Patients for whom intravenous access is difficult are frequent users of the Emergency Department. When common sites of peripheral access are sclerosed or inaccessible, alternative measures of access include placement of a central venous catheter. The paradigm of placing a central line for every patient for whom landmark peripheral techniques fail can result in decreased patient satisfaction, inefficient use of ED nursing and physician resources and the serious complications of central venous access.
- Failed landmark technique
- Anticipated difficult access
- Central Venous Access undesirable.
Overview of Central and Peripheral IV Access:
- Arterial puncture
- Any familiar site of IV access can be used (antecubital fossa, dorsum of hand, etc.)
- The basilic vein is particularly suited to ultrasound guided iv placement
- Avoid the brachial veins due to proximity of the brachial artery.
- Gather equipment and Ultrasound Machine
- Scout out vein (locate, check for thrombus, scan proximally and distally)
- Determine depth of target vein using markers on side of US screen.
- Out of Plane US guidance
- Puncture skin and identify needle tip
- Advance probe until needle tip no longer visualized
- Advance needle until tip visualized again
- Repeat previous two steps until vein is entered
- Confirm tip is in vein with saline flush injection
- In-Plane US guidance
- Visualize vein in Short Axis
- Rotate 90 degrees for Long Axis
- Use “ski-lift” technique to puncture skin
- Advance needle tip under direct visualization
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