Vascular Access

Abstract

Abstract Access to the venous system can be used for both drug delivery and volume resuscitation. Peripheral intravenous (PIV) access is the main route of drug delivery. Central venous line (CVL) access is indicated for delivery of vasoactive or caustic medications, large and rapid volume infusions, total parenteral nutrition, invasive monitoring (central venous pressures, pulmonary artery pressures), and certain procedures (extracorporeal membrane oxygenation, transvenous pacing, dialysis). Intraosseous access can be used when PIV access is difficult, especially in emergency situations such as cardiac arrest due to more rapid and successful access, though it is usually a temporary (usually <24 hour) modality. For PIV and CVL access, ultrasound can be used to visualize the target vein in real time as well as neighboring neurovascular structures to determine the optimal entry point and needle trajectory. Maintaining sterility is important. Visualizing the vessel in cross-section and advancing the needle in an out-of-plane approach is the simplest technique when using ultrasound. Local lidocaine infiltration can be used to increase patient comfort. Confirming venous, and not arterial or extravascular, placement is key in minimizing complications. Other complications include fluid extravasation, compartment syndrome, air embolism, hemo-/pneumothorax (with CVL), and infection.