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Optimizing Venous Access Using the Web

2007; Lippincott Williams & Wilkins; Volume: 29; Issue: 7 Linguagem: Inglês

10.1097/01.eem.0000285245.80608.1a

1552-3624

Ivan Miller, Glenn Fink,

Vascular Procedures and Complications

Figure“Doctor, we need a central line on Ms. Smith, we've all tried, and she's got nothing.” After a quiet groan, we have several options to consider: search for a hidden peripheral vein, blind stick, external jugular, or go right to a central line. Central venous access begs further questions: femoral, internal jugular, subclavian. Surface landmarks or ultrasound-guided? Modern medicine has extended the lives of many patients with serious illness, which is obviously a good thing, but one of the consequences of modern medical care is the increasing difficulty of gaining IV access. In most EDs, venous access problems arise many times a day. We've all seen cases where diagnosis and treatment were delayed as a result of difficulties in venous access. The main fallback, the central line, is more invasive and has a significant complication rate. What is the proper sequence of peripheral and central veins to consider? How does bedside ultrasound affect our choices? Questions outnumber answers. It is important that all emergency departments understand and offer the complete spectrum of intravenous access methods to improve efficient patient care and reduce risk. Most intravenous catheters are easily started in the hand, forearm, or antecubital region, but what happens when your best clinician can't get into the veins in these areas after multiple attempts? The dorsal veins of the foot are used in the pediatric population without hesitation. What are the relative risks of using foot veins in the adult population? What are the risks of using the saphenous vein? The risks of using these secondary sites must be compared with the risks of inserting central lines. Remember, many of the complications such as deep vein thrombosis and line sepsis may occur after the patient has left the emergency department. How does edema of an extremity alter the decision? Are the risks of inserting an intravenous catheter in an arm mildly edematous from axillary lymph node dissection greater than the risks of a central line? Is the edema of fluid overload more or less prone to complications than from lymphatic obstruction? Is an IV in the foot of a fluid overloaded patient riskier than a femoral line? How are these risk-benefit ratios modified by diabetes, peripheral arterial disease, and the presence of risk factors for thromboembolic disease? Despite its importance in emergency medicine, a unifying theory of venous access seems to have fallen between the cracks. We will leave it to the academic community and professional societies to develop and promote sophisticated guidelines for this increasingly tough clinical challenge. A review of the literature reveals a growing chorus arguing that the use of bedside ultrasound dramatically improves access to peripheral as well as central veins. A small sample of Internet articles on the use of bedside ultrasound by physicians and nurses to locate peripheral veins are included here. (See box.) With minimal training and a bedside ultrasound device, these otherwise hidden veins can be cannulated in less time and with fewer sticks than with traditional methods. Online Sources Once you have decided a patient needs a central line, you'll decide which vein to use based on the immediate logistics, the clinical circumstances, and your level of comfort with the various approaches. Specific complications vary with specific sites. Femoral vein sites are prone to infection and thrombosis while the subclavian sites are subject to vascular injury and pneumothorax. The internal jugular site is prone to vascular injury. Standard emergency medicine texts describe placement of catheters in the major deep veins. (Roberts and Hedges' Clinical Procedures in Emergency Medicine is online at www.mdconsult.com.) Or you could turn to the New England Journal of Medicine online (http://content.nejm.org/cgi/content/full/348/12/1123/DC1) for a video on insertion of internal jugular and subclavian vein catheters (using the traditional landmark technique). As you might expect, the use of ultrasound to guide central line placement has been shown to improve outcomes and some consider it the standard of care. The web site of Washington University in St. Louis has a page entitled, “The Role of Ultrasound in Central Line Placement” that reviews several articles on ultrasound-guided central line placement. (http://emed.wustl.edu/emed/emed.nsf/J/7899E3EA153B9401862572050066A0A4?OpenDocument.) Cmedownload (www.cmedownload.com) has several videos illustrating the use of ultrasound for vascular access, which are available for purchase individually or as part of several multi-video series on ultrasound. Interventional radiologists have published useful articles that will expand your knowledge of central lines. Although they describe techniques and technology that are currently beyond the scope of most emergency departments, we recommend them to emergency physicians interested in an advanced understanding of central lines. The article “Quality Improvement Guidelines for Central Venous Access” from the Journal of Vascular and Interventional Radiology reviews definitions, indications, success rates, and complications of image-guided central venous access. (www.jvir.org/cgi/reprint/14/9/S231.pdf.) The more detailed article “Central Vein Access” from Emedicine at www.emedicine.com/radio/topic859.htm treats improved success rates using ultrasound for central line placement as an established fact. The article notes that ultrasound allows you to determine if the vein is thrombosed. The discussion on picc lines, ports, and dialysis catheters will increase your knowledge of these modalities. The section on guidewire complications will remind you not to pull hard on “stuck” guidewires of patients with pacemakers and IVC filters. There are several useful articles that motivate and describe the process of implementing ultrasound for IV access. With tight budgets and time constraints, these articles will assist you in negotiating with your hospital administration and your nursing staff. And don't forget, your hospital IV therapy team will benefit from a portable ultrasound unit. According to these and other authors, effective use of ultrasound improves the quality of care. Look for recommendations from the Agency for Healthcare Research and Quality (www.ahrq.gov/clinic/ptsafety/chap21.htm) for ultrasound guided placement of all central venous catheters. Given this, a Joint Commission mandate would not be surprising. ONLINE RESOURCES FOR PLACING VENOUS ACCESS LINESFigureAcademic Emergency Medicine: These articles suggest that a large majority of difficult-to-access patients will have an accessible peripheral vein when an ultrasound machine is used. “Emergency Nurses' Utilization of Ultrasound Guidance for Placement of Peripheral Intravenous Lines in Difficult-access Patients,” www.aemj.org/cgi/content/abstract/11/12/1361. “Ultrasound-Guided IV Placement Superior to Traditional Approaches at Establishing Peripheral Intravenous Access in Difficult-access Patients,” www.aemj.org/cgi/content/abstract/11/5/582-b?ck=nck. “Success Rate of Peripheral IV Catheter Insertion by Emergency Physicians Using Ultrasound Guidance,” www.aemj.org/cgi/content/abstract/10/5/487-a. American Journal of Nursing: This article provides case histories and ultrasound images and describes the implementation process. The nurses achieved peripheral IV access in 87 percent of failed cases, the physicians 91 percent. They noted cannulation of the basilic and other deep veins required a 2.5 inch catheter to prevent dislodgement of the catheter. “EMERGENCY: Ultrasound-Guided Peripheral IV Insertion in the ED: A Two-Hour Training Session Improves Placement Success Rates in One ED,” www.nursingcenter.com/library/journalarticleprint.asp?Article_ID=604776. Israeli Journal of Emergency Medicine: This review provides great detail of necessary elements for the implementation of ultrasound IV access program. “Ultrasound-Guided Peripheral Venous Access,” www.isrjem.org/Dec06_VenousAccess_Goldstein_postprod.pdf.