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