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Procedures for the Hospitalized Patients:

Alternative Approaches & Advanced Troubleshooting

Eric Isaacs, MD FACEP, FAAEM
Robert Rodriguez, MD FACEP, FAAEM
Rachel Chin, MD FACEP (original Author)
San Francisco General Hospital Emergency Services
University of California, San Francisco

Course Objectives:
1 Develop an approach to failed vascular access in adults
2 Become familiar with ultrasound technology
3 Learn vascular access, pericardiocentesis, thoracentesis, paracentesis procedures
under ultrasound guidance

Case Presentation #1
The nurse calls you b/c the 40 y/o man admitted for cellulitus, now complains of chest
pain and has peaked T waves on EKG. He is a known dialysis patient with poor vascular access.
The nurses are unable to obtain a peripheral IV in his arms or legs.
Question: Where do you try next to get rapid vascular access?
Answer: Peripheral sites such as the external jugular or deep brachial vein

External Jugular (EJ) Vein

9 Begins as the confluence of the posterior auricular and retromandibular veins at the
mandibular angle
9 Courses medially over sternocleidomastoid (SCM) before piercing fascia to join with
subclavian vein under clavicular head of SCM.
9 Greater auricular nerve travels alongside the EJ (supplies sensation to external ear)

Right EJ vein of supine patient

Adapted from Netter’s Atlas of Human Anatomy (1989)
9 Trendelenburg at 10-15 degrees to increase jugular venous pressure
9 Turn head slightly away from side of EJ cannulation to stretch vein
9 Valsalva just as cannulating vein to increase intraluminal pressure and visibility
9 Reduce vein-rolling: Select bifurcation puncture site or puncture vein from the side
9 Aim needle only 5-10 degrees deep

9 May not have flashblack of blood in catheter
9 “Floating the IV”: The forward flow of IV fluid opens the vein more and helps guide
catheter insertion in the absence of a needle.
9 Secure the IV around the ear.
9 Seldinger technique for central venous access via the EJ vein
• 18-gauge or larger IV bore to allow for guidewire diameter
• Complications of an EJ central line:
1. Time consuming
2. Unable to feed the guidewire (20% failure rate) – especially more difficult
from left EJ because of tortuous course
3. Pneumothorax
4. Puncture of wire through-and-through the vein
5. Thoracic duct puncture (left EJ)

Deep Brachial Vein

9 Brachial veins are paired structures, which lie medial
and lateral to the brachial artery.
9 Not palpable or visible externally

9 Relaxed extension of arm

9 Tourniquet arm proximally
9 Palpate biceps tendon at antecubital crease
9 Medially, palpate brachial artery
9 Brachial vein lies medial to artery Right antecubital fossa
9 Use a 2-inch angiocatheter
9 Puncture skin at antecubital crease, aiming the needle 45 degrees deep

9 Often needle will simultaneously puncture through both the anterior and posterior wall.
Withdrawing needle may give you a flashback of blood.
9 Success rate = 70-80%
9 Complications
• Paresthesias 18% (Kramer et al, 1988) • Hematoma formation 1.6% (Kramer)
• Brachial A puncture 8% (Kramer) • IV decannulation 8% (Keyes et al, 1999)

9 Can be site for central venous access

Case Presentation #2
A nurse places a 20-gauge peripheral IV in your post-cardiac arrest patient and the vital
signs stabilize. You want to establish a central line for vasopressor support later
Question: Where do you try next to get rapid vascular access?
Answer: Central line (subclavian > IJ > femoral) unless patient is about to arrest. If so,
then select a central line site where you are most confident in securing a line

Central Line
9 Lies medially to the femoral artery
just inferior to the inguinal ligament
9 About 3-4 inches below inguinal
ligament, it distally courses deep
9 Greater saphenous vein is a
superficial take-off vein from the
femoral vein

Dissection of right groin

(Adapted from Netter’s Atlas of Human
Anatomy, 1989)
Troubleshooting Tips
1. Locating the femoral vein without a pulse: The “V” technique

Right Groin (Cadaver


1. Place thumb on pubic

2. Place index finger on
anterior superior iliac
spine (ASIS)
3. Femoral vein is at “V”
of hand, under inguinal
2. Difficulty feeding the guidewire
Basic Tips:
9 Re-aspirate syringe for blood to ensure that your needle is still in the vein
9 Flatten needle angle: Guidewire may be abutting vein wall at a sharp angle
9 Twirl guidewire: Guidewire may be wedged against a valve or vein wall.
Twirling the wire may loosen it and allow for advancement.
Advanced Tips:
9 New central line kit available where guidewire can be introduced through
the back of the syringe and into the needle. Takes away one step
of removing the syringe from the needle for guidewire
9 Find the true inguinal ligament
• A common mistake is to puncture the skin too inferiorly below the
inguinal ligament from either fear of peritoneal injury or a
“sagging” inguinal ligament. Be sure to manipulate the inguinal
ligament so that it is a straight line rather than U-shaped. This may
require pushing the abdominal pannus or excess skin superiorly
during the procedure.
• If you inadvertently start too inferiorly, your needle may cannulate
nothing… or the greater saphenous vein (GSV). Often the
guidewire can not be introduced through the GSV because of the
vein’s valves and smaller diameter.

Femoral Line: Acute Complications

1. Femoral artery puncture: 9-15% (McGee and Gould, 2003)
2. Hematoma formation: 3.8-4.4% (McGee and Gould, 2003)
3. 23% failure rate for femoral lines in pulseless patients. (Emerman et al, 1979)

Femoral Line: Subacute Complications

1. Thrombosis
9 Mian et al, 1997: Prospective study with 42 patients where patients had
bilateral lower extremity ultrasounds performed within 7 days of femoral
central line placement. Result: 26.2% had a DVT in that same extremity
(versus 0% in the other leg without a femoral line)
9 Merrer et al, 2001: Randomized study with 289 patients in 8 French ICU’s
where patients either underwent a femoral versus subclavian line. Result:
21.5% of patients with a femoral line had thrombotic complications (versus
only 1.9% for patients with subclavian lines)
2. Infection: 19.8% of patients with a femoral line had catheter colonization (versus
4.5% for patients with subclavian lines). Catheter-related clinical sepsis
occurred in 4.4% of femoral line patients versus 1.5% for those with
subclavian lines. (Merrer et al, 2001)
9 IJ vein lies anterolaterally to the carotid artery at the apex of the triangle, formed
by the clavicle and the two heads of the sternocleidomastoid muscle.
9 Joins the subclavian vein just under the clavicle

IJ Vein Anatomy from

Head-of-Bed View
(Adapted from McGee and
Gould, New Engl J Med,

Troubleshooting: Why Can’t I Find the Vein? (Armstrong et al, 1994, Bazaral and
Harlan, 1981)
1. ERROR: No Trendelenburg positioning
9 At least a 14% Trendelenburg angle increases the diameter of the IJ vein as
much as a Valsalva maneuver
2. ERROR: Overextension or overrotation of neck
9 Can cause the sternocleidomastoid muscle to compress the IJ vein
3. ERROR: Excessively deep carotid artery palpation
9 Can cause inadvertent compression of the thin-walled IJ vein

Tip: Select the right IJ over the left IJ

1. Left IJ has more tortuous route to SVC
9 Difficulty feeding guidewire
9 Catheter malposition (in left subclavian, right subclavian, right IJ)
9 Generally more time-consuming and has more complications than right IJ
cannulation (Sulek et al, 2000)
2. Dome of left lung is higher than the right lung
9 Theoretical greater risk of pneumothorax
3. Thoracic duct empties at junction of left IJ and left subclavian vein

Internal Jugular Line: Acute Complications

1. Carotid artery puncture: 3.0-9.4% (McGee and Gould, 2003; Ruesch et al, 2002)
2. Hematoma formation: <0.1-2.2% (McGee and Gould, 2003)
3. Pneumothorax: <0.1-0.2% (McGee and Gould, 2003; Iovino et al, 2001)
4. Catheter tip malposition: 1.8-14% (Ruesch et al, 2002; Gladwin et al, 1999;
Iovino et al, 2001)
Internal Jugular Line: Subacute Complications
1. Thrombosis: Generally low risk but wide range of published thrombosis rates 0-
66% (Roberts and Hedges, 1998; Ruesch et al, 2002)
2. Catheter-related bacteremia: 8.6% (versus 3.9% for subclavian—not statistically
significant with relative risk CI 0.62-8.09) (Ruesch et al, 2002)
9 Consider IJ line over subclavian line only for short-term access (<5-7
days), because low acute complication rate outweighs risk of thrombosis
and infection. (Timsit, 2003)

9 Axillary vein runs medially to become the subclavian vein as it passes over 1st rib
9 Subclavian vein lies immediately posterior to the medial 1/3 of clavicle and is
separated from deeper subclavian artery by anterior scalene muscle
9 1-2 cm in diameter

Subclavian Vein
Anatomy from Patient’s
Right Side View
(Adapted from McGee
and Gould, New Engl J
Med, 2003)

Tip #1: Positioning

9 No need to position the patient in Trendelenburg—the vein is kept patent by
surrounding costoclavicular ligaments
9 Basic tip: Place small towel roll between the scapulas to reduce deltoid muscle bulge,
which may hinder keeping the needle from pointing too intrathoracically. Be
careful of overretracting the shoulders, which can compress the subclavian vein.
9 Advanced tip: Abduct arm slightly to flatten the deltoid muscle bulge
Tip #2: Preventing IJ Tip Placement
9 Most common malpositioning of subclavian catheter is into ipsilateral IJ vein.
9 Technique (Ambesh et al, 2002)
• Using the needle-stabilizing hand, place index finger in supraclavicular fossa
while feeding the guidewire with the other hand. This prevents the guidewire
from entering the ipsilateral IJ vein.
• Incidence of malpositioned tip in IJ: 6% (control) vs 0% (test case)
• Interestingly: Patients with malpositioned catheter in IJ had ear pain or trickling
throat sensation

Tip #3: Supraclavicular Approach (“The Pocket Shot”)

9 Subclavian vein courses superiomedially under the clavicle and over the 1st rib to join
IJ vein. Lateral to the sternocleidomastoid (SCM), subclavian vein is located
superior and posterior to clavicle
9 Technique
• Puncture site: 1 cm lateral to SCM and 1 cm posterior clavicle
• Aim needle inferomedially (bisecting angle of clavicle with SCM) and anteriorly
about 10 degrees
9 Advantages
• Can be done upright (congestive heart failure patients) and in obese patients
• More accessible than infraclavicular approach during a “code” when CPR is being
performed (Dronen et al, 1982)
• More accessible than internal jugular line during a “code” when a patient is
intubated because does not require turning of head (Dronen et al, 1982)
• Fewer complications than infraclavicular route (needle pointing away from lung
and artery)
ƒ Overall: 2.0 (versus 5.1%) (Sterner et al, 1986)
ƒ Pneumothorax: 1.1% (versus 2.5%) (Pittiruti et al, 2000: A retrospective,
single-institution study of 1273 infraclavicular lines and 847
supraclavicular lines)
ƒ Subclavian artery puncture: 3.5% (versus 2.8%) (Pittiruti et al, 2000)
ƒ Catheter tip malposition: 0.9% (versus 10.8%) (Sterner et al, 1986)
• Most successfully positioned neck central line, because of almost straight
pathway from right supraclavicular site to superior vena cava (Roberts and
Hedges, 1998; Pittiruti et al, 2000; Dronen et al, 1982)

Anatomy of Supraclavicular
Approach from Patient’s Right
Side View
(Adapted from McGee and
Gould, New Engl J Med, 2003)
Subclavian Line: Acute Complications (Infraclavicular approach)
1. Subclavian artery puncture: 0.5-4.9% (McGee and Gould, 2003; Ruesch et al,
2. Hematoma formation: 1.2-2.1% (McGee and Gould, 2003)
3. Hemothorax: 0.4-0.6% (McGee and Gould, 2003)
4. Pneumothorax: 1.5-3.1% (McGee and Gould, 2003; Iovino et al, 2001)
5. Tip malposition: 1.8-9.3% (Ruesch et al, 2002; Mansfield et al, 1994; Iovino et
al, 2001)

Subclavian Line: Subacute Complications (Infraclavicular approach)

1. Thrombosis:
9 Merrer at al, 2001: 1.9% (versus 21.5% for femoral line)
9 Ruesch et al, 2002: 1.4% in meta-analysis of 899 central line placements
2. Catheter-related clinical sepsis
9 Merrer et al, 2001: 1.5% (versus 4.4% for femoral line)
9 Ruesch et al, 2002: 3.9% (versus 8.6% for IJ line—not statistically significant
3. Catheter colonization: 4.5% (versus 19.8% for femoral line) (Merrer et al, 2001)
4. Subclavian stenosis: In 50% of patients receiving subclavian catheters for
dialysis, venous stenosis developed. Nephrologists recommend IJ line if need
dialysis. (Barrett et al, 1988)

Ultrasound Roadmap
Vascular access: why use ultrasound?
Errors in Medicine
• 2000 Institute of Medicine Report
• Agency for Health Care Research and Quality
• Reviewed 79 patient safety practices
• Among top 10 recommendations: use of US-guided catheter placement

To Err Is Human: Building a Safer Health System. 2000. Committee on Quality of Health Care
in America

Making health care safe. A critical analysis of patient safety practices. AHRQ 2001

9 Noninvasive imaging
9 Vascular probe: 7.5 Mhz frequency, flat transducer
• High frequency allows for more detail at the expense of visualizing deeper
9 Basic tenets in vascular ultrasound:
• Blood vessels are black (anechoic).
9 Compression
Veins compress easily
Arteries much less compressible
9 Arteries are pulsatile, despite compression.
• Dot on probe correlates with dot on screen.
9 Major veins (IJ, common fem.) vary in size with respiration, Valsalva, Trendelenburg
9 Tourniquet for peripheral, deep brachial
9 Doppler

Trick of Trade: Can use vaginal probe instead, if you do not have a vascular probe— same 7.5-
Mhz frequency transducer. (Phelan, 2003)

Ultrasound Probe on Patient’s Right Neck Normal Vascular Ultrasound of

(Dot on Probe Faces Medially) Right IJ Vein and Carotid Artery

Ultrasound-Guided Internal Jugular Central Line

9 Technique: Marking the IJ vein site
• Position patient (Trendelenburg, slight head rotation away from IJ vein site)
• Identify IJ vein in cross-section with US
• Locate best IJ vein site and center image on US screen
• Mark vein path anterior and posterior to probe with needle hub (on the skin)
• Wipe off US gel and re-mark sites with permanent marker
• Prep site sterilely and commence IJ line placement, aiming for site between 2 marks
9 Alternative Technique: Live-Time US Guidance
• Identify IJ vein and determine if want to cannulate
• Sheath US probe / cabling with sterile cover, and place sterile gel on field
• Place US probe so cross-sectional image of IJ vein is centered on US screen
• Insert needle while watching US screen (needle will appear as hyperechoic line)
• Advantage: More real-time feedback of needle location
• Disadvantage:
o Usually requires assistant
o Messier with gel on field
o More difficult to maintain sterile technique
9 Trick of Trade: If the internal jugular vein diameter is less than 7 mm, select a different
vein site. Independent predictor of unsuccessful line placement (Mey et al, 2003)
9 My Recommendation: Use ultrasound imaging for all IJ central lines, if time
9 Anatomical Variation: High incidence of unexpected IJ vein location and size
• Troianus et al, 1996: In 1136 patients, the IJ vein overlapped the carotid artery in
54% of pts
• Denys and Uretsky, 1991: In 183 mostly cardiac transplant recipients, 5.5% had a
variant right IJ vein, which did not correlate with external anatomical landmarks.
• Gordon et al, 1998: 5.5% of 869 prospective patients had carotid artery LATERAL
to IJ vein.

Vascular Ultrasound of
Variant Anatomy:
IJ vein is directly superficial
(rather than lateral) to carotid

9 The Supporting Literature

1. Hind et al, 2003: Meta-analysis showed US-guided IJ line had much lower failure rate
(RR 0.14)
2. Miller et al, 2002: Prospective study in teaching ED setting comparing US-guided
versus traditional landmark-guided IJ line
• Time from skin puncture to blood flash: 115 sec (US) vs 512 sec (landmark)
• Number of attempts: 1.6 (US) vs 3.5 (landmark)
• For “difficult stick” patients, time to line placement: 93 sec (US) vs 463 sec
3. Denys et al, 1993: Similar study as Miller et al but in cardiology setting, looking at
• Artery puncture: 1.7% (US) vs 8.3 (landmark)
• Hematoma: 0.2% (US) vs 3.3% (landmark)

Ultrasound-Guided Subclavian Central Line

9 Technically difficult because of vein’s location posterior to clavicle (especially
difficult in obese pts)
9 Literature is equivocal as to whether ultrasound improves success rate and reduces

Ultrasound-Guided Deep Brachial Line

9 Supplements landmark technique
9 Increases success of deep vein cannulation (Keyes et al, 1999)
Central Line Case Scenarios: Which central line site would you first choose for a patient…
9 with severe orthopnea from flash pulmonary edema?
* Answer: Subclavian SC or IC (consider external jugular)
* Both can be done sitting up, but the SC approach has better success for CVP
9 in asystole?
* Answer: Subclavian SC or femoral
* Generally, select the site where you feel you can cannulate the quickest. IJ’s
and IC subclavian lines are operationally difficult to insert during intubation
and CPR.
9 with sepsis?
* Answer: Subclavian SC > subclavian IC > US-guided IJ >> femoral
* Because infection is already a major concern, placing a line with the least
infectious complications is best—the subclavian line
9 with new renal failure?
* Answer: US-guided IJ > subclavian
* Dialysis catheters have been to cause venous stenosis when in the subclavian
9 with an INR of 6?
* Answer: US-guided IJ or femoral
* Because of the risk of subclavian artery puncture, the IJ (under US-guidance
only) or the femoral vein should be cannulated. As the INR increases, the
femoral vein should be the primary site of central access, because of the
severe consequences of carotid artery puncture.
Bottom line: Think of the subclavian site first.

Why do ultrasound?
• Identification of effusion/tamponade
• Avoid important structures in chest ie heart, great vessels, liver
• Increased success & safety
• Blind technique complications 7-50%
• New options: anterior approach

• Pt supine
• Transducer — cardiac or abdominal probe
• Sterile prep
• Select an approach
• Needle under transducer
• Probe away from needle
• NS injections into pericardium as guide

Subxyphoid approach
Parasternal or apical
Largest pocket

Why use ultrasound?

• Verify the effusion - replace decubitus films
• Can increase patient safety
• Can increase chance of success

Step 1: Verify the effusion

• Pt lying supine
• Transducer — abdominal probe
• Mid-axillary line, approximately T8-11
• Locate diaphragm, liver/spleen, and look above for effusion

Step 2: Procedure
• Real time
• Mark good spot
• Sterile prep
• Locate interspace
• Needle under probe


Why use ultrasound?

• Maybe there is no fluid
• Locate the bladder
• Procedure carries some risk
• Exam is easy

How to do the ultrasound

• Patient supine
• Transducer — abdominal probe
• Adjust depth & gain
• Same as FAST:
• Look for large pockets of fluid
The procedure
• Identify and mark best spot
• Real-time guidance
• Sterile set-up
• Needle must pass under transducer
• Watch for deformation of abd wall
• May see hyperechoic needle

Experimental: Adult Intraosseous (IO) Line

9 Most studies for IO line placement are in the pediatric literature.

9 More popular use of the adult IO line in Europe, Canada, and the military.
9 Commercially-made IO line kits available which are
FDA approved
• BIG (Bone Injection Gun)
• FAST1 (First Access for Shock and Trauma-1)
Macnab et al, 2000: This prospective study of 50 adult patients with Bone
Injection Gun model
prehospital placement of sternal FAST1 IO needle involved 6 ED’s
and 5 EMS sites in Canada and the U.S. There was an
84% success rate, with most failures occurring because
patients were “very obese”. The average IV flow rate
was 80 cc/min with only gravity pressure. No
complications on 2-month followup.
9 Potential puncture sites (Macnab et al, 2000; Iserson
KV, 1989)
• Sternum (closer to central circulation, low
fracture potential)
• Proximal tibia (primary site for children, but
likely the cortex is too thick in adults)
• Distal radius
• Distal tibia (just superior to the medial malleolus)
9 New 2005 ACLS guidelines likely to have recommendations to
incorporate IO line into resuscitation algorithms.

Cross-section of sternum and FAST1 system


9 The site choice for central line placement should be based on the associated acute and
subacute complications. Except for a few unique cases, the subclavian central line ranks as
the most ideal option. Specific to the subclavian line, the supraclavicular approach seems to
have fewer mechanical complications than the infraclavicular approach.

9 With the increasing availability of vascular ultrasound, the incidence of complications for
deep brachial and internal jugular vein lines should decline drastically.

9 Procedures such as pericardiocentesis, thoracentesis, and paracentesis should be done under

ultrasound guidance to avoid complications.

9 Physicians should become proficient with ultrasound-guided line placements, because they
will become the standard of care in the future.

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