Procedures for the Hospitalized Patients: Alternative Approaches & Advanced Troubleshooting

Eric Isaacs, MD FACEP, FAAEM

Robert Rodriguez, MD FACEP, FAAEM Rachel Chin, MD FACEP (original Author)

San Francisco General Hospital Emergency Services University of California, San Francisco

Course Objectives:

1 Develop an approach to failed vascular access in adults 2 Become familiar with ultrasound technology 3 Learn vascular access, pericardiocentesis, thoracentesis, paracentesis procedures

under ultrasound guidance

Case Presentation #1 The nurse calls you b/c the 40 y/o man admitted for cellulitus, now complains of chest

pain and has peaked T waves on EKG. He is a known dialysis patient with poor vascular access. The nurses are unable to obtain a peripheral IV in his arms or legs.

Question: Where do you try next to get rapid vascular access? Answer: Peripheral sites such as the external jugular or deep brachial vein

External Jugular (EJ) Vein Anatomy

Begins as the confluence of the posterior auricular and retromandibular veins at the mandibular angle

Courses medially over sternocleidomastoid (SCM) before piercing fascia to join with subclavian vein under clavicular head of SCM.

Greater auricular nerve travels alongside the EJ (supplies sensation to external ear)

Right EJ vein of supine patient Adapted from Netter’s Atlas of Human Anatomy (1989) Position

Trendelenburg at 10-15 degrees to increase jugular venous pressure Turn head slightly away from side of EJ cannulation to stretch vein

Technique Valsalva just as cannulating vein to increase intraluminal pressure and visibility Reduce vein-rolling: Select bifurcation puncture site or puncture vein from the side Aim needle only 5-10 degrees deep

Pearls

May not have flashblack of blood in catheter “Floating the IV”: The forward flow of IV fluid opens the vein more and helps guide

catheter insertion in the absence of a needle. Secure the IV around the ear. Seldinger technique for central venous access via the EJ vein

• 18-gauge or larger IV bore to allow for guidewire diameter • Complications of an EJ central line:

1. Time consuming 2. Unable to feed the guidewire (20% failure rate) – especially more difficult

from left EJ because of tortuous course 3. Pneumothorax 4. Puncture of wire through-and-through the vein 5. Thoracic duct puncture (left EJ)

Deep Brachial Vein Anatomy

Brachial veins are paired structures, which lie medial and lateral to the brachial artery.

Not palpable or visible externally Position

Relaxed extension of arm

Technique Tourniquet arm proximally Palpate biceps tendon at antecubital crease Medially, palpate brachial artery Brachial vein lies medial to artery Right antecubital fossa Use a 2-inch angiocatheter Puncture skin at antecubital crease, aiming the needle 45 degrees deep

Pearls

Often needle will simultaneously puncture through both the anterior and posterior wall. Withdrawing needle may give you a flashback of blood.

Success rate = 70-80% Complications • Paresthesias 18% (Kramer et al, 1988) • Brachial A puncture 8% (Kramer)

• Hematoma formation 1.6% (Kramer) • IV decannulation 8% (Keyes et al, 1999)

Can be site for central venous access

Case Presentation #2 A nurse places a 20-gauge peripheral IV in your post-cardiac arrest patient and the vital

signs stabilize. You want to establish a central line for vasopressor support later Question: Where do you try next to get rapid vascular access?

Answer: Central line (subclavian > IJ > femoral) unless patient is about to arrest. If so, then select a central line site where you are most confident in securing a line rapidly.

Central Line 1. FEMORAL LINE Anatomy

Lies medially to the femoral artery just inferior to the inguinal ligament

About 3-4 inches below inguinal ligament, it distally courses deep

Greater saphenous vein is a superficial take-off vein from the femoral vein

Dissection of right groin

(Adapted from Netter’s Atlas of Human Anatomy, 1989)

Troubleshooting Tips 1. Locating the femoral vein without a pulse: The “V” technique

Right Groin (Cadaver

Dissection): V-Technique

1. Place thumb on pubic

tubercle. 2. Place index finger on

anterior superior iliac spine (ASIS)

3. Femoral vein is at “V” of hand, under inguinal ligament

2. Difficulty feeding the guidewire

Basic Tips: Re-aspirate syringe for blood to ensure that your needle is still in the vein Flatten needle angle: Guidewire may be abutting vein wall at a sharp angle Twirl guidewire: Guidewire may be wedged against a valve or vein wall.

Twirling the wire may loosen it and allow for advancement. Advanced Tips:

New central line kit available where guidewire can be introduced through the back of the syringe and into the needle. Takes away one step of removing the syringe from the needle for guidewire introduction.

Find the true inguinal ligament • A common mistake is to puncture the skin too inferiorly below the

inguinal ligament from either fear of peritoneal injury or a “sagging” inguinal ligament. Be sure to manipulate the inguinal ligament so that it is a straight line rather than U-shaped. This may require pushing the abdominal pannus or excess skin superiorly during the procedure.

• If you inadvertently start too inferiorly, your needle may cannulate nothing… or the greater saphenous vein (GSV). Often the guidewire can not be introduced through the GSV because of the vein’s valves and smaller diameter.

Femoral Line: Acute Complications

1. Femoral artery puncture: 9-15% (McGee and Gould, 2003) 2. Hematoma formation: 3.8-4.4% (McGee and Gould, 2003) 3. 23% failure rate for femoral lines in pulseless patients. (Emerman et al, 1979)

Femoral Line: Subacute Complications

1. Thrombosis Mian et al, 1997: Prospective study with 42 patients where patients had

bilateral lower extremity ultrasounds performed within 7 days of femoral central line placement. Result: 26.2% had a DVT in that same extremity (versus 0% in the other leg without a femoral line)

Merrer et al, 2001: Randomized study with 289 patients in 8 French ICU’s where patients either underwent a femoral versus subclavian line. Result: 21.5% of patients with a femoral line had thrombotic complications (versus only 1.9% for patients with subclavian lines)

2. Infection: 19.8% of patients with a femoral line had catheter colonization (versus 4.5% for patients with subclavian lines). Catheter-related clinical sepsis occurred in 4.4% of femoral line patients versus 1.5% for those with subclavian lines. (Merrer et al, 2001)

2. INTERNAL JUGULAR (IJ) LINE Anatomy

IJ vein lies anterolaterally to the carotid artery at the apex of the triangle, formed by the clavicle and the two heads of the sternocleidomastoid muscle.

Joins the subclavian vein just under the clavicle

IJ Vein Anatomy from Head-of-Bed View

(Adapted from McGee and Gould, New Engl J Med,

2003)

Troubleshooting: Why Can’t I Find the Vein? (Armstrong et al, 1994, Bazaral and Harlan, 1981)

1. ERROR: No Trendelenburg positioning At least a 14% Trendelenburg angle increases the diameter of the IJ vein as

much as a Valsalva maneuver 2. ERROR: Overextension or overrotation of neck

Can cause the sternocleidomastoid muscle to compress the IJ vein 3. ERROR: Excessively deep carotid artery palpation

Can cause inadvertent compression of the thin-walled IJ vein Tip: Select the right IJ over the left IJ

1. Left IJ has more tortuous route to SVC Difficulty feeding guidewire Catheter malposition (in left subclavian, right subclavian, right IJ) Generally more time-consuming and has more complications than right IJ

cannulation (Sulek et al, 2000) 2. Dome of left lung is higher than the right lung

Theoretical greater risk of pneumothorax 3. Thoracic duct empties at junction of left IJ and left subclavian vein

Internal Jugular Line: Acute Complications

1. Carotid artery puncture: 3.0-9.4% (McGee and Gould, 2003; Ruesch et al, 2002) 2. Hematoma formation: <0.1-2.2% (McGee and Gould, 2003) 3. Pneumothorax: <0.1-0.2% (McGee and Gould, 2003; Iovino et al, 2001) 4. Catheter tip malposition: 1.8-14% (Ruesch et al, 2002; Gladwin et al, 1999;

Iovino et al, 2001)

Internal Jugular Line: Subacute Complications

1. Thrombosis: Generally low risk but wide range of published thrombosis rates 0-66% (Roberts and Hedges, 1998; Ruesch et al, 2002)

2. Catheter-related bacteremia: 8.6% (versus 3.9% for subclavian—not statistically significant with relative risk CI 0.62-8.09) (Ruesch et al, 2002)

Consider IJ line over subclavian line only for short-term access (<5-7 days), because low acute complication rate outweighs risk of thrombosis and infection. (Timsit, 2003)

3. SUBCLAVIAN LINE

Anatomy Axillary vein runs medially to become the subclavian vein as it passes over 1st rib Subclavian vein lies immediately posterior to the medial 1/3 of clavicle and is

separated from deeper subclavian artery by anterior scalene muscle 1-2 cm in diameter

Subclavian Vein Anatomy from Patient’s

Right Side View (Adapted from McGee and Gould, New Engl J

Med, 2003)

Tip #1: Positioning

No need to position the patient in Trendelenburg—the vein is kept patent by surrounding costoclavicular ligaments

Basic tip: Place small towel roll between the scapulas to reduce deltoid muscle bulge, which may hinder keeping the needle from pointing too intrathoracically. Be careful of overretracting the shoulders, which can compress the subclavian vein.

Advanced tip: Abduct arm slightly to flatten the deltoid muscle bulge

Tip #2: Preventing IJ Tip Placement Most common malpositioning of subclavian catheter is into ipsilateral IJ vein. Technique (Ambesh et al, 2002) • Using the needle-stabilizing hand, place index finger in supraclavicular fossa

while feeding the guidewire with the other hand. This prevents the guidewire from entering the ipsilateral IJ vein.

• Incidence of malpositioned tip in IJ: 6% (control) vs 0% (test case) • Interestingly: Patients with malpositioned catheter in IJ had ear pain or trickling

throat sensation

Tip #3: Supraclavicular Approach (“The Pocket Shot”) Subclavian vein courses superiomedially under the clavicle and over the 1st rib to join

IJ vein. Lateral to the sternocleidomastoid (SCM), subclavian vein is located superior and posterior to clavicle

Technique • Puncture site: 1 cm lateral to SCM and 1 cm posterior clavicle • Aim needle inferomedially (bisecting angle of clavicle with SCM) and anteriorly

about 10 degrees Advantages • Can be done upright (congestive heart failure patients) and in obese patients • More accessible than infraclavicular approach during a “code” when CPR is being

performed (Dronen et al, 1982) • More accessible than internal jugular line during a “code” when a patient is

intubated because does not require turning of head (Dronen et al, 1982) • Fewer complications than infraclavicular route (needle pointing away from lung

and artery) Overall: 2.0 (versus 5.1%) (Sterner et al, 1986) Pneumothorax: 1.1% (versus 2.5%) (Pittiruti et al, 2000: A retrospective,

single-institution study of 1273 infraclavicular lines and 847 supraclavicular lines)

Subclavian artery puncture: 3.5% (versus 2.8%) (Pittiruti et al, 2000) Catheter tip malposition: 0.9% (versus 10.8%) (Sterner et al, 1986)

• Most successfully positioned neck central line, because of almost straight pathway from right supraclavicular site to superior vena cava (Roberts and Hedges, 1998; Pittiruti et al, 2000; Dronen et al, 1982)

Anatomy of Supraclavicular Approach from Patient’s Right

Side View (Adapted from McGee and

Gould, New Engl J Med, 2003)

Subclavian Line: Acute Complications (Infraclavicular approach)

1. Subclavian artery puncture: 0.5-4.9% (McGee and Gould, 2003; Ruesch et al, 2002)

2. Hematoma formation: 1.2-2.1% (McGee and Gould, 2003) 3. Hemothorax: 0.4-0.6% (McGee and Gould, 2003) 4. Pneumothorax: 1.5-3.1% (McGee and Gould, 2003; Iovino et al, 2001) 5. Tip malposition: 1.8-9.3% (Ruesch et al, 2002; Mansfield et al, 1994; Iovino et

al, 2001) Subclavian Line: Subacute Complications (Infraclavicular approach)

1. Thrombosis: Merrer at al, 2001: 1.9% (versus 21.5% for femoral line) Ruesch et al, 2002: 1.4% in meta-analysis of 899 central line placements

2. Catheter-related clinical sepsis Merrer et al, 2001: 1.5% (versus 4.4% for femoral line) Ruesch et al, 2002: 3.9% (versus 8.6% for IJ line—not statistically significant

difference) 3. Catheter colonization: 4.5% (versus 19.8% for femoral line) (Merrer et al, 2001) 4. Subclavian stenosis: In 50% of patients receiving subclavian catheters for

dialysis, venous stenosis developed. Nephrologists recommend IJ line if need dialysis. (Barrett et al, 1988)

Ultrasound Roadmap Vascular access: why use ultrasound? Errors in Medicine

• 2000 Institute of Medicine Report • Agency for Health Care Research and Quality • Reviewed 79 patient safety practices • Among top 10 recommendations: use of US-guided catheter placement

To Err Is Human: Building a Safer Health System. 2000. Committee on Quality of Health Care in America Making health care safe. A critical analysis of patient safety practices. AHRQ 2001

Noninvasive imaging Vascular probe: 7.5 Mhz frequency, flat transducer

• High frequency allows for more detail at the expense of visualizing deeper structures

Basic tenets in vascular ultrasound: • Blood vessels are black (anechoic).

Compression Veins compress easily Arteries much less compressible

Arteries are pulsatile, despite compression. • Dot on probe correlates with dot on screen.

Major veins (IJ, common fem.) vary in size with respiration, Valsalva, Trendelenburg Tourniquet for peripheral, deep brachial Doppler

Trick of Trade: Can use vaginal probe instead, if you do not have a vascular probe— same 7.5-Mhz frequency transducer. (Phelan, 2003)

Ultrasound Probe on Patient’s Right Neck Normal Vascular Ultrasound of (Dot on Probe Faces Medially) Right IJ Vein and Carotid Artery

Ultrasound-Guided Internal Jugular Central Line

Technique: Marking the IJ vein site • Position patient (Trendelenburg, slight head rotation away from IJ vein site) • Identify IJ vein in cross-section with US • Locate best IJ vein site and center image on US screen • Mark vein path anterior and posterior to probe with needle hub (on the skin) • Wipe off US gel and re-mark sites with permanent marker • Prep site sterilely and commence IJ line placement, aiming for site between 2 marks

Alternative Technique: Live-Time US Guidance • Identify IJ vein and determine if want to cannulate • Sheath US probe / cabling with sterile cover, and place sterile gel on field • Place US probe so cross-sectional image of IJ vein is centered on US screen • Insert needle while watching US screen (needle will appear as hyperechoic line) • Advantage: More real-time feedback of needle location • Disadvantage:

o Usually requires assistant o Messier with gel on field o More difficult to maintain sterile technique

Trick of Trade: If the internal jugular vein diameter is less than 7 mm, select a different vein site. Independent predictor of unsuccessful line placement (Mey et al, 2003)

My Recommendation: Use ultrasound imaging for all IJ central lines, if time allows.

Anatomical Variation: High incidence of unexpected IJ vein location and size • Troianus et al, 1996: In 1136 patients, the IJ vein overlapped the carotid artery in

54% of pts • Denys and Uretsky, 1991: In 183 mostly cardiac transplant recipients, 5.5% had a

variant right IJ vein, which did not correlate with external anatomical landmarks. • Gordon et al, 1998: 5.5% of 869 prospective patients had carotid artery LATERAL

to IJ vein.

Vascular Ultrasound of Variant Anatomy:

IJ vein is directly superficial (rather than lateral) to carotid

artery

The Supporting Literature 1. Hind et al, 2003: Meta-analysis showed US-guided IJ line had much lower failure rate

(RR 0.14) 2. Miller et al, 2002: Prospective study in teaching ED setting comparing US-guided

versus traditional landmark-guided IJ line • Time from skin puncture to blood flash: 115 sec (US) vs 512 sec (landmark) • Number of attempts: 1.6 (US) vs 3.5 (landmark) • For “difficult stick” patients, time to line placement: 93 sec (US) vs 463 sec

(landmark) 3. Denys et al, 1993: Similar study as Miller et al but in cardiology setting, looking at

complications • Artery puncture: 1.7% (US) vs 8.3 (landmark) • Hematoma: 0.2% (US) vs 3.3% (landmark)

Ultrasound-Guided Subclavian Central Line

Technically difficult because of vein’s location posterior to clavicle (especially difficult in obese pts)

Literature is equivocal as to whether ultrasound improves success rate and reduces complications.

Ultrasound-Guided Deep Brachial Line

Supplements landmark technique Increases success of deep vein cannulation (Keyes et al, 1999)

Central Line Case Scenarios: Which central line site would you first choose for a patient… with severe orthopnea from flash pulmonary edema?

* Answer: Subclavian SC or IC (consider external jugular) * Both can be done sitting up, but the SC approach has better success for CVP

positioning in asystole?

* Answer: Subclavian SC or femoral * Generally, select the site where you feel you can cannulate the quickest. IJ’s

and IC subclavian lines are operationally difficult to insert during intubation and CPR.

with sepsis? * Answer: Subclavian SC > subclavian IC > US-guided IJ >> femoral * Because infection is already a major concern, placing a line with the least

infectious complications is best—the subclavian line with new renal failure?

* Answer: US-guided IJ > subclavian * Dialysis catheters have been to cause venous stenosis when in the subclavian

vein with an INR of 6?

* Answer: US-guided IJ or femoral * Because of the risk of subclavian artery puncture, the IJ (under US-guidance

only) or the femoral vein should be cannulated. As the INR increases, the femoral vein should be the primary site of central access, because of the severe consequences of carotid artery puncture.

Bottom line: Think of the subclavian site first.

Pericardiocentesis Why do ultrasound?

• Identification of effusion/tamponade • Avoid important structures in chest ie heart, great vessels, liver • Increased success & safety • Blind technique complications 7-50% • New options: anterior approach •

Procedure: • Pt supine • Transducer — cardiac or abdominal probe • Sterile prep • Select an approach • Needle under transducer • Probe away from needle • NS injections into pericardium as guide

Subxyphoid approach Parasternal or apical Largest pocket

Thoracentesis Why use ultrasound?

• Verify the effusion - replace decubitus films • Can increase patient safety • Can increase chance of success

Step 1: Verify the effusion

• Pt lying supine • Transducer — abdominal probe • Mid-axillary line, approximately T8-11 • Locate diaphragm, liver/spleen, and look above for effusion

Step 2: Procedure • Real time • Mark good spot • Sterile prep • Locate interspace • Needle under probe

Paracentesis Why use ultrasound?

• Maybe there is no fluid • Locate the bladder • Procedure carries some risk • Exam is easy

How to do the ultrasound

• Patient supine • Transducer — abdominal probe • Adjust depth & gain • Same as FAST: • Look for large pockets of fluid

The procedure • Identify and mark best spot • Real-time guidance • Sterile set-up • Needle must pass under transducer • Watch for deformation of abd wall • May see hyperechoic needle

Experimental: Adult Intraosseous (IO) Line

Most studies for IO line placement are in the pediatric literature. More popular use of the adult IO line in Europe, Canada, and the military. Commercially-made IO line kits available which are

FDA approved • BIG (Bone Injection Gun) • FAST1 (First Access for Shock and Trauma-1)

Macnab et al, 2000: This prospective study of 50 adult patients with Bone Injection Gun model prehospital placement of sternal FAST1 IO needle involved 6 ED’s (www.waismed.com/big/asp) and 5 EMS sites in Canada and the U.S. There was an 84% success rate, with most failures occurring because patients were “very obese”. The average IV flow rate was 80 cc/min with only gravity pressure. No complications on 2-month followup.

Potential puncture sites (Macnab et al, 2000; Iserson KV, 1989)

• Sternum (closer to central circulation, low fracture potential) • Proximal tibia (primary site for children, but

likely the cortex is too thick in adults) • Distal radius • Distal tibia (just superior to the medial malleolus)

New 2005 ACLS guidelines likely to have recommendations to incorporate IO line into resuscitation algorithms.

Cross-section of sternum and FAST1 system (www.life-assist.com/pyng/product.htm)

SUMMARY

The site choice for central line placement should be based on the associated acute and subacute complications. Except for a few unique cases, the subclavian central line ranks as the most ideal option. Specific to the subclavian line, the supraclavicular approach seems to have fewer mechanical complications than the infraclavicular approach.

With the increasing availability of vascular ultrasound, the incidence of complications for deep brachial and internal jugular vein lines should decline drastically.

Procedures such as pericardiocentesis, thoracentesis, and paracentesis should be done under

ultrasound guidance to avoid complications.

Physicians should become proficient with ultrasound-guided line placements, because they will become the standard of care in the future.

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