Placing Peripheral IVs, Central
Venous Catheters, and Intraosseous
Lines
AFAMS Resident Orientation
April 8, 2012
Outline
• Basic principles of IV infusions
• Indications, contraindications, acceptable
locations, and complications of placing
– Peripheral IVs
– Central Lines
– Intraosseous Access
• Brief descriptions of technique for each vascular
access procedure
Basics of Intravenous Infusion
• IV Flow rate is proportional to catheter radius4
• IV Flow rate is inversely proportional to catheter length
• Therefore, fluid flows faster in a wide short catheter
than in a narrow long catheter
• The smaller the catheter Gauge, the wider the catheter
radius
– 14 G is wider than 20 G
Peripheral IV Indications
• Sample Blood
• Infuse fluids
• Infuse blood products
• Infuse IV medications
Peripheral IV Contraindications
• Extremities with
– Massive edema
– Burns or injuries
– Cellulitis
• Mastectomy
– Concern for adequate vascular flow
• Indwelling fistula
– Avoiding possible vascular damage near a fistula
Complications
• Insertion site infection
• Superficial Thrombophlebitis
• Interstitial Leakage
Placement a Peripheral IV
• Practice Universal Precautions
– Always wear gloves
– Consider face and eye protection
• Avoid needle sticks
– Do not recap needles
– Do not put needles back in the sheath
– Dispose in proper sharps container
• Always start peripheral and move proximal if
initially unsuccessful
Placement a Peripheral IV: Equipment
• Gloves and protective equipment
• Appropriate size IV catheter (14G – 25 G)
• Tourniquet
• Gauze
• Transparent Dressing (Tegaderm)
• IV bag with tubing
Placement a Peripheral IV
• Wear gloves
• Apply tourniquet proximal to
insertion site
• Palpate vein
• Clean skin with alcohol prep
• Remove protective cover of
catheter
• With left hand stabilize the
vein while you insert
catheter, bevel up, with your
right hand
• Angle of insertion should be
approximately 35 degrees
Placement a Peripheral IV
• As catheter is advanced,
watch for blood “flash”
• Once “flash” is seen,
slowly advance needle 1
cm, then stabilize needle
and advance catheter
into vein
• Remove tourniquet
• Attach catheter to saline
lock
• Dispose of needle in
sharps container
Indications for Central Line Placement
• Infusion of sclerosing or hyperosmolar medications
– Pressors, chemotherapy, TPN, etc.
• Access for hemodynamic monitoring
– Swan-Ganz Catheter
• Lack of peripheral access
• Transvenous pacing
• Aspiration of venous air (Intra-operative issue only)
Central Venous Access Locations
• Internal Jugular Vein
• Femoral Vein
• Subclavian Vein
• Uncommon
– Arm (brachiocephalic vein)
– External Jugular Vein
• Usually cannulate dwith a peripheral IV
General Concepts to Central Venous
Catheter Placement
• Obtain informed consent
• Set up your equipment
• Position the patient
• Practice Universal precautions
– Gown
– Gloves
– Eye protection
General Concepts to Central Venous
Catheter Placement
• Clean the area with chlorhexidine or betadine
• Drape the area to reduce infection risk
• Use plenty of lidocaine superficially and
deeper in the soft tissue
External Jugular Vein
Advantages
• Easy to learn to perform
• Essentially peripheral
venipuncture
• Pneumothorax is
uncommon
• Arterial puncture is
uncommon
Disadvantages
• Inability to cannulate vein
common (≈ 20 %)
• Practice required to use guide
wire
• Wire or catheter may perforate
veins
• May interrupt CPR during code
External Jugular Anatomy
Femoral Vein
Advantages
• Does not interrupt CPR
during a code
Disadvantages
• If pulse is absent, vein may
be hard to locate
• Vein does not collapse
• Longer delivery time of drug
to heart
• Easy access to central
circulation
• Risk of thrombosis (0.5 %),
infection (1 to 2 %),
colonization (25 to 30 %)
and inadvertent puncture of
the femoral artery (5 to 8 %)
with vascular injury
• Useful for hypovolemic
shock
Femoral Vein Anatomy
Femoral Vein Technique
• Position patient supine
• Measure halfway between Anterior Superior Iliac Spine and
Pubs Symphysis along the inguinal ligament
– Femoral Artery site
• Palpate Femoral Artery
• Target venopuncture 2 cm inferior to inguinal ligament and
2 cm medial to femoral artery
• Advance needle at 20-30 degrees while aspirating until
venous flash is seen
Femoral Vein Technique
• After venous flash remove syringe
• Advance wire through needle
• Remove Needle holding pressure over puncture site
– NEVER LET GO OF THE WIRE!
• Advance catheter over wire
• Remove wire
Femoral Vein Access Complications
• Infection
• Thrombophlebitis
• Retroperitoneal
hemorrhage
• Inadvertent puncture of
bladder
• Vasovagal reaction
• A-V fistula
• Hematoma
• Femoral artery
thrombosis or embolism
Internal Jugular
Advantages
• More sterile than femoral
vein
• Can do hemodynamic
monitoring with IJ
– Swan-Ganz catheter
• Can do with ultrasound
assistance
• Quick delivery of drug to
the heart
Disadvantages
• Risk of pneumothorax
• Risk of carotid artery
puncture
• Cannot be done while CPR
is being done
Internal Jugular Vein Superficial
Anatomy
Internal Jugular Vein Venous Anatomy
Internal Jugular Vein
• Patient supine, 15-degree
angle in Trendelenberg,
head down
• 3 Different approaches
– Central
– Anterior
– Posterior
• Right side IJ is preferred
– Dome of pleura is lower
– Straight line to right atrium
– Thoracic duct not in the way
Internal Jugular Vein Technique
• Standing at head of patient
• Visualize triangle formed by
heads of sternocleidomsatoid
5 cm superior to clavicle
• Palpate carotid pulse with left
hand
• Use finder needle, insert at
30-45 degree angle aiming
toward ipsilateral nipple
• If blood is not aspirated
within 2.5 cm slowly
withdrawal needle and
reposition
Internal Jugular Vein Technique
• After venous flash remove syringe
• Advance wire through needle
• Remove Needle holding pressure over puncture site
– NEVER LET GO OF THE WIRE!
• Advance catheter over wire
• Remove wire
Subclavian Vein Insertion
Advantages
• Superficial vein
• Can remain in place for long
time
• Can do central
hemodynamic monitoring
(IJ is preferred)
Disadvantages
• Difficult to compress in
bleeding situation
• High rate of pneumothorax
• Risk of subclavian artery
injury
Subclavian Venous Access
Subclavian Venous Access
• Position patient in 15
degrees of
Trendelenberg
• Abduct patient’s arm
• Insert Needle 2-3 cm
inferior to the midpoint
of clavicle
• Keep needle parallel to
floor
• Advance needle under
clavicle and towards
sternal notch
Subclavian Vein Technique
• After venous flash remove syringe
• Advance wire through needle
• Remove Needle holding pressure over puncture site
– NEVER LET GO OF THE WIRE!
• Advance catheter over wire
• Remove wire
Comparison of Central Access Sites
Arm
External Internal
Jugular Jugular
Subclavian Femoral
Ease/Safety
1
2
4
5
3
Long term use
4
3
2
1
5
Success
5
4
1
3
2
Complications
1
2
3
4
3
Swan-Ganz Use
5
2
1-right
4-right
3-left
3-left
3
note: 1 = best, 5 = worst.
From: Blitt, CD. Monitoring in Anesthesia and Critical Care Medicine, 2nd ed. New York: Churchill Livingstone, 1987:189.
Central Venous Catheter Complications
Local Complications
• Hematoma
• Cellulitis
• Thrombosis
• Phlebitis
Serious Complications
• Embolism
• Vascular Erosions
• Pericardial Tamponade
• Pneumothorax
• Thrombosis
• Catheter Associated
Infection
• Misinterpretation
Intraosseous (IO) Access
• Intraosseous infusion is
possible because of
large veins that drain
medullary sinuses in the
bone marrow of long
bones
IO Indications
• Pediatrics in shock or
cardiopulmonary arrest
• Acute life-threatening
situations when standard
venous access cannot be
rapidly achieved
• Any situation when
venous access cannot be
achieved quickly
IO Access
Advantages
• Easy accesses
Disadvantages
• Painful
• Can infuse all types of
medication and fluid
• Infusion comparable to a 21
gauge needle
• Easily done in a CPR or code
scenario
• Temporary Access only
– SHOULD NOT BE LEFT IN
LONGER THAN 24 HOURS
Intraosseous Access Sites
• Proximal tibia (popliteal vein)
• Femur (branches of femoral vein)
• Distal tibia (great saphenous vein)
• Proximal humerus (axillary vein)
• Manubrium (internal mammary and azygos veins)
Intraosseous Contraindications
• Fractured bone
• Extremity with vascular interruption
• Cellulitis, burns, or osteomyelitis at cannulation site
• Patients with osteogenesis imperfecta or osteopetrosis
• Patients with right to left intracardiac shunts
– Greater risk for bone-marrow emboli
IO Required Equipment
• Betadine or
chlorhexidine solution
• Universal precautions
– Gloves
– Gown
– Eye protection
• Syringe with saline flush
• Intraosseous needle
IO Technique
• Wear universal
precautions
• Clean the insertion area
• Infiltrate the skin,
subcutaneous tissue
and periosteum with
1% lidocaine
• Palpate the landmarks
and identify insertion
site
IO Technique
• Direct needle perpendicular
to entry site
• Apply pressure with a
twisting motion
• As the needle passes
through the cortex and into
the marrow cavity a
“release of resistance is felt
• Unscrew the needle cap and
remove the stylet
• Confirm placement by
aspiration of marrow
• Begin infusion
IO Technique: Tibia
• Clean the insertion site
• In children insertion is 2
cm distal and 1 cm
medial to tibial plateau
IO Technique: Tibia
• In adults insertion site is
the distal tibia
• 1-2 cm superior to
malleolus
• Medial is preferred to
the lateral malleolus
IO Complications
• Bone fracture
• Osteomyelitis
• Compartment
syndrome
• Microscopic fate and
bone marrow emboli
Conclusions
• Vascular access is an important part of treatment
in all hospitalized patients
• Many options for vascular access exist
– Peripheral IV
– Central Line (multiple locations)
– Intraosseous Access (multiple locations)
• Choice of option and location made based on
patient characteristics
– Always choose the least invasive option if possible