Peripheral Intravenous Line

Almost every patient in the intensive care unit needs intravenous access.¹^–³ If fluids or drugs need to be delivered, if the patient cannot be managed entirely on a PO regimen, if the need to resuscitate may arise, access to the vascular system is required. Most often patients need more invasive access, but peripheral intravenous access still has its utility.

Equipment

The equipment for peripheral venous line placement includes the following: (1) intravenous catheter (always have extras); if volume access is required, a 14-gauge catheter is ideal but often impractical, and a 16-gauge may be a better choice; (2) alcohol wipes; (3) tourniquets; (4) TB or 3-mL syringe with 1% lidocaine plain; (5) 25-gauge needle, preferably a short one; (6) intravenous bag and tubing to connect to catheter, as well as a short section of tubing with flush in it; and (7) steri-drape and tape to secure the line.

Technique

Site of insertion matters, since some places are easier to place lines into than others. The back of the hand is usually handy to review an important point. Look for a Y-shaped vein and aim for the confluence. When you place the line in the hand, think of where the end of the catheter goes. If the end of the catheter is where the wrist bends, you can get a positional line. Antecubital is a favorable site but the patients have to keep their arm straight, so only use this if nothing else looks good. There are big veins in the forearm, but they are mostly L-type veins. Sometimes the anterior aspect of the wrist is the only vein you can see. In obese patients this is sometimes the only option.

Steps for inserting a peripheral intravenous line are shown in Figure 44-1. Always wear gloves. Place the tourniquet, but do not tie it in a knot. Get the vein to pop up by asking the patient to pump the fist, lightly tapping the vein, or hanging the arm down. Other ways to get the vein to stick up include putting warm blankets on the arm or using the blood pressure cuff: inflate the cuff above systolic pressure; wait a minute, then let the cuff down between systolic and diastolic so the blood can go in but can’t get out.

Figure 44-1 Peripheral intravenous line placement. A, Lay out all the equipment in an organized way. B, Look for a good vein, ideally one shaped like an inverted Y. C, Make sure the tourniquet can be undone with one hand. D, Try to get the vein to stand out. E, Apply alcohol wipe and administer lidocaine. F, Pull the skin taut and keep it taut. G, Approach at a shallow angle to get the needle and catheter tip in. H, Without letting go of the taut skin, advance the catheter. I, Undo the tourniquet. J, Hold down above the catheter.

Look for a vein that has an inverted Y and aim for the middle of the Y. Apply a little bit of local anesthetic. (Local anesthesia is not necessary if the first attempt at placing the line is successful, but it is very helpful in cases of repeated attempts.) Use the non-dominant hand to pull the skin taut as a drum. Use the dominant hand to stick the catheter through the skin and into the vein. When the first flash of blood appears in the hub of the needle, advance another millimeter or two to get the catheter into a vein, not just the tip of the needle. Without letting go of the skin, use the dominant hand to advance the catheter all the way into the vein. Keep the needle in. With the non-dominant hand, compress the vein just above the catheter. With the dominant hand, undo the tourniquet. With the dominant hand, pull out the needle and discard it. Connect the intravenous tubing and secure it to the catheter. Place a steri-drape and ensure the line stays in place. Open the line and make sure it runs. Watch for infiltration. If everything works well, remember to slow down the IV.

Clinical Pearls

Most resistance to flow occurs in the long tubing line. A 16-gauge runs as well as a 14-gauge. If there is any doubt about the vein, it is better to use the 16-gauge. The veins that look like an L rather than a Y are harder to hold down and will more likely “roll” away from you. If peripheral veins look impossible, put in a central line. It is a lot less painful than multiple peripheral attempts, after which one may end up placing a central line anyway. Some patients are difficult to get lines into, such as chemotherapy patients, intravenous drug abusers, morbidly obese patients, and those with a history of difficult lines. Only experienced staff should be inserting those lines, and adequate time should be allowed for line placement. A common mistake is to stop when you get a flash of blood in the hub; you might only have the tip of the needle in the vein. The catheter itself is a few millimeters away and you have to insert the catheter into the vein too. If you let go of the skin once you get the blood flash, the skin retracts back, and the underlying vein also pops back, and then the catheter tip is no longer in the vein. Always secure the IV right away as the patient will move later. Intravenous lines tend to infiltrate, especially when they are covered up by sheets or blankets, so they must be inspected frequently.

Complications

Some of the known complications of intravenous line placement are phlebitis, infection, and extravasation. Contributing factors for phlebitis are size of the catheter itself, site of insertion and skill of the practitioner, and duration. Infection may be aggravated by contaminated infusions, poor technique, and inadequate preparation of the skin. Age, duration, site of insertion, and type of cannula may make patients susceptible to extravasation.

Radial Arterial Line

Indications and Contraindications

The radial artery is the most common location for placing an arterial line.⁴^–⁸ It is indicated for close blood pressure measurement, where small changes in blood pressure will make a big difference, as well as frequent blood gas sampling. Radial arterial line is contraindicated in patients who underwent radial artery harvesting for a bypass, arterial insufficiency of the hand, and infection at the site. Interestingly, Raynaud’s phenomenon is not a contraindication for placement of a radial arterial line.

Equipment

The equipment for radial arterial line placement includes the following: (1) a board to hold the wrist in extension; (2) tape; (3) 1% lidocaine in a small syringe with a small (25-gauge) needle; (4) cannula (either specially designed Arrow 20-gauge cannula, or a regular cannula) and (5) transducer and pressure tubing.

Technique

Steps for inserting a radial arterial line are shown in Figure 44-2. First, explain the procedure and obtain consent. Set up the equipment so there is pressure tubing ready to connect as soon as the line is in, as the blood will be pumping out at arterial pressure. Zero the transducer and make sure the pressure tubing is pressurized. Using the patient’s non-dominant hand, extend the wrist and flatten out the hypothenar eminence so there is a straight shot into the radial artery. Going up and over the thenar eminence is much more difficult. Prep and apply a little local anesthetic. In the through-and-through technique, poke all the way into and through the artery, then pull back until the blood flows (signifying the catheter’s re-entry into the artery) and then advance the catheter up into the artery. A variant of this technique involves a wire: go through the artery, pull the needle out, then pull back until there is pulsatile flow, slide a wire in, then advance the catheter over the wire. In the go-in-the-first-time technique, do not go all the way through. When blood flow is seen, advance a little (making sure the catheter is in the artery, not just the needle tip), then advance the catheter. There are proponents and detractors of both techniques, so use the one that works best for you. Keep in mind that the blood should keep flowing and the catheter should slide easily with either technique. Hold the artery to keep the blood from spilling when you pull out the needle. Connect the pressure tubing to the catheter via Luer Lok (a non-Luer may fall out). Check the tracing to ensure that there is an arterial waveform. Once the line is in, do not keep the wrist in extreme extension to avoid stretching the median nerve.

Figure 44-2 Radial arterial line placement. A, To approach the radial artery one needs to go over the thenar eminence. B, Extending the wrist allows a straight shot to the radial artery. C, Approach at a shallow angle to get the needle in, then slide up a little more to get the catheter in as well. D, Make sure the blood keeps flowing as you advance. E, Slide the catheter in, then hold down above the line so the blood does not squirt out. F, It is recommended to use the Luer-Lok to avoid disconnecting the line.

If the first attempt is missed, apply pressure and try another spot. Avoid working through a hematoma. Infection is less likely in the high flow of an arterial system than a low-flow venous system, but it can still happen. Ischemia is one of the most feared complications, but it is an unusual event. Allen’s test is not a good screening test. Be careful of pushing air into the arterial circulation to avoid embolization. When flushing the line, flush for just a second, wait, then flush again. A prolonged flush can push air all the way into the cerebral circulation.

Clinical Pearls

The radial artery is very skinny and placing a line in it requires extremely fine motor control of the muscles of the hand. Standing and bending over while performing the procedure decreases the success rate; sitting down will increase the success rate. It is best to come at the artery in a shallow angle, along the same axis that the artery is describing. If the trace looks damped, there might be a loose connection or an air bubble in the system. After placing the line, if the hand looks ischemic, call a vascular specialist and make sure one is available in case surgical intervention is needed. You may opt to inject nitroglycerin or papaverin down the line, then pull the line out; as you pull, aspirate in case there is a clot on the end.

Complications

One of the complications that may occur with radial arterial line placement is arterial occlusion. The frequency of this complication correlates with the type and size of cannula, with 20-gauge Teflon having the lowest complication rate. Post-cannulation aneurysms are rare and related to abnormal state of the vessel wall, multiple attempts at cannulation, and hematoma or infection at the cannulation site. Other complications include infection (rare), hematoma, and sclerosis (narrowing of the artery with repeated punctures).

Brachial Arterial Line

Indications and Contraindications

The indications for placing a brachial arterial line ^9,¹⁰ are the same as for other arterial lines, i.e., when close blood pressure monitoring and frequent blood gases are needed. In reality, most often a brachial line is chosen after the radial arterial line placement has been unsuccessful and the femoral artery is not an option due to aorto-occlusive disease or history of femoral vascular surgery. Contraindications for placing a brachial arterial line include vascular disease in the arm and infection at the intended site.

Equipment

The equipment for brachial arterial line placement includes the following: (1) a 20-gauge, 12-cm line kit (it is not recommended to place a short line in the brachial artery, because it can come out as the patient moves around); (2) sterile prep, drapes, and gloves; (3) an arm board.

Technique

Steps for inserting a brachial arterial line are shown in Figure 44-3. Explain the procedure and get consent. Position the patient’s arm flat on the arm board. Palpate the brachial artery, just medial to the midline in the antecubital fossa. Make a mark on the skin with a marker. Prep, drape, and administer local anesthetic. We recommend the Seldinger technique for line placement. Use the hollow needle to nick the vessel. Disconnect, observe for good blood flow, and then advance wire up the hollow needle. Remove the needle, advance the catheter up the wire, remove the wire, hook up and sew in the line. Ensure all the connections are tight, the trace is good, and that one can draw back easily.

Figure 44-3 Brachial arterial line placement. A, Equipment kit for brachial arterial line placement. B, Never put a short line in the brachial artery as it will kink when the arm bends. C, Feel the brachial pulse just medially to the biceps tendon. D, Administer local anesthesia. E, Use the standard Seldinger technique to arrive at the artery. F, Advance the wire, making sure it progresses easily. G, The wire is in place. H, Slide the catheter up, check the location again, connect the tubing, and sew it in place.

Complications

Complications of brachial arterial line placement include local damage to the artery itself, arterial spasms, as well as accidental intra-arterial injection of drugs. As with any other invasive lines, chances of infections exist but are rare for arterial lines and will be minimized by using strict aseptic technique. Daily risk of infection for a peripheral arterial catheter is 1.9% per day compared to 3.3% per day for central lines. Arterial sclerosis is also a potential complication, as repeated punctures at the same site may scar the artery and lead to lumen narrowing. This can be overcome by choosing another site of the same artery or choosing a different artery.

Femoral Arterial Line

Indications and Contraindications

Similar to radial arterial line, femoral arterial line ¹¹^–¹³ is indicated for close blood pressure measurement, where small changes in blood pressure can make a big difference, as well as frequent blood gas sampling. Also, in some cases one can anticipate the need for an intra-aortic balloon pump later on, so having a line already in the femoral artery will allow quick access. Femoral arterial line is contraindicated in patients with recent femoral surgery (aorto-iliac procedure, femoral-femoral or femoral-popliteal bypass), infection at the site, those who already have a venous line in the femoral region (can get an arteriovenous malformation), and patients with an occluded aorta (the blood pressure measurement will not be accurate).

Equipment

The equipment for femoral arterial line placement includes the following: (1) as for any arterial line, have pressurized tubing ready to connect, as well as a monitor to look at the arterial trace; (2) a long catheter with a soft tip (rather than a sharp tip that could erode through the back of the femoral artery and cause a retroperitoneal bleed); (3) a 16-gauge 16-cm single-lumen central line kit (anything smaller or shorter tends to kink); (4) sterile prep and gloves; (5) if the patient is obese, it is very helpful to have someone assist in pulling back the pannus to facilitate access to the artery.

Technique

Steps for inserting a femoral arterial line are shown in Figure 44-4. Explain the procedure and obtain consent. If the operator is right-handed, the right femoral artery is easier to approach. The left femoral artery is easier to approach for a left-handed person. Prep and drape in sterile fashion and have an assistant nearby. Apply local anesthetic liberally as the femoral artery is very deep and it can be uncomfortable. The mnemonic NAVEL is useful to remember for anatomic structures from lateral to medial (Nerve, Artery, Vein, Empty space, Lymphatics). It is recommended to use a long needle without a finder. Stick below the inguinal crease and go for the pulse. Use ultrasound guidance to find the vessel if it is available. When blood flow is seen, ensure it is arterial and not venous. Pass the wire through the needle without forcing it; it should pass easily. When the wire is in, remove it. Make a small nick in the skin, pass the catheter, again check that there is good flow, sew in place, and put a good dressing on.