Chapter 25: Vascular Access

INTRODUCTION

Establishing reliable vascular access in an emergency is of critical importance. Many factors, including body habitus, volume depletion, shock, history of injection drug use, congenital deformity, and cardiac arrest, can make obtaining vascular access in the critically ill or injured patient extremely difficult. The introduction of point-of-care ultrasound (POCUS) into emergency and acute care settings has been an important advancement for facilitating rapid and successful vascular access.

CLINICAL CONSIDERATIONS

For central access, the use of an anatomic landmark-guided approach has been the traditional practice. Internal jugular vein location traditionally relies on the sternocleidomastoid muscle and clavicular landmarks; the femoral vein relies on the inguinal ligament and femoral artery pulsation landmarks; and the subclavian vein relies on clavicular landmarks. In many patients, however, these landmarks may be distorted, obscured, or nonexistent. In addition, normal variations in the anatomic relationship of the internal jugular vein may make cannulation difficult.¹ In the emergent situation, attempting central vascular access with poor external landmarks is frequently approached using a “best guess” estimate of the vessel location. This may lead to multiple needle passes to locate the vessel. Excessive bleeding, inadvertent arterial puncture, vessel laceration, pneumothorax, and hemothorax are some of the potential complications of central vascular access. The incidence of complications increases when multiple attempts are required for cannulation.²⁻⁵ In patients with an underlying coagulopathy (pathologic or therapeutic), multiple attempts can carry significant morbidity due to hemorrhage.^6,7

There is extensive evidence supporting the use of ultrasound in central venous access, deep peripheral venous access, and nursing-assisted venous access. When compared to the external landmark approach, ultrasound-guided internal jugular vein cannulation results in fewer complications and is more effective in time-to-cannulation and first-attempt success.^2,6,8–12 For femoral vein cannulation, the ultrasound-guided approach was found to be more successful than the landmark approach in patients presenting in cardiac arrest.¹³ In 2001, a report published by the Agency for Healthcare Research and Quality (AHRQ) on patient safety in health care included a chapter strongly advocating the use of ultrasound in central venous catheter placement.¹⁴ The resulting scientific and policy positions favor the use of ultrasound for central venous access stronger than any other POCUS application. The National Institute for Clinical Excellence (NICE) has also recommended that central venous catheters be inserted under ultrasound guidance.¹⁵ Thus, in most institutions, ultrasound use for the placement of central venous catheters has become a patient safety best practice, and for difficult line placements it is becoming standard of care. The adoption of ultrasound for central line placement has markedly increased the presence of ultrasound units in emergency departments (EDs). Furthermore, with respect to the pediatric population, a recent meta-analysis supports the use of ultrasound for central venous access in children as it improves success rates and decreases the number of vessel-puncture attempts.¹⁶

Peripheral venous access is ...