Anesthesia Student Survival Guide.pdf - Index of

iv, GAstric tube, ArteriAl & centrAl line PlAcement techniques ● 241
You decide that you will need another IV to proceed. What options do you
have to establish access?
There are many “tricks” anesthesiologists use to secure venous access in
patients with difficult anatomy. The first is to look beyond the forearms:
the upper arm, distal hand, and feet are sometimes options. Only a small
IV is needed for induction, and then as you had previously planned, better
veins may become visible after induction. The external jugular vein can be
percutaneously cannulated in many patients. Gentle pressure applied to the
distal neck just above the clavicle can help you visualize this valveless vein.
The femoral vessels are sometimes used, and the femoral artery is a useful
landmark for locating the femoral vein, about 1 cm medial to the pulse. A
femoral line may be somewhat compromised during laparoscopy because
the increased abdominal pressure will impede flow. A second option
is to enhance visibility of veins. Warming the extremity or use of topical
nitroglycerin ointment to promote vasodilation are sometimes successful
(thought the latter can cause a headache as a side effect). Inflating a blood
pressure cuff on the arm to above the arterial pressure for a few minutes,
then lowering it to approximately 30 mm Hg, which is above venous but
below arterial pressure, may reveal veins by causing mild ischemia-induced
vasodilation. Operators skilled in the technique have used ultrasound to
locate veins too deep to see or feel. In particular, the deep brachial vein in
the arm above the elbow can be localized in many patients. Finally, central
venous access via the internal jugular or subclavian veins may be the only
option. Again, ultrasound has been shown to reduce complications,
particularly for the internal jugular approach.
Suggested Further Reading
Braner DAV, Lai S, Eman S, Tegtmeyer K (2007) Central venous catheterization
– subclavian vein [Video]. N Engl J Med 357:e26
McGee DC, Gould MKN (2003) Preventing complications of central venous
catheterization [Review article]. N Engl J Med 348:1123–1133
Ortega R, Sekhar P, Song M, Hansen CJ, Peterson L (2008) Peripheral intravenous
cannulation [Video]. N Engl J Med 359:e26