Chapter 34

### Introduction

Intravascular devices and catheters can be inserted in the intensive care unit (ICU) for a variety of purposes, including fluid and drug administration, pressure monitoring, pacemaking, or cardiac augmentation. Several techniques can be used to obtain access to and cannulate the vessel. Parenthetically, these same techniques can be used for other procedures such as thoracentesis or paracentesis.

### Definitions and Terms

• ▪  Needle through catheter: Large bore needle inserted into vessel and smaller bore catheter threaded through needle into vessel
• ▪  Catheter over needle: smaller bore needle inserted into vessel and large bore catheter threaded over needle into vessel
• ▪  Seldinger technique: Small bore needle inserted into vessel, wire passed through needle into vessel, needle removed, catheter threaded over wire into vessel, wire removed
• ▪  Modified Seldinger technique: Small bore needle inserted into vessel, wire passed through needle into vessel, needle removed, dilator/sheath passed over wire into vessel, wire and dilator removed, catheter threaded through sheath into vessel, sheath removed

### Techniques

• ▪  Vessel identification
• —Anatomy: Some vessels are identified primarily through anatomic landmarks.
• • Internal jugular: Typically cannulated at the apex of the triangle formed by the sternal and clavicular portions of the sternocleidomastoid muscle and the clavicle, wherein the needle is inserted at this location and aimed toward the ipsilateral nipple
• • Subclavian vein: Typically passes under the clavicle in the midclavicular line, and the needle is inserted so as to pass under the clavicle at this point aiming toward the sterna notch
• —Pulses: Vessel location may be indicated by arterial pulse.
• —The internal jugular vein is typically adjacent and lateral to the internal carotid artery.
• —The femoral vein is medial to the femoral artery in the groin.
• —Ultrasound: Increasingly portable, high fidelity ultrasound devices are available at the bedside to guide vascular cannulation.
• ▪  Vessel cannulation
• —Direct cannulation: The needle is inserted into the vessel and a catheter is threaded directly over it into the vessel (Figure 34-1).
• —Transfixion: The needle is passed through both the front and back walls of the vessel and withdrawn until there is free blood flow, at which point the cannula is threaded off of the needle into the vessel (Figure 34-2).
• —Seldinger variants: The vessel is cannulated with a needle or catheter as above, and a wire is passed into the vessel over which dilators or catheters can readily be exchanged while access to the vessel is maintained with the wire (Figure 34-3).
Figure 34-1.

Direct cannulation, wherein (1) the vessel is cannulated and the (2) the catheter is threaded over the needle.

Figure 34-2.

Transfixion, in which (1) the front and (2) the back walls of the vessel are transfixed after which the needle is withdrawn until there ...

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