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Unlocking Common ED Procedures: Approach to the Patient with Difficult Vascular Access

Obtaining peripheral intravascular (IV) access is a common procedure in the Emergency Department and an essential aspect of managing critically ill patients... up to 30% of which are in patients with difficult vascular access (DVA). Factors associated with DVA include obesity, diabetes, and IV drug use, among others. While some of these patients may ultimately require central venous catheter placement, any astute emergency physician should have a few tricks up his or her sleeve to obtain initial vascular access and avoid the time and associated risks of this invasive procedure.

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 Approach to the Patient with Difficult Vascular Access

Obtaining peripheral intravascular (IV) access is a common procedure in the Emergency Department and an essential aspect of managing critically ill patients.

 New Kid on the Block: The “Easy IJ”

The “Easy IJ” involves placing an extra-long 18-gauge single-lumen catheter (those typically used for US-guided IVs) in the internal jugular vein. In one study in the emergency setting among patients who had failed traditional ultrasound-guided PIV placement, this technique was successful 88% of the time.

 Unlocking Common ED Procedures: Micropuncture Kits for Difficult Vascular Access

The micropuncture needle’s echogenic nature improves visualization with ultrasonography, providing the most benefit for patients with small vascular structures or aberrant anatomy. In short, the use of echogenic micropuncture needles is a vital skill for the emergency physician, and can be beneficial when placing peripheral IV or arterial catheters in challenging cases, although little literature has been published in this area.

Articles of Interest

Approach to Difficult Vascular Access

Deep veins of the upper arm are generally larger and are the best targets, especially the basilic and cephalic veins.

Difficult venous access in the emergency department

Placement of peripheral venous devices (PIV) could be challenging, especially in difficult venous access (DIVA) patients. Ultrasound guided long peripheral intravenous devices (US-LPIV) have been proposed as an alternative. The aim of our study is to compare performance of PIVs vs US-LPIVs in DIVA patients admitted to the emergency department.

Hemodynamic access for the crashing patient: The dirty double

Currently I begin by placing two catheters in the femoral artery and vein, immediately next to each other. This may be done using a single sterile field. The central venous catheter is placed first because it is generally more important. In highly acute situations, a nurse may attach extension tubing to the central line and start using it immediately (prior to inserting the arterial catheter). This will compromise the sterility of a portion of the sterile field, which can then be covered with a sterile towel. These lines are placed with the intention that they will be “dirty” lines which must be removed within ~24 hours. They are placed using sterile gloves, a mask, and a sterile sheet but without full sterility.

Peripherally inserted central catheter

Peripherally inserted central catheters (PICCs), often incorrectly tautologically termed PICC lines, are a type of central venous catheter predominantly used amongst oncology patients and those with chronic diseases (e.g. cystic fibrosis). Basilic and brachial veins are most commonly used; preprocedure ultrasound can be performed to identify an appropriately-sized vessel and ensure it is clot-free.

Seldinger Technique for Placement of “Peripheral” Internal Jugular Line: Novel Approach for Emergent Vascular Access

Since its introduction in 1953, the Seldinger technique has been used with great success to cannulate a multitude of blood vessels, hollow viscous structures, and potential anatomical spaces.

The Vanishing Target Sign: Confirmation of Intraluminal Needle Position for Ultrasound Guided Vascular Access

In our experience, consistent success with USGPIV placement in patients with difficult access using a dynamic one-person technique is a challenging procedure. In an attempt to help teach this effectively, we have developed a method that employs a sign we call the “vanishing target” to ensure intraluminal positioning of the catheter needle tip.

Ultrasound: Skills of Ultrasound-guided Vascular Access

Vascular access is a common procedure in the emergency department. Using ultrasound to visualise vessels is helpful, but the additional skill of using ultrasound to guide the procedure is even more so. Central, femoral and basilic vein cannulations are described, together with key aspects of imaging technique.

Vascular Access in Pediatric Patients in the Emergency Department: Types of Access, Indications, and Complications

It is a mainstay of any ED practice, and often a life-saving procedure: vascular access. But it is challenging to obtain and maintain in pediatric patients, especially in life-threatening cases when every second is critical.

Resources

SAEM

Vascular Access is the cornerstone of emergency medicine and part of every emergency medicine physician’s safety net. With that said, not every patient that enters the ER will require vascular access. It is important to know when to obtain access and what type of access should be used. Furthermore, an emergency medicine physician must be comfortable placing all forms of access.

Association for Vascular Access

The Association for Vascular Access (AVA) is an organization of healthcare professionals founded in 1985 to support and promote the specialty of vascular access. The mission of AVA is to distinguish the vascular access specialty and define standards of vascular access through an evidence-based approach designed to enhance healthcare.

Canadian Vascular Access Association

CVAA will empower and engage its members to advocate for safe, quality care across the healthcare continuum by providing leadership and promoting education, partnerships, knowledge and research in vascular access and infusion therapy with a vision for optimal patient outcomes.

IVteam

Vascular access device and IV infusion therapy updates. Vascular access teams, PICC teams and infusion therapy teams benefit from this global intravenous educational resource.

Journal of the Association for Vascular Access

The Journal of the Association for Vascular Access (JAVA), the official journal of the Association for Vascular Access, is a multidisciplinary, peer-reviewed scholarly journal. The journal endeavors to promote excellence in vascular access practice in all health care settings. JAVA strives to advance the field of vascular access by disseminating new and relevant information to its readership.

Journal of Vascular Access

it considers the publication of original manuscripts dealing with clinical and laboratory investigations in the fast growing field of vascular access. In addition reviews, case reports and clinical trials are welcome, as well as papers dedicated to more practical aspects covering new devices and techniques.

NIVAS

NIVAS is the first independent multi-professional society to be founded in the UK in this century. It is the new voice for all those involved in vascular access and infusion therapies.

Stay Connected

Our goal: reduce medical tubing misconnections and improve patient safety.

The Controversies in Dialysis Access

The CiDA Scientific Program provides the highest quality of interactive education for everyone involved in the care and treatment of dialysis patients.

Vascular Access Society

Our objectives are to raise interest in the field of hemodialysis vascular access, to promote and conduct basic and clinical research and to organize congresses, meetings and courses.

Vessel Health

Preserving the vessel health of our patients.

World Congress Vascular Access

Vascular access congress for professionals.