Chapter 27

### Introduction

Vascular access procedures, such as central venous and arterial catheterization, are commonly performed in the critical care setting. An estimated 5 million central venous catheters (CVCs) are placed annually in the United States1 in a variety of settings, including critical care units, emergency departments, operating rooms, and in outpatient venues. The usual indications for CVC placement are to assist in hemodynamic monitoring; as a route for the administration of vasoactive medications, total parenteral nutrition, or other vascular irritants; and as a route for drawing blood. In addition, the Surviving Sepsis guidelines advocate measuring mixed venous oxygen saturation in the management of septic shock, which could ultimately lead to increased utilization of oximetric CVCs.

Arterial catheters are an important tool in the management of many intensive care unit (ICU) conditions, including shock, severe hypertension, and other circumstances, in which blood pressure monitoring is important. For a number of reasons, it seems that the role for arterial catheterization in the ICU may also increase. First, with the introduction of “minimally invasive” techniques now available to help estimate cardiac output, arterial catheter placement is becoming increasingly important for the management of selected patients with heart failure. Second, arterial catheterization can be used to assess the response to therapy in patients with pulmonary hypertension. Finally, there has been a significant amount of attention focused recently on respiratory variation of the peak arterial pressure as a means to predict fluid responsiveness in shock states.2

Peripherally inserted CVCs (PICCs) and peripherally inserted catheters sited in a midline position (midlines) have gained increased popularity as an alternative to CVCs in the care of selected patients because of their ease of insertion, longevity, and low rate of early complications. They have become an important component of the central venous access armamentarium. Peripheral intravenous (IV) catheters, long overlooked by the medical ultrasound community, can be placed with very high success rates even in very difficult to cannulate patients when performed under ultrasound guidance.

Vascular access is associated with a relatively low rate of serious complications.1 However, an improved understanding of complications and why they occur may help the provider to reduce their risk. Complications associated with vascular access procedures are well described,1 and can be categorized as patient or operator dependent (Table 27-1). Patient-dependent factors include body habitus, coagulopathy, and anatomic variation. Operator-dependent factors include the operator’s level of experience, time allotted to perform the procedure, and human factors, like fatigue and lack of ultrasound guidance.35 The most common complications of CVC placement include accidental arterial puncture, failed placement, malposition of the catheter tip, hematoma, pneumothorax, and hemothorax, the frequency of which vary depending on the site of catheter insertion (Table 27-2). Arterial catheter placement can be complicated by venous puncture, multiple arterial punctures, significant hematoma, and failed placement. PICCs and midline placement are also associated with hematomas and arterial insertions. ...

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