INTRAVENOUS TECHNIQUES

1. To understand the proper indications for central intravenous access

2. To know how to perform central intravenous techniques during CPR

Objectives

INDICATIONS FOR IV THERAPY

• Administer drugs and fluids

• Obtain venous blood

• Insert catheters into central circulation

ESTABLISH IV LIFELINE

• Routine part of advanced life support

• As early as possible

TYPES OF IV CANNULAS

• Hollow needles

• Indwelling plastic catheters inserted over hollow needle

• Indwelling plastic catheters inserted through a hollow needle or over a guide wire

TYPES OF IV TECHNIQUESCatheter-Over-The-Needle-Technique

TYPES OF IV TECHNIQUESCatheter-Through-The-Needle-Technique

TYPES OF IV TECHNIQUESSeldinger Technique with Guidewire

IV THERAPY

• Plastic catheter

• 14- and 16-gauge in adult

• Length depends on site

Selection of Catheters

IV THERAPY

• IV preferable to intracardiac

• Use of peripheral or femoral vein does not interrupt CPR

• Aseptic technique if possible

• Femoral must have long cannula to thoracic cavity

General Principles

IV THERAPY

• IV tubing with injection sites

• 500 mL N/S

• Plastic bottle or bag

• Keep open at 10 mL/hour

General Principles (cont.)

IV THERAPY

• Hematoma

• Cellulitis

• Thrombosis

• Phlebitis

Complications

Local

IV THERAPY

• Sepsis

• Pulmonary thromboembolism

• Catheter fragment embolism

• Air embolism

Complications (cont.)

Systemic

PERIPHERAL VENIPUNCTURE

• Effective route for drugs during CPR

• Does not interrupt CPR

• Easy technique

Advantages

PERIPHERAL VENIPUNCTURE

• In circulatory collapse, vein may be absent

• Access to central circulation may be difficult

• Isotonic solutions only

• Phlebitis common with saphenous vein

Disadvantages

FEMORAL VEIN

• Does not interrupt CPR

• Vein does not collapse

• Easy access to central circulation

Advantages

FEMORAL VEIN

• If pulse absent. Vein is hard to locate

• Long delivery time of drug into central circulation unless long catheter advanced into thoracic cavity

Disadvantages

FEMORAL VEIN

• Thrombosis or phlebitis may extend to deep or illiac veins or vena cava

• Arterial cannulation – loss of limb

• Hematoma

Complications

INTERNAL JUGULAR AND SUBCLAVIAN VENIPUNCTURE

• Access to central circulation

• Emergency access to venous circulation

Specific indications

INTERNAL JUGULAR AND SUBCLAVIAN VENIPUNCTURE

• Needle, 6 cm long

• 16-gauge catheter, 15-20 cm long

• Depth of placement from surface markers

General principles

INTERNAL JUGULAR AND SUBCLAVIAN VENIPUNCTURE

• Patient supine, 15-degree angle, head down

• Occlude needle to prevent air entry

• Never pull catheter back through needle

• Use of guidewire eliminates hazard

• Affix catheter with suture

General principles (cont.)

INTERNAL JUGULAR VENIPUNCTURE

• Dome of pleura is lower

• Straight line to right atrium

• Thoracic duct not in the way

Right Side of Neck Preferred

INTERNAL JUGULAR OVER SUBCLAVIAN

• Less risk of pleural puncture

• Hematomas in neck are visible

• Easier during CPR

Advantages

SUBCLAVIAN OVER INTERNAL JUGULAR

• More subsequent neck movement possible with prolonged cannulation

Advantages

INTERNAL JUGULAR AND SUBCLAVIAN VENIPUNCTURE

• Adjacent structures easily damaged

• More training required

• May interrupt CPR

• High complication rate

• Higher complications with thrombolytic therapy

Disadvantages

INTERNAL JUGULAR AND SUBCLAVIAN VENIPUNCTURE

• Hematoma may compromise airway

• Damage to adjacent artery, nerve, or lymphatic duct

• Perforation of endotracheal cuff

Specific local complications

INTERNAL JUGULAR AND SUBCLAVIAN VENIPUNCTURE

• Pneumothorax – Need follow-up chest x-ray

• Hemothorax

• Air embolism

• Infiltration into mediastinum or pleural space

• Arrhythmia from catheter tip

Specific systemic complications

SUBCLAVIAN CANNULATION VIA EXTERNAL JUGULAR VEIN

• Easy to learn to perform

• Peripheral venipuncture

Advantages

SUBCLAVIAN CANNULATION VIA EXTERNAL JUGULAR VEIN

• Practice required to use guide wire

• Wire or catheter may perforate veins

• May interrupt CPR

Disadvantages