Vascular Access

Insertion of Peripheral Intravenous Cannula,Central venous catheter, and Arterial line.

Prepared by Dr Mahmoud AlmustafaAssociate prof., Dept. of Anesthesia, Faculty of Medicine – Jordan

University2019/2020

Peripheral venous lineinsertion

Factors affecting the flow

• Pressure gradient• Radius• Length of tube• Viscosity of fluid

Hagen-poiseulle equation

The most important factor

• Radius

Color coding

1- PreparationPrepare the Following:

• Pressure cuff / tourniquet• Disinfectant and swab (alcohol swab)• Intra-venous Canula ( 2 -3 sizes)• Fixation plaster• A normal saline/other crystalloid filled

syringe• Gloves (if required)

2- Explain the procedure to thepatient

• Be empathic and reassuring as much asyou can

• Explain reason and importance of whatyou are intending to do

3- Position:

• the patient is lying down or sitting, withhis/her hand outstretched and supportedfrom below.

• You should sit next to the patient on theinsertion side in a comfortable position

4- Choose the target vein- It should be straight for

enough distance toaccommodate theCanula’s lengthIts size should be large

enough for your canula’sgauge and match theintended aim of the I.Vaccess (e.g. BloodTransfusion needs largerbore canulas)If applicable, choose siteswhere the veins andarteries are far apartand/or veins are lessmobile (e.g. dorsum ofhand)

5- Compress (fill) the vein:** by applying the tourniquet

proximal to the puncture site

- Broad thin tourniquets are bestused

- The pressure applied by thetourniquet should not be veryhigh (only compressing theveins but not the arteries)

- Ask the patient to make a fist (topump blood back into the vein)and wait

- Tap with your fingers over thevein to make further dilatation.

*** This step may precede step 4 ifyou don’t see veins

6- Disinfect Disinfect the puncture site as quickly as

possible using an alcohol swab andallow drying for 15 seconds

7- Tighten the veinby tightening theskin above it usingyour other handThis shouldcontinue until thecanula is fullyinserted (rememberthat you can’t easilypenetrate a mobileobject)

*** You can practice the above steps on yourself,colleagues or at home, to gain practice***

7- Puncture• Puncture the vein at an

angle 30-40 towards theskin and guide theneedle following thecourse of the vein untilblood flash-back isobserved in the bloodcollecting chamber atthe proximal end of theneedle

8- Pull back the needle• pull back the needle

approximately 1 cm untilblood flows through theplastic catheter to confirmthat the catheter is in thevessel.

• Train yourself to do thiswith three fingers of youroperating (dominant hand)

( the index finger holdingthe canula still, and thethumb and Middle fingerpulling back the needle)

9- Advance the catheter• With leaving the needle part

untouched, advance theplastic catheter –full length-into the vein. This should beaccomplished with gentleforce, so you can recognizeany resistance.

• Don’t Advance the catheterforcefully and if anyresistance is recognized, re-check integrity of insertion.

10- Release the pressurecuff/Tourniquet:

• Forgetting to dothis , ha resulted inCatastrophicconsequences!!!

(Especially inneonates and smallpediatric patients)

11- Fix the I.V. Canula

• using the preparedplaster strips / orready made canuladressing

12- Remove the needle• first apply a

compressing pressurewith your non-dominanthand just proximal tothe canula (rememberits intra-vessel length),

• pull the needle out, andapply the canula cover,or connect the infusionline.

13- Check the patency andfunction of the canula

• by injecting fewmls of normalsaline (or tuningon the infusion)and observing forease ofinjection/infusionflow, and swellingformation.

Needle disposition

• When handling the needle make sure itis always directed away from patient,yourself, and other staff and quicklyand safely discard it in the propersharps container

Important Points!!- The three most common causes of failure to canulate a vein

are:1- Failure to stretch the skin and consequently fix the vein, or prematurely releasing the

skin before the canula is fully advanced2- Pulling back the guide needle too early, before the plastic catheter enter the vein3- Advancing the canula despite resistance Avoid: - Infected areas,- Thrombosed veins: hard and non-compressible on palpation- Joint areas: risk of kinking of canula- Paralyzed Limbs: risk of thrombosis- Limbs with lymphatic blockage (e.g. after breast surgery)- Vein valves: if you see a lump in the vein course

Maneuvers to make the vein morevisible:

• Applying the tourniquet proximal to thepuncture site

• Put limb in dependent position• Use muscle pump to fill the vein ( ask

patient to open and close hand severaltimes)

• Tapping over the vein• Warming the puncture site: by rubbing

or applying warm water bag• Spray area with alcohol or nitrolingual

spray if available

Canula Care• Inspect frequently for development of any

erythema, or swelling along the vein course• Change dressing if not clean• Always flush canula with few mls of normal

saline after administration of drugs etcthrough the same port

• Change the canula every 2 – 3 days and morefrequently if was used for blood or lipidsolution transfusion.

Central venous line

• Indications• Sites• Procedure• Complications

Indications and uses

Indications for the use of central lines include Monitoring of the central venous pressure (CVP) in acutely ill patients to quantify fluid balance

Long-term Intravenous antibioticsLong-term Parenteral nutrition especially in chronically ill patients

Long-term pain medicationsChemotherapy

Drugs that are prone to cause phlebitis in peripheral veins (caustic), such as:Calcium chlorideChemotherapy

Hypertonic salinePotassium chloride

AmiodaronePlasmapheresis

DialysisFrequent blood draws

Frequent or persistent requirement for intravenous accessNeed for intravenous therapy when peripheral venous access is impossible

BloodMedication

Rehydration

Sites of insertion

• Subclavian vein• Internal jugular vein• Basilic vein• Femoral vein• External jugular vein.

Complications of CVL insertion

• Pneumothorax (subclavian,IJV)• Bleeding and haematoma formation• Arterial puncture• Infection• arrhythmias (subclavian,IJV)

Questions???

Rt IJ Vein

Using U/S

Allen’s test

Arterial line insertion

Transducer

Indications

Using U/S

THANK YOU