VASCULAR ACCESS DEVICES

ARTERIAL LINE PLACEMENT D. PREPARE THE EQUIPMENT AND STERILE •FIELD Assemble the arterial pressure–monitoring equipment o Place the IV saline bag within the pressure bag o connect the arterial pressure tubing to the saline bag o Hang the bag, pinch the drip chamber to fill it halfway with fluid, and run solution through the tubing to flush the air out o Connect the pressure transducer to the pressure monitor o Remove all vent caps and replace with sealed caps at all the ports o Pressurize the bag to 300 mm Hg 301 ARTERIAL CATHETERIZATION

ARTERIAL LINE PLACEMENT D. PREPARE THE EQUIPMENT AND STERILE FIELD • Dress in sterile garb and use barrier protection • Test the cannulation equipment: o Rotate the catheter about the needle and slide the guidewire into and out of the needle to verify smooth motion • Swab the ventral wrist area broadly with antiseptic solution • Allow the antiseptic solution to dry for at least 1 minute • Place sterile towels and drapes about the site 302 ARTERIAL CATHETERIZATION

ARTERIAL LINE PLACEMENT •E. INSERTION 303 Anesthetize the cannulation site. Do not make a skin bleb so big that it obscures palpation of the radial artery • Relocate the radial artery in the wrist • Hold the cannulation device between your thumb and forefinger • Insert the cannulation device with the needle bevel facing up directly over the midline of the radial pulse at least 1 cm proximal to the radial head and advance it proximally (cephalad) at about a 30- to 45-degree angle into the skin ARTERIAL CATHETERIZATION

ARTERIAL LINE PLACEMENT E. INSERTION • Steadily advance the cannulation device until a flash of bright • red blood appears Place a gauze square under the cannulation device at the • insertion site Observe the reservoir or barrel of the device to verify pulsatile blood flow • Thread the guidewire through the needle and into the artery • Securely hold the needle hub and slide the catheter, using a twisting motion, over the needle and guidewire and into the artery 304 ARTERIAL CATHETERIZATION

ARTERIAL LINE PLACEMENT E. INSERTION • Connect the arterial line and verify an arterial pressure waveform on the monitor screen • Suture the catheter in place at the insertion site • Apply a transparent occlusive dressing • Loop the arterial tubing and tape it to the skin away from the insertion site • Write the date and time of cannulation on the dressing 305 ARTERIAL CATHETERIZATION

6. INTRAOSSEOUS CATHETERIZATION 306

INTRODUCTION • Intraosseous (IO) cannulation is a https://www.ems1.com/ems- rapid and safe method to products/medical-equipment/vascular- establish vascular access in a access/articles/top-ems-game-changers-7- critically ill or injured patient when intraosseous-infusion-LdjQxsE8aV69422r/ peripheral or central venous access is difficult or delayed 307 • It is done by placing a sturdy needle through cortical bone and into the medullary cavity—to emergently infuse fluids and blood products to patients INTRAOSSEOUS CATHETERIZATION

INTRODUCTION • INDICATION As a temporary alternative to venous catheterization when peripheral and central venous access are difficult, particularly in emergency situations (eg, shock, cardiac arrest) 308 INTRAOSSEOUS CATHETERIZATION

INTRODUCTION • CONTRAINDICATION o Bone fracture or recent cannulation attempt; infused fluids will extravasate into soft tissues through the cortical defects o Injured inferior vena cava; use sites that drain into the superior vena cava o Infection or burn at needle-insertion site o Osteoporosis and osteogenesis imperfecta; bone is easily fractured during procedure 309 INTRAOSSEOUS CATHETERIZATION

INTRODUCTION • Intravenous (IV) medications and fluids that can be administered by an IO route in an emergent situation: o Colloids o Steroids o Crystalloids o Sodium o Blood products o Antibiotics bicarbonate o Vasopressors o Dextrose o Inotropes o Heparin o Contrast o Hyperosmolar agents fluids o Sedatives o Analgesics 310 INTRAOSSEOUS CATHETERIZATION

INTRODUCTION • COMPLICATIONS o Extravasation of fluid into soft tissues (poor control during insertion results in the needle either not entering the bone; exiting the opposite cortex; or creating a too-large, leaky hole in the cortex) o Bleeding, causing compartment syndrome o Infection (osteomyelitis in < 2 to 3% of intraosseous cannulations) o Skin sloughing o Fat embolism 311 INTRAOSSEOUS CATHETERIZATION

INTRODUCTION POWER DRIVER STABILIZER NEEDLE SETS EZ-CONNECT https://www.teleflex.com/usa/en/product- areas/emergency-medicine/intraosseous- 312 access/arrow-ez-io-system/index.html INTRAOSSEOUS CATHETERIZATION

INTRODUCTION Cannula sets depending on patients https://www.researchgate.net/figure/Different- age and excessive tissue over the EZ-IO-R-cannula-sets-Vidacare-R-depending-on- insertion site patients-age-and-excessive_fig5_43533851 COLOR SIZE PATIENT PINK 15 mm PEDIATRIC 3 to 39 kg BLUE 25 mm ADULT YELLOW 45 mm > 39 kg OBESE NEEDLE SET CATHETER AND STYLET STYLET SAFETY CAP CATHETER HUB HUB 313 INTRAOSSEOUS CATHETERIZATION

INSERTION SITES 314 • ADULTS o The distal tibia is the preferred site for manual insertion o The proximal humerus is an alternate site. It has the potential advantage, during shock or cardiac arrest, of being closer to the central circulation o The proximal tibia can be used in adults, but because the bone is thick, a powered device is preferred for cannulation • CHILDREN o In children < 6 years old, the proximal tibia is the preferred site. o The distal femur is an alternate site o For older children, the medial surface of the distal tibia 2 cm above the medial malleolus may be easier INTRAOSSEOUS CATHETERIZATION

INSERTION SITES OTHER SITES TO CONSIDER COMMON INSERTION SITES CLAVICLE PROXIMAL HUMERUS STERNUM ILIAC CREST RADIUS FEMUR DISTAL FEMUR (pediatrics only) CALCANEUS PROXIMAL TIBIA DISTAL TIBIA https://www.nuemblog.com/blo 315 g/io-intraosseous-lines INTRAOSSEOUS CATHETERIZATION

INTRAOSSEOUS CATHETER INSERTION 316

INTRAOSSEOUS CATHETER INSERTION A. PREPARE THE EQUIPMENT • Pre-flush all IV lines and connecting tubes with normal saline. • Put on gloves, face mask and face shield • Prepare a syringe with 5 to 10 mL sterile saline in it • For insertion-site anesthesia, draw 3 to 5 mL of • 1% lidocaine into a syringe and attach the 25-gauge needle For medullary space anesthesia, draw 3 to 5 mL of 2 % • preservative-free IV lidocaine into a syringe Prepare the manual needle or the power drill 317 INTRAOSSEOUS CATHETERIZATION

INTRAOSSEOUS CATHETER INSERTION B. PREPARE THE INSERTION SITE • Swab the area of skin around the cannulation site with antiseptic solution, using outwardly expanding concentric circles. For children, include both the proximal tibia and distal femur in the swabbed area • Allow the antiseptic solution to dry for at least 1 minute • From this point forward, non sterile items are forbidden from the anticipated needle-insertion site 318 INTRAOSSEOUS CATHETERIZATION

INTRAOSSEOUS CATHETER INSERTION C. INSERTION OF INTRAOSSEOUS NEEDLE • Inject 1% lidocaine into the skin and soft tissues along the anticipated needle-insertion path, including the periosteum • Palpate the insertion site with your nondominant hand • Firmly hold the drill or the manual needle in your dominant • hand Position the needle tip at the point of insertion, perpendicular • to the long axis of the bone Point the needle slightly (10 to 15 degrees) away from the joint space and growth plate 319 INTRAOSSEOUS CATHETERIZATION

INTRAOSSEOUS CATHETER INSERTION C. INSERTION OF INTRAOSSEOUS •NEMEADNLEUAL INSERTION o Stabilize the needle shaft at the skin surface with an index finger o Advance the needle with moderate pressure and a to- and-fro rotary, coring motion. Advance along a straight path, to prevent fluid extravasation o Stop advancing the needle when you feel the pop (sudden loss of resistance) that indicates penetration through the cortex and into the medullary space 320 INTRAOSSEOUS CATHETERIZATION

INTRAOSSEOUS CATHETER INSERTION C. INSERTION OF INTRAOSSEOUS NEEDLE • INSERTION USING POWER DRILL o Penetrate the skin: Squeeze the trigger, and apply gentle pressure to penetrate the skin o Advance the needle: Continue to squeeze the trigger while applying steady, downward pressure against the resistance of the cortical bone o Immediately release the trigger and stop advancing the needle when you feel the sudden loss of resistance that indicates entry into the medullary space o Detach the drill from the needle, keeping the needle in place 321 INTRAOSSEOUS CATHETERIZATION

INTRAOSSEOUS CATHETER INSERTION D. CONFIRM INTRAMEDULLARY NEEDLE PLACEMENT • Seeing the needle remaining upright without support is the first sign of proper needle placement • Remove the cap and the stylet, attach pre-flushed extension tubing, and aspirate. Free return of blood (marrow) confirms correct intramedullary placement. If no marrow is aspirated, push 5 to 10 mL of normal 322 saline through the needle. If you feel resistance to the push and see or palpate local swelling (extravasation), remove the needle and cannulate another bone. INTRAOSSEOUS CATHETERIZATION

INTRAOSSEOUS CATHETER INSERTION E. BEGIN INTRAMEDULLARY INFUSION 323 • First, instill intramedullary anesthesia (for a conscious patient): Slowly (over 2 minutes) infuse 3 to 5 mL of 2 % preservative-free IV lidocaine, stopping when the pain is gone (maximum dose 0.025 mL/kg, or 40 mg [2 mL]). Wait 1 minute, and then flush with 5 to 10 mL of normal saline • Begin the infusion. (IV fluid flowing freely without extravasating into surrounding tissues is another sign of correct placement) INTRAOSSEOUS CATHETERIZATION

INTRAOSSEOUS CATHETER INSERTION F. DRESS THE SITE https://link.springer.com/ chapter/10.1007/978-3- • Wrap sterile gauze about the 319-25286-5_15 needle entry site and securely tape in place; commercial 324 intraosseous kits may contain specialized dressings • If needed, immobilize the extremity to further protect the site INTRAOSSEOUS CATHETERIZATION

INTRAOSSEOUS CATHETER INSERTION G. AFTERCARE • For recurring medullary pain from the infusion, repeat the slow 2% lidocaine infusion and saline flush as described above, using one-half of the initial lidocaine dose every hour as needed • Intraosseous delivery systems should be removed as soon as practical after peripheral or central IV access has been achieved and within 24 hours of insertion (ideally within 3 to 4 hours). Pull out the needle using a steady clockwise rotation. Attach a locking cap or an empty syringe to the needle hub to afford a better grip if needed 325 INTRAOSSEOUS CATHETERIZATION

INTRAOSSEOUS CATHETER INSERTION G. AFTERCARE • After needle removal, apply a sterile occlusive dressing. Chlorhexidine-impregnated discs at the insertion point and transparent membrane dressings are commonly used 326 INTRAOSSEOUS CATHETERIZATION

REFERENCES images HAND DRAWN CHALK SYRINGE https://www.alamy.com/vector-set-of-hand-drawn-chalk-syringe-image437017348.html AHA JOURNALS: CIRCULATION https://www.ahajournals.org/doi/10.1161/01.CIR.0000155244.66886.CA ISTOCK BY GETTY IMAGES: BLOOD VESSEL https://www.istockphoto.com/search/2/image?phrase=blood+vessel DOCTOR ASSAM https://doctorassam.com/ MEDICAL CLIP ART: SALINE SOLUTION https://www.pinterest.ph/pin/57069120265509263/ iEM FOR MEDICAL STUDENTS AND INTERNS: INTRAOSSEOUS LINE/ACCESS https://iem-student.org/io-line/ QUORA https://www.quora.com/Why-are-small-handheld-drills-rather-than-hypodermic-needles-used-by-medical- professionals-to-gain-immediate-vascular-access A PROCEDURAL GUIDE TO MIDLINE CATHETER INSERTION https://www.rch.org.au/uploadedFiles/Main/Content/anaes/a_procedural_guide_to_midline_insertion.pdf 327

REFERENCES PERIPHERAL VENOUS CATHETER https://en.wikipedia.org/wiki/Peripheral_venous_catheter PERIPHERAL LINE PLACEMENT https://www.ncbi.nlm.nih.gov/books/NBK539795/ PERIPHERAL INTRAVENOUS IV DEVICE MANAGEMENT https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Peripheral_Intravenous_IV_Device_Manageme nt/ HOW TO INSERT A CANNULA https://www.wikihow.com/Insert-a-Cannula IV THERAPY: TIPS, CARE AND COMPLICATIONS https://lms.rn.com/getpdf.php/2006.pdf MIDLINE CATHETER POLICY https://edu.cdhb.health.nz/Hospitals-Services/Health-Professionals/CDHB-Policies/Fluid-Medication- Manual/Documents/Midline-Catheter.pdf VASCULAR WELLNESS: MIDLINES 328 https://www.vascularwellness.com/midlines/ NURSE KEY: INFUSION THERAPY https://nursekey.com/infusion-therapy/ HEALTH LINE: WHAT IS A MIDLINE CATHETER https://hlic.net/what_is_a_midline_catheter/

REFERENCES MIDLINE CATHETERS: PREREQUISITE NURSING KNOWLEDGE 329 https://www.elsevier.com/__data/assets/pdf_file/0020/271064/ch0086.pdf NATIONAL CANCER INSTITUTE: CENTRAL VENOUS ACCESS CATHETER https://www.cancer.gov/publications/dictionaries/cancer-terms/def/central-venous-access-catheter NATIONAL CANCER INSTITUTE: PERIPHERALLY INSERTED CENTRAL CATHETER https://www.cancer.gov/publications/dictionaries/cancer-terms/def/peripherally-inserted-central-catheter PICC LINE INSERTION – PRE-COURSE MATERIAL https://www.csmen.scot.nhs.uk/media/1449/picc-line-precourse-material.pdf NCBI: PERCUTANEOUS CENTRAL CATHETER https://www.ncbi.nlm.nih.gov/books/NBK459338/ DEPARTMENT OF HEALTH GUIDELINES: PERIPHERALLY INSERTED CENTRAL VENOUS CATHETERS https://www.health.qld.gov.au/__data/assets/pdf_file/0032/444497/icare-picc-guideline.pdf HSS: PERIPHERALLY INSERTED CENTRAL CATHETER https://www.hss.edu/conditions_picc-insertion-procedure.asp DYNAMED: CLABSI VS CRBSI https://www.dynamed.com/condition/catheter-related-bloodstream-infection-crbsi NCBI: CENTRAL LINE PLACEMENT https://www.ncbi.nlm.nih.gov/books/NBK470286/ CENTRAL LINE CARE https://www.fairview.org/services/central-line-care

REFERENCES 330 WIKIRADIOGRAPHY: VASCATH http://www.wikiradiography.net/page/Vas_Cath LA VASCULAR: VASCATH (QUINTON CATHETER) https://lavascular.com/vascath/ ST. GEORGE’S UNIVERSITY HOSPITAL: VASCATH CENTRAL VENOUS INSERTION https://www.stgeorges.nhs.uk/wp-content/uploads/2018/01/RAD_VCVC_02.pdf MEDSCAPE: CENTRAL VENOUS ACCESS VIA TUNNELED CATHETER https://emedicine.medscape.com/article/1375734-overview NURSE.ORG: PORT-A-CATH: HOW TO ACCESS THE PORT https://nurse.org/articles/what-is-a-port-a-cath/ BRITISH JOURNAL OR ANESTHESIA: LONG TERM VENOUS ACCESS https://watermark.silverchair.com/ MEMORIAL SLOAN KETTERING CANCER CENTER: ABOUT YOUR IMPLANTED PORT https://www.mskcc.org/cancer-care/patient-education/your-implanted-port PORT PLACEMENT https://www.backtable.com/shows/vi/topics/procedure/port-placement DEPARTMENT OF HEALTH: TOTALLY IMPLANTABLE CENTRAL VENOUS ACCESS PORT https://www.health.qld.gov.au/__data/assets/pdf_file/0030/444486/icare-port-guideline.pdf CLEVELAND CLINIC: IMPLANTED PORT https://my.clevelandclinic.org/health/treatments/21701-implanted-port

REFERENCES CHEST.ORG: WHEN IS PERIPHERAL ARTERIAL LINE INDICATED IN ICU PATIENT https://www.chestnet.org/leadership/thought-leader-blog/2018/10/arterial-lines MEDSCAPE: ARTERIAL LINE PLACEMENT https://emedicine.medscape.com/article/1999586-periprocedure#b5 WIKIPEDIA: ARTERIAL LINE https://en.wikipedia.org/wiki/Arterial_line MSD MANUAL: HOW TO DO INTRAOSSEOUS CANNULATION, MANUALLY AND WITH A POWER DRILL https://www.msdmanuals.com/professional/critical-care-medicine/how-to-do-peripheral-vascular- procedures/how-to-do-intraosseous-cannulation,-manually-and-with-a-power-drill WIKIPEDIA.ORG: DIALYSIS https://en.wikipedia.org/wiki/Dialysis MSD MANUAL: VASCULAR ACCESS https://www.msdmanuals.com/professional/critical-care-medicine/approach-to-the-critically-ill- patient/vascular-access RHOCHIPOST: INDICATIONS FOR DIALYSIS: A MNEMONIC AND EXPLANATION https://rhochistj.org/RhoChiPost/indications-dialysis-mnemonic-explanation/ NURSING MANAGEMENT: CARING FOR A PATIENT’S VASCULAR ACCESS FOR HEMODIALYSIS https://journals.lww.com/nursingmanagement/fulltext/2010/10000/caring_for_a_patient_s_vascular_access_f or.11.aspx AZURA VASCULAR CARE: IMPORTANT FACTS ABOUT ARTERIOVENOUS GRAFT 331 https://www.azuravascularcare.com/infodialysisaccess/arteriovenous-graft-facts/

REFERENCES WILEY ONLINE LIBRARY: CANNULATION CAMP: BASIC CANNULATION TRAINING FOR DIALYSIS STAFF 332 https://onlinelibrary.wiley.com/doi/full/10.1002/dat.20622 KIDNEY.ORG: NEEDLES AND CANNULAS FOR ARTERIOVENOUS FISTULA ACCESS https://www.kidney.org/sites/default/files/Fistula%20Bulletin_0.pdf NURSE KEY: HEMODIALYSIS https://nursekey.com/haemodialysis/ NATIONAL LIBRARY OF MEDICINE: VASCULAR ACCESS CANNULATION IN HEMODIALYSIS PATIENTS: TECHNICAL APPROACH https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213941/ AZURA VASCULAR CARE: CENTRAL VENOUS CATHETER PLACEMENT https://www.azuravascularcare.com/medical-services/dialysis-access-management/central-venous-catheter- placement/ BC RENAL: CENTRAL VENOUS CATHETER: INITIATION OF DIALYSIS http://www.bcrenal.ca/resource-gallery/Documents/CVC%20Initiation%20of%20Dialysis.pdf 7MED: VASCULAR ACCESS AND ITS SITES https://www.7medindia.com/knowledge-base/vascular-access-management/taking-care-of-your-catheter KIDNEY CARE: HEMODIALYSIS ACCESS WITH AN ARTERIOVENOUS FISTULA https://www.kidneycareuk.org/about-kidney-health/treatments/dialysis/haemodialysis-access-arteriovenous- fistula/ EDTNA/ERCA: VASCULAR ACCESS MANAGEMENT AND CARE https://www.edtnaerca.org/resource/edtna/files/publications/free/VA-management-and-care-FMC-free.pdf