Vascular access; large bore (16-18G) is optimal for blood transfusion and faster than central lines (except MAC/Cordis); preserves central access (important for ESRD pts)
Relative contraindications
Infection over the site, severe bleeding diathesis
Avoid EJs unless have been trained due to airway compromise if extravasation occurs
Bleeding risk guidelines: Plts > 10k, no specific INR guidelines
Location selection: anuric AKI or ESRD–discuss with Nephrology, avoid limb with HD access
Target selection: Confirm venous choice with compressibility and lack of doppler flow. Should follow the rule of 2s: vein must be at least twice the diameter of the catheter being placed, should be no more than 2 inches in depth from the surface of the skin, and should have at least 2 inches of straight (non-tortuous) length
Supplies
Ultrasound with linear probe
Needle, preferably 18G or 20G ultrasound specific needles
Longer catheter if needed; but note, using the longer catheter in a non-obese patient can make procedure more difficult (have to insert more catheter) and cause kink(excessive length can takes it to next vascular bifurcation point)
Kit
This will typically include gauze, torniquet, tubing, and dressing
Hold probe close to skin, holding probe far from the end allows too much movement
Start at 45° angle, use 45-45-90 rule to determine starting location (start as far from center of probe as the vessel is deep). Flatten angle once in the vessel to advance ("walk" your way through the vessel by repeatedly identifying needle tip in the lumen and advancing)
Going too shallow could use up too much catheter leaving nothing to put in the vein.
Going too steep can cause catheter kinking at the hub where it sticks out of the skin
Use both short axis and long axis views to ensure correct placement
Short axis: vessel looks round like a target, helps to scout out the tip, and is best for ensuring the vein is entered as opposed to a neighboring artery
Long axis: intended for the final few mm of catheter advancement into the vein to ensure both bevel and plastic sheath lumen traverse the endothelial layer before threading catheter
Post-procedural considerations
Don’t forget to remove tourniquet. Remove before flushing to prevent blowing vein.
Bleeding complication: if arterial, remove catheter and hold pressure at least 5 mins
