus landmark‐guided axillary artery cannulation for hemodynamic monitoring in the intensive care unit. ICU Director 2011;May:54–9.
  2. Saugel B, Scheeren TWLW, Teboul J‐LL. Ultrasound‐guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care 2017; 21(1):225.
  3. Weiner M, Geldard P, Mittnacht A. Ultrasound‐guided vascular access: a comprehensive review. J Cardiothorac Vasc Anesth 2013; 27(2):345–60.

Suggested websites


www.carefusion.com/our‐products/browse‐brands/chloraprep


www.ethicon.com/healthcare‐professionals/infection‐prevention/biopatch‐protective‐disk‐chg


www.3m.com/3M/en_US/company‐us/all‐3m‐products/~/All‐3M‐Products/Health‐Care/Medical/Tegaderm/?N=5002385+8707795+8707798+8711017+8711738+3294857497&rt=r3


Images

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Figure 3.1 Catheter types: (A) multilumen, (B) large bore (e.g. dialysis, plasmapheresis), and (C) introducer.

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Figure 3.2 Non‐occlusive thrombus in right internal jugular vein.

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Figure 3.3 Depth scale set at 2.6 cm. Note that entry point to vessel is at 1 cm. The operator should be aware of these depths while performing the procedure.

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Figure 3.4 Note the angle between the needle and ultrasound probe is 70–80°. This optimizes needle tip visualization and vein penetration. This angle is suggested for central venous access of the internal jugular, lateral subclavian (or axillary), and femoral veins.

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Figure 3.5 Ultrasound of the guidewire. (A) Following cannulation of the vein the guidewire is passed through the introducer needle and the needle is removed. (B) The ultrasound is again placed at the insertion site to visualize the guidewire (C) and confirm that the guidewire is in the vein and not in the artery (D) before dilation of the vessel is performed.

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Figure 3.6 Arterial line catheter types. (A) Longer catheter (12 cm) used for axillary or femoral arterial lines. (B) Shorter catheter (4.5 cm) used for radial arterial lines.

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Figure 3.7 Arterial line catheter types. (A) Angiocatheter. (B) Assembly (needle, angiocath, and guidewire incorporated into a single unit). (C, D) Guidewire and introducer needle separately.

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Figure 3.8 Introducer needle angles for arterial catheter insertion. (A) Axillary line cannulation with needle positioning shown at a steeper angle (70–80°). This steeper angle is used to improve visualization of the needle tip under ultrasound (not shown) in the larger axillary or femoral vessels. (B) Radial line cannulation with needle positioning shown at a more shallow angle (e.g. 45° or less) to avoid penetrating the posterior wall of this small artery.

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Figure 3.9 Arterial line waveform with peak wave followed by dicrotic notch. An adequate waveform (e.g. not damped) should be confirmed before suturing the catheter in place.

Nov 20, 2022 | Posted by in ANESTHESIA | Comments Off on 3: Vascular Access
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