Venous Access

Introduction:
To familiarize to the physician with the importance of Short and long caliber peripheral lines are preferred for rapid volume resuscitation.
Access to Circulation:
Its use in the management of traumatized patient.
Venous access can use for investigation, blood sampling, fluid resuscitation and medication via injection.
There are Following Places in body that use for the Venous Access;

• Percutaneous peripheral venous access.
• Central access.
• Surgical cut-down.
• Intra-osseous access.

Percutaneous peripheral venous access:
Most Suitable site for PVA is Forearm, Cubital fossal vein.
Mainly there are used two large bore IV catheters (14 and 16 gauge).
Sterilize technique should be use in emergency and urgency situation.
Lower limbs can also be used for the venous access but complication can occur like thrombosis, cellulitis and phlebitis.

Central access:
It is use in traumatized unstable patient or in shocked patient.
There is use of CV line, in size of (8 to 12 French).
They provide high flow rate because of large diameter (2.5 to 4 mm) of catheter (Swan Sheath).
It can also use for the monitoring, assessing, to check volume status and for resuscitation.

* There are some sites where you can perform the central venous access;

1. Subclavian vein.
2. Internal Jugular vein.
3. Femoral vein.

1. Subclavian vein:
Criteria : Its selection depend on an experienced physician.

Advantages:
Easily accessible
It maintain CV line in fixed position due to fibrous tissue (Attached to the 1st Rib, clavicle and subclavicle muscles).
Allows the measurement of CVP (Central venous pressure).

Disadvantages:
It can cause suspected cervical spine injury.
In Complication Pneumothorax, arterial puncture, Hemothorax etc can occur.

2. Internal Jugular vein:
Criteria : IJV is most popular in CV line insertions.
But this site is not preferred in neck trauma (C-spine).

Advantages:
Right IJV have extra advantages rather than left IJV;
It Provide the straight route to the right heart.
It is Slightly larger than left IJV.
The dome of pleura is lower on the right side.

Disadvantages:
On left side it can cause thoracic duct injury which not occur on right side.

3. Femoral vein:
Criteria : Its is easy to cannulation because it is large in diameter of vein.

Advantages:
Ease of insertion.
No risk of thoracic injury.

Disadvantages:
Limits the flexion of leg at the hip.
Thrombosis.
Femoral artery puncture.

Surgical cut-down:
The procedure in which a vein is exposed through an incision and cannulated under the direct vision.
It is particularly performed in those patient in whom Percutaneous and central access are contraindicated that are traumatized patient and this procedure normally performed in children.

Sites for venous Cut-down:
It is mostly performed in superficial veins;

1. Long/Greater saphenous vein at the ankle.
2. Proximal long/Greater saphenous veins.
3. Antecubital veins.

1. Long/Greater saphenous vein at the ankle:

It is Approx. 1 cm above and anterior to the center of the medial malleolus.
This is safe site and have low morbidity.
It is of smaller in size at the ankle difficult to perform the procedure.
It is away from the central circulation.
It is not beneficial in leg fractures and splinting etc.

2. Proximal long/Greater saphenous veins:
It is Approx. 5 cm inferior to the inguinal ligament and 5 cm medial to the femoral pulse (or 5 cm medial to the mid point of the inguinal ligament in a pulse less patient).
It is better alternative to the ankle venous cut-down, it is near to the central circulation.

3. Antecubital veins:
Basilic vein, Proximal and distal cephalic veins in the arm can be used for a cut-down.
Basilic vein, because of its less acute union with the Subclavian vein is preferred site.
In complication damage to the brachial artery and median nerve.

Intra-osseous access:
The ability of the bone marrow to accept an infusion of fluids and drugs with subsequent effects like those of an intravenous infusion has been well documented.
Criteria: This route should be utilized for initial resuscitation.
Sites: Any marrow containing cavity is a potential site for infusion, These are the commonly recommended sites;

1. Proximal Tibia.
2. Distal Tibia.
3. Distal Femur.

1. Proximal Tibia:

Anteromedial surface, 2-3 cm below the tibial tuberosity.

2. Distal Tibia:

Anterior surface of the distal tibia, approximately 2 cm above the medial malleolus.

3. Distal Femur:

Antero-lateral surface, 3 cm above the lateral condyle of femur.

Advantages:
This route can be quickly, safely and reliably established and permits rapid venous uptake of the drugs and fluids.

Complications:
It can cause infections like local cellulitis and abscess.
Osteomyelitis.
Fracture of the bone.
Compartment syndrome.
Epiphyseal plate injury.