Abstract

Background: Perioperatively, the preferred site for central venous access by anesthesia providers is the right internal jugular vein (RIJV). Maneuvers such as Trendelenburg position and positive end-expiratory pressure are commonly performed to increase the size of the RIJV and increase the success rate of cannulation.

Methods: We evaluated the size of RIJV at various anatomic levels in the neck to assess the most advantageous level for cannulation with patients in a flat, supine position without use of Trendelenburg. In this study 18 healthy subjects were placed in a flat, supine position for measurements of the cross-sectional area (CSA) of the RIJV using vascular ultrasound. Three measurements were obtained at each of the 5 anatomic levels of the neck. The first baseline measurement was taken at the level of cricoid cartilage (0 cm), followed by measurements at 4 other levels: cephalad to the cricoid cartilage at +1 and +2 cm, and caudad to the cricoid cartilage at −1 and −2 cm. The measurements of the CSA in centimeters² were electronically calculated after manual anatomic outlining of the vein. Factors that may influence the RIJV size, including age, gender, and body surface area, were included in the data analysis.

Results: The average CSA of the RIJV at the 5 levels measured (from +2 to −2 cm) were 0.91, 0.97, 1.06, 1.10, and 1.14 cm², respectively. The CSA of the RIJV was significantly larger at every 1-cm interval from the most cephalad level at +2 cm to the −2 cm most caudad level, except for the 0 to the −1 cm interval. Statistically significant difference in the CSA (P < .001 or 20%), was noted from the −2 to the +2 cm levels. No differences were found based on age, gender, or body surface area.

Conclusions: The anatomic level of the neck in relation to the cricoid cartilage at which jugular puncture is performed should be considered together with other maneuvers that may increase RIJV size. Success of RIJV cannulation may be increased by accessing the vein at a point with the largest CSA—1 to 2 cm caudad of the cricoid cartilage—especially in cases when the patient does not tolerate Trendelenburg position or ultrasound guidance is not available.

Abstract

Purpose: Various venous access devices are available, including peripheral venous lines, peripherally inserted central catheters lines, and subcutaneous port catheters. The latter provides medium-to long-term venous access and includes medical devices that can be inserted either on the chest (chest ports) or in the arm (arm ports). We report the techniques, dedicated indications, and main complications of arm port insertion using the ultrasonography (US) guidance method.

Methods: Tips and tricks of percutaneous real-time US-guided vein access technique in the arm are reviewed, and a brief literature review is reported.

Results: Technical feasibility is almost 99%. US guidance allows depiction of anatomic variants, reduces the number of failed attempts, and increases the technical access rate compared with venography-guided access. Comparison of arm ports to chest ports reveals a higher global complication rate. We also report typical (mechanical) complications and dedicated indications, including contraindications to chest port insertion and selected patients for whom chest ports are not possible (eg, those with breast, head, and neck cancer; obesity; cosmesis; and requiring upright position).

Conclusions: Arm port insertion under US guidance is safe and effective, and has dedicated indications.

Abstract

Background: The need for peripheral intravenous (IV) access in anatomically challenging patients is becoming a more commonly encountered clinical problem. The significant investment devoted to physician training for ultrasound-guided vascular access has not yet been matched by a similar commitment to nursing. Nurses, paramedics, and physicians are becoming more enthusiastic about peripheral IV access with ultrasound (PIVUS); however, institutional and clinician support has not yet been forthcoming. The learning curve for PIVUS has never been rigorously studied, and may be flatter than previously assumed.

Methods: Registered nurses were selected to participate as trainees. Training involved 1:1 sessions consisting of formal orientation to portable ultrasound, mentoring, and practice sessions with a nurse practitioner who has expertise in ultrasound-guided peripheral vascular access; hands-on, supervised practice cannulating vessels on a nonhuman tissue simulator; and supervised attempts on live patients.

Results: Seven of 8 trainees completed the training. The average number of patient encounters required to achieve 10 successful IV placements was 25 (range =18–32). The average time required for successful vessel cannulation was 19.57 minutes (range =5–62 minutes). An average of 25 attempts was required to achieve proficiency, and average of 50 cases was required to maintain consistency.

Conclusions: In today's practice environment, PIVUS skills are increasingly important. The results of our study demonstrate that, with appropriate hands-on training and supervision, these skills can be effectively taught to registered nurses.

Abstract

Peripheral intravenous catheter (PIVC) insertion and subsequent care have been highlighted as areas for improvement in the management of intravascular devices; however, only the fundamentals of PIVC care are routinely taught to registered nurses in Australia. In 2013, a vascular access-focused elective postgraduate course, Peripheral Intravenous Access and Care (8035NRS) was commenced for students enrolled in any of the Griffith University master's degree programs. It was developed with the intent to translate research knowledge into practice by providing access to the latest research findings and current best practices in peripheral intravenous access. Topics covered preinsertion, insertion, and postinsertion care and were developed for the online environment, which is known to be conducive to individual student learning styles. Learning activities included viewing short videos delivered by local and international clinical researchers. This course is the first known university-provided, postgraduate academic course on this subject in Australia, and possibly 1 of the few available internationally. The course succeeded in its aim of increasing knowledge and skills about safe, evidence-based PIVC insertion and care to registered nurses. Its development and implementation at the postgraduate level may be regarded as a strategy to provide a greater understanding regarding scope and relevance for nursing practice and for informed decision making on optimum integration at the undergraduate level. This ultimately will increase positive patient outcomes and the patient experience of vascular access.

Abstract

Proper securement provides a safe vascular access device environment for both patients and health care providers. Successful securement protects central venous catheters from several sources of failure until the end of therapy by preventing central venous catheter movement during all phases of care. Movement causes vein trauma, bacterial migration, distal tip location variation, loss of dressing integrity, and even total dislodgement. Any of these events can have serious consequences, including catheter-related bloodstream infection, thrombosis, delay of treatment, catheter replacement, and potential hemorrhage, all of which can be life-threatening events, and increase costs. We review patient issues, practice issues, and the types of securement currently used in clinical settings.