1. INTRAVENOUS TECHNIQUES 1.To understand the proper indications for central intravenous access 2.To know how to perform central intravenous techniques during CPR Objectives

2. INDICATIONS FOR IV THERAPY Administer drugs and fluids Obtain venous blood Insert catheters into central circulation

3. ESTABLISH IV LIFELINE Routine part of advanced life support As early as possible

4. TYPES OF IV CANNULAS Hollow needles Indwelling plastic catheters inserted over hollow needle Indwelling plastic catheters inserted through a hollow needle or over a guide wire

5. TYPES OF IV TECHNIQUES Catheter-Over-The-Needle-Technique

6. TYPES OF IV TECHNIQUES Catheter-Through-The-Needle-Technique

7. TYPES OF IV TECHNIQUES Seldinger Technique with Guidewire

8. IV THERAPY Plastic catheter 14- and 16-gauge in adult Length depends on site Selection of Catheters

9. IV THERAPY IV preferable to intracardiac Use of peripheral or femoral vein does not interrupt CPR Aseptic technique if possible Femoral must have long cannula to thoracic cavity General Principles

10. IV THERAPY IV tubing with injection sites 500 mL N/S Plastic bottle or bag Keep open at 10 mL/hour General Principles (cont.)

11. IV THERAPY Hematoma Cellulitis Thrombosis Phlebitis Complications Local

12. IV THERAPY Sepsis Pulmonary thromboembolism Catheter fragment embolism Air embolism Complications (cont.) Systemic

21. PERIPHERAL VENIPUNCTURE Effective route for drugs during CPR Does not interrupt CPR Easy technique Advantages

22. PERIPHERAL VENIPUNCTURE In circulatory collapse, vein may be absent Access to central circulation may be difficult Isotonic solutions only Phlebitis common with saphenous vein Disadvantages

27. FEMORAL VEIN Does not interrupt CPR Vein does not collapse Easy access to central circulation Advantages

28. FEMORAL VEIN If pulse absent. Vein is hard to locate Long delivery time of drug into central circulation unless long catheter advanced into thoracic cavity Disadvantages

29. FEMORAL VEIN Thrombosis or phlebitis may extend to deep or illiac veins or vena cava Arterial cannulation – loss of limb Hematoma Complications

34. INTERNAL JUGULAR AND SUBCLAVIAN VENIPUNCTURE Access to central circulation Emergency access to venous circulation Specific indications

35. INTERNAL JUGULAR AND SUBCLAVIAN VENIPUNCTURE Needle, 6 cm long 16-gauge catheter, 15-20 cm long Depth of placement from surface markers General principles

36. INTERNAL JUGULAR AND SUBCLAVIAN VENIPUNCTURE Patient supine, 15-degree angle, head down Occlude needle to prevent air entry Never pull catheter back through needle Use of guidewire eliminates hazard Affix catheter with suture General principles (cont.)

37. INTERNAL JUGULAR VENIPUNCTURE Dome of pleura is lower Straight line to right atrium Thoracic duct not in the way Right Side of Neck Preferred

42. INTERNAL JUGULAR OVER SUBCLAVIAN Less risk of pleural puncture Hematomas in neck are visible Easier during CPR Advantages

43. SUBCLAVIAN OVER INTERNAL JUGULAR More subsequent neck movement possible with prolonged cannulation Advantages

44. INTERNAL JUGULAR AND SUBCLAVIAN VENIPUNCTURE Adjacent structures easily damaged More training required May interrupt CPR High complication rate Higher complications with thrombolytic therapy Disadvantages

45. INTERNAL JUGULAR AND SUBCLAVIAN VENIPUNCTURE Hematoma may compromise airway Damage to adjacent artery, nerve, or lymphatic duct Perforation of endotracheal cuff Specific local complications

46. INTERNAL JUGULAR AND SUBCLAVIAN VENIPUNCTURE Pneumothorax – Need follow-up chest x-ray Hemothorax Air embolism Infiltration into mediastinum or pleural space Arrhythmia from catheter tip Specific systemic complications

47. SUBCLAVIAN CANNULATION VIA EXTERNAL JUGULAR VEIN Easy to learn to perform Peripheral venipuncture Advantages

48. SUBCLAVIAN CANNULATION VIA EXTERNAL JUGULAR VEIN Practice required to use guide wire Wire or catheter may perforate veins May interrupt CPR Disadvantages