CASE STUDY
Placement of a Central Venous Catheter in the Antecubital Vein Using a Modified Seldinger Technique Nicholas D. Caputo, MD, MSc, FAAEM,1,2 and Matthew Auld, CCRN1
Abstract
Introduction
Purpose: To describe a case of a patient requiring inotropic support without central venous access in which the central venous catheter (CVC) was placed in the antecubital vein using a modified seldinger technique. Background: Placement of CVC in the field in retrieval medicine can be time consuming and is not without risk of complication. Minimizing time in the field can lead to better outcomes for patients who are seriously medically ill or traumatically injured. The ED also offers a more controlled environment for the safe and accurate placement of CVCs. However, there are times in the prehospital environment when more secure access than peripheral is needed in order to administer the appropriate treatment. Herein, a modified seldinger technique is described for the peripheral placement of a CVC. Case Report: A 53-year-old man presented to a remote health clinic in the outback of Australia with complaints of weakness, persistent vomiting and chest pain. He subsequently arrested for a brief period (~3 minutes) from suspected hyperkalemia complicated by MI and upon resuscitation was bradycardic, obtunded and hypotensive. Clinic staff were only able to gain an 18G left antecubital IV. The patient required an adrenaline infusion, IVF and other medications. Using the angiocatherter already in place, a guide wire was placed through and a quadruple lumen CVC was placed without complication allowing for infusion of medications (adrenaline drip, meropenem) and IVF. The catheter was removed after a CVC was placed under US guidance and sterile conditions in the ICU 12 hours later. Conclusion: This case represents a dilemma faced in the prehospital environment by retrieval teams and offers a novel technique as a temporizing solution until appropriate CVC access can be gained.
The need for and type of vascular access (peripheral vs. central vs. intraosseous) in the prehospital setting is a decision that is determined by several factors including patient pathology, team composition, resource availability, timeliness, and environment.1-3 The placement of any invasive instrument is not without risk, both directly (ie, phlebitis from peripheral intravenous catheter [PIV] or pneumothorax from the central venous catheter [CVC]) and indirectly (ie, time to transport).4,5 However, despite known complications, access is warranted for the administration of needed medications during events such as cardiac arrest or shock. Gaining early intravenous access allows the prehospital team to administer such treatments at the cost of time. Evidence suggests that ambulance crews who cannulate spend more time on scene.6 Time to hospital has been shown as an independent predictor of outcome, which has led to a consensus that, when safe, crews should cannulate en route to prevent on-scene delays.7,8 However, in remote, retrieval medicine, it can be difficult to place such additional lines during transport because of turbulence and insufficient space and access in helicopters/fixed wing planes. When access in the remote, prehospital environment is deemed inadequate or additional access is required, further delays ensue. This case report describes the use of a modified Seldinger technique for more secure peripheral access in a patient requiring additional therapy that could be delivered by a single peripheral line and in whom scene delays could not be prolonged.
1. Careflight, NTEMRS, Darwin, NT, Australia 2. Department of Emergency Medicine, Lincoln Medical and Mental Health Center, Bronx, NY Address for correspondence: Nicholas D. Caputo, MD, MSc, FAAEM, Department of Emergency Medicine, Lincoln Medical and Mental Health Center, 234 East 149th Street, Bronx, NY 10451, [email protected] 1067-991X/$36.00 Copyright 2014 by Air Medical Journal Associates http://dx.doi.org/:10.1016/j.amj.2014.05.009 280
Case Report A 55-year-old aboriginal man presented to a remote health clinic with complaints of weakness, persistent vomiting, and chest pain. He had a past medical history significant for hypertension, type 2 diabetes mellitus, ischemic heart disease, and a right arteriovenous fistula for previous hemodialysis; he had a renal transplant in 2002. He reported feeling weak for several days and on the previous day had vomited more than 10 times and was not able to take any fluids or food. The morning of presentation he was so weak that he could not walk, and he was complaining of mild, substernal, nonradiating, chest pain, so his family brought him to the clinic. In the clinic, he was noted to be hypotensive (systolic blood pressure ⫽ 70) with a heart rate in the 40s, tachypneic (respiratory rate of 32), hypoxic (oxygen 91% on room air), and obtunded. A left 18-G PIV was placed, and he was put on oxygen. Additional access was attempted but stopped after Air Medical Journal 33:6
Figure 1. The placement of the CVC in the left antecubital vein (arrow). The head of the patient is to the right of the picture.
multiple failures. Available laboratory investigation revealed a potassium level of 6.6 mEq/L, glucose of 23 mmol/L, venous blood gas of 7.39/48/49/18, and a lactate level of 2.5 mmol/L. An electrocardiogram showed sinus bradycardia with widened QRS intervals. The patient subsequently went into cardiac arrest for 3 minutes. Return of spontaneous circulation occurred after 1 dose of adrenaline and the administration of calcium gluconate by the clinic staff. After return of spontaneous circulation, the patient was again noted to be continually hypotensive (systolic ⫽ 70-80), bradycardic (heart rate in the 40s), tachypneic (respiratory rate ⫽ 24), hypoxic (92% on Hudson facemask), and obtunded. The clinic staff then administered albuterol by nebulization, insulin, and ceftriaxone per the advice of an intensivist at the nearest hospital. Retrieval was requested, and on assessment by the critical care retrieval team 40 minutes later, the patient’s status was unchanged. On examination, the patient was still obtunded, awaking to noxious stimuli, reported right-sided chest pain, and was actively vomiting. He remained hypotensive and bradycardic. He had dry mucosa and no stridor or neck bruits. His chest was clear. A left radial arterial line was placed for more accurate blood pressure readings, and an arterial blood gas test was obtained (7.39/35/78/18, lactate ⫽ 1.93). The troponin test was negative. The left antecubital 18-G angiocatheter was deemed insufficient because the patient most likely suffered arrest from hyperkalemia and was also significantly dehydrated. After discussion with the retrieval nurse and pilot about the situation, the decision was made to replace the 18-G angiocatheter with a multilumen CVC because this patient required inotropic support and large fluid volume replacement and time was limited because of impending weather patterns.
Procedure After gaining informed consent from the patient’s family, the dressing was removed from the PIV site. The area was November-December 2014
cleaned with chlorhexidine and draped in a sterile fashion. The saline lock was removed, and blood flowed back freely from the angiocatheter. The guidewire was placed into the angiocatheter and advanced without resistance to the 20-cm point. The angiocatheter was then removed. The insertion point was dilated slightly. Finally, the multilumen CVC was placed completely into the patient’s vein and secured in place (Fig. 1). All 4 lumens aspirated easily. An adrenaline infusion was started along with normal saline infusion, and a dose of meropenem was added at the advice of the intensivist. The patient’s hemodynamics improved with adrenaline, and his mental status normalized as he awoke. He was transported to the intensive care unit where this access was used for several more hours until it was taken out and replaced with an appropriately placed CVC under ultrasound guidance. This procedure differs from the placement of a peripherally inserted central catheter (PICC) line in several ways. A PICC line is placed under maximal sterile conditions like a central line using ultrasound guidance or fluoroscopy in some institutions. Also, a PICC line accesses the brachial, cephalic, or basilica vein directly. Here, the antecubital vein is accessed without adjunctive guidance, and the deeper veins are accessed through this more superficial vein.
Discussion The need for and type of vascular access required in the prehospital retrieval environment is dictated by many variables. In our case, the patient was postarrest with concern for subsequent episodes of arrest. There was need for a more secure vascular access because an adrenaline infusion was needed to improve hemodynamics and perfusion to the brain, which subsequently improved his overall clinical status and made for an uncomplicated transfer. Time in the clinic was an issue. As discussed with the retrieval nurse, medical retrieval consultant, and intensivist, the patient’s airway was not an issue because he was maintaining protection and his hypoxia was thought to be caused by his respiratory depression, which was most likely from decreased perfusion to his brain. By increasing his output and perfusion, the thought was that his respiratory status would improve, resolving the hypoxia. Vascular access was critical in this case because the patient needed volume replacement and inotropic support. However, faced with impending weather changes, the pilot could only guarantee takeoff within an hour of arrival to the clinic. Intraosseous access was discussed because evidence suggests the success rate and speed of insertion are better than CVC access in the field; however, this patient already had PIV access.9-12 Central venous access was considered, but because of concern for timing and the questionable full aseptic technique, this was ruled out. This left using the functioning catheter already in place as a means as a quick access point to insert the CVC peripherally. This peripherally placed CVC was then used as a temporizing measure until the patient arrived at the hospital. This technique, besides allowing for multiple infusions and large-volume resuscitation through a 281
peripheral access point, also allowed for the traditional access points of CVC to be saved for attempts in the hospital under more appropriate settings. The peripheral line was discontinued within 12 hours of replacement, which was well within the guidelines for the removal of lines placed in the field as set forth by the Centers for Disease Control and Prevention.13
Conclusion This case represents a dilemma faced in the prehospital environment by retrieval teams and offers a novel technique as a temporizing solution until appropriate CVC access can be gained.
References 1. Göransson KE, Johansson E. Indication and usage of peripheral venous catheters inserted in adult patients during emergency care. J Vasc Access. 2011;12:193-199. 2. Boyle MF, Kuntz B. Saline locks in prehospital care. Prehosp Disaster Med. 1994;9:190192. 3. Gausche M, Tadeo RE, Zane MC, et al. Out-of-hospital intravenous access: unnecessary procedures and excessive cost. Acad Emerg Med. 1998;5:878-882. 4. Göransson KE, Johansson E. Prehospital peripheral venous catheters: a prospective study of patient complications. J Vasc Access. 2012;13:16-21.
282
5. Davis DP, Ramanujam P. Central venous access by air medical personnel. Prehosp Emerg Care. 2007;11:204-206. 6. Powar M, Nguyen-Van-Tam J, Pearson J, Dove A. Hidden impact of paramedic interventions. J Accid Emerg Med. 1996;13:383-385. 7. Pepe PE, Wyatt CH, Bickell WH, Bailey ML, Mattox KL. The relationship between total pre-hospital time and out-come in hypotensive victims of penetrating injuries. Ann Emerg Med. 1987;16:293-297. 8. Demetriades D, Chan L, Cornwell E, et al. Paramedic vs. private transportation of trauma patients. Effect on outcome. Arch Surg. 1996;131:133-138. 9. Leidal BA, Kirchhoff C, Bogner V, et al. Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Saf Surg. 2009;3:24. 10. Harrington LL, Rehbolz C, Mitchell PM, et al. Out-of-hospital placement of adult intraosseous access using EZ-IO device. Ann Emerg Med. 2007;50:s81. 11. Frascone RJ. Consecutive field trials using two different intraosseous devices. Prehosp Emerg Care. 2007;11:164-171. 12. Sunde G, Heradstveit BE, Vikenes BH, Heltne JK. Emergency intraosseous access in a helicopter emergency medical service: a retrospective study. Scand J Trauma Resusc Emerg Med. 2010;18:52. 13. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. MMWR Recomm Rep. 2002;51:1-29.
Air Medical Journal 33:6
Placement of a Central Venous Catheter in the Antecubital Vein Using a Modified Seldinger Technique Nicholas D. Caputo, MD, MSc, FAAEM,1,2 and Matthew Auld, CCRN1
Abstract
Introduction
Purpose: To describe a case of a patient requiring inotropic support without central venous access in which the central venous catheter (CVC) was placed in the antecubital vein using a modified seldinger technique. Background: Placement of CVC in the field in retrieval medicine can be time consuming and is not without risk of complication. Minimizing time in the field can lead to better outcomes for patients who are seriously medically ill or traumatically injured. The ED also offers a more controlled environment for the safe and accurate placement of CVCs. However, there are times in the prehospital environment when more secure access than peripheral is needed in order to administer the appropriate treatment. Herein, a modified seldinger technique is described for the peripheral placement of a CVC. Case Report: A 53-year-old man presented to a remote health clinic in the outback of Australia with complaints of weakness, persistent vomiting and chest pain. He subsequently arrested for a brief period (~3 minutes) from suspected hyperkalemia complicated by MI and upon resuscitation was bradycardic, obtunded and hypotensive. Clinic staff were only able to gain an 18G left antecubital IV. The patient required an adrenaline infusion, IVF and other medications. Using the angiocatherter already in place, a guide wire was placed through and a quadruple lumen CVC was placed without complication allowing for infusion of medications (adrenaline drip, meropenem) and IVF. The catheter was removed after a CVC was placed under US guidance and sterile conditions in the ICU 12 hours later. Conclusion: This case represents a dilemma faced in the prehospital environment by retrieval teams and offers a novel technique as a temporizing solution until appropriate CVC access can be gained.
The need for and type of vascular access (peripheral vs. central vs. intraosseous) in the prehospital setting is a decision that is determined by several factors including patient pathology, team composition, resource availability, timeliness, and environment.1-3 The placement of any invasive instrument is not without risk, both directly (ie, phlebitis from peripheral intravenous catheter [PIV] or pneumothorax from the central venous catheter [CVC]) and indirectly (ie, time to transport).4,5 However, despite known complications, access is warranted for the administration of needed medications during events such as cardiac arrest or shock. Gaining early intravenous access allows the prehospital team to administer such treatments at the cost of time. Evidence suggests that ambulance crews who cannulate spend more time on scene.6 Time to hospital has been shown as an independent predictor of outcome, which has led to a consensus that, when safe, crews should cannulate en route to prevent on-scene delays.7,8 However, in remote, retrieval medicine, it can be difficult to place such additional lines during transport because of turbulence and insufficient space and access in helicopters/fixed wing planes. When access in the remote, prehospital environment is deemed inadequate or additional access is required, further delays ensue. This case report describes the use of a modified Seldinger technique for more secure peripheral access in a patient requiring additional therapy that could be delivered by a single peripheral line and in whom scene delays could not be prolonged.
1. Careflight, NTEMRS, Darwin, NT, Australia 2. Department of Emergency Medicine, Lincoln Medical and Mental Health Center, Bronx, NY Address for correspondence: Nicholas D. Caputo, MD, MSc, FAAEM, Department of Emergency Medicine, Lincoln Medical and Mental Health Center, 234 East 149th Street, Bronx, NY 10451, [email protected] 1067-991X/$36.00 Copyright 2014 by Air Medical Journal Associates http://dx.doi.org/:10.1016/j.amj.2014.05.009 280
Case Report A 55-year-old aboriginal man presented to a remote health clinic with complaints of weakness, persistent vomiting, and chest pain. He had a past medical history significant for hypertension, type 2 diabetes mellitus, ischemic heart disease, and a right arteriovenous fistula for previous hemodialysis; he had a renal transplant in 2002. He reported feeling weak for several days and on the previous day had vomited more than 10 times and was not able to take any fluids or food. The morning of presentation he was so weak that he could not walk, and he was complaining of mild, substernal, nonradiating, chest pain, so his family brought him to the clinic. In the clinic, he was noted to be hypotensive (systolic blood pressure ⫽ 70) with a heart rate in the 40s, tachypneic (respiratory rate of 32), hypoxic (oxygen 91% on room air), and obtunded. A left 18-G PIV was placed, and he was put on oxygen. Additional access was attempted but stopped after Air Medical Journal 33:6
Figure 1. The placement of the CVC in the left antecubital vein (arrow). The head of the patient is to the right of the picture.
multiple failures. Available laboratory investigation revealed a potassium level of 6.6 mEq/L, glucose of 23 mmol/L, venous blood gas of 7.39/48/49/18, and a lactate level of 2.5 mmol/L. An electrocardiogram showed sinus bradycardia with widened QRS intervals. The patient subsequently went into cardiac arrest for 3 minutes. Return of spontaneous circulation occurred after 1 dose of adrenaline and the administration of calcium gluconate by the clinic staff. After return of spontaneous circulation, the patient was again noted to be continually hypotensive (systolic ⫽ 70-80), bradycardic (heart rate in the 40s), tachypneic (respiratory rate ⫽ 24), hypoxic (92% on Hudson facemask), and obtunded. The clinic staff then administered albuterol by nebulization, insulin, and ceftriaxone per the advice of an intensivist at the nearest hospital. Retrieval was requested, and on assessment by the critical care retrieval team 40 minutes later, the patient’s status was unchanged. On examination, the patient was still obtunded, awaking to noxious stimuli, reported right-sided chest pain, and was actively vomiting. He remained hypotensive and bradycardic. He had dry mucosa and no stridor or neck bruits. His chest was clear. A left radial arterial line was placed for more accurate blood pressure readings, and an arterial blood gas test was obtained (7.39/35/78/18, lactate ⫽ 1.93). The troponin test was negative. The left antecubital 18-G angiocatheter was deemed insufficient because the patient most likely suffered arrest from hyperkalemia and was also significantly dehydrated. After discussion with the retrieval nurse and pilot about the situation, the decision was made to replace the 18-G angiocatheter with a multilumen CVC because this patient required inotropic support and large fluid volume replacement and time was limited because of impending weather patterns.
Procedure After gaining informed consent from the patient’s family, the dressing was removed from the PIV site. The area was November-December 2014
cleaned with chlorhexidine and draped in a sterile fashion. The saline lock was removed, and blood flowed back freely from the angiocatheter. The guidewire was placed into the angiocatheter and advanced without resistance to the 20-cm point. The angiocatheter was then removed. The insertion point was dilated slightly. Finally, the multilumen CVC was placed completely into the patient’s vein and secured in place (Fig. 1). All 4 lumens aspirated easily. An adrenaline infusion was started along with normal saline infusion, and a dose of meropenem was added at the advice of the intensivist. The patient’s hemodynamics improved with adrenaline, and his mental status normalized as he awoke. He was transported to the intensive care unit where this access was used for several more hours until it was taken out and replaced with an appropriately placed CVC under ultrasound guidance. This procedure differs from the placement of a peripherally inserted central catheter (PICC) line in several ways. A PICC line is placed under maximal sterile conditions like a central line using ultrasound guidance or fluoroscopy in some institutions. Also, a PICC line accesses the brachial, cephalic, or basilica vein directly. Here, the antecubital vein is accessed without adjunctive guidance, and the deeper veins are accessed through this more superficial vein.
Discussion The need for and type of vascular access required in the prehospital retrieval environment is dictated by many variables. In our case, the patient was postarrest with concern for subsequent episodes of arrest. There was need for a more secure vascular access because an adrenaline infusion was needed to improve hemodynamics and perfusion to the brain, which subsequently improved his overall clinical status and made for an uncomplicated transfer. Time in the clinic was an issue. As discussed with the retrieval nurse, medical retrieval consultant, and intensivist, the patient’s airway was not an issue because he was maintaining protection and his hypoxia was thought to be caused by his respiratory depression, which was most likely from decreased perfusion to his brain. By increasing his output and perfusion, the thought was that his respiratory status would improve, resolving the hypoxia. Vascular access was critical in this case because the patient needed volume replacement and inotropic support. However, faced with impending weather changes, the pilot could only guarantee takeoff within an hour of arrival to the clinic. Intraosseous access was discussed because evidence suggests the success rate and speed of insertion are better than CVC access in the field; however, this patient already had PIV access.9-12 Central venous access was considered, but because of concern for timing and the questionable full aseptic technique, this was ruled out. This left using the functioning catheter already in place as a means as a quick access point to insert the CVC peripherally. This peripherally placed CVC was then used as a temporizing measure until the patient arrived at the hospital. This technique, besides allowing for multiple infusions and large-volume resuscitation through a 281
peripheral access point, also allowed for the traditional access points of CVC to be saved for attempts in the hospital under more appropriate settings. The peripheral line was discontinued within 12 hours of replacement, which was well within the guidelines for the removal of lines placed in the field as set forth by the Centers for Disease Control and Prevention.13
Conclusion This case represents a dilemma faced in the prehospital environment by retrieval teams and offers a novel technique as a temporizing solution until appropriate CVC access can be gained.
References 1. Göransson KE, Johansson E. Indication and usage of peripheral venous catheters inserted in adult patients during emergency care. J Vasc Access. 2011;12:193-199. 2. Boyle MF, Kuntz B. Saline locks in prehospital care. Prehosp Disaster Med. 1994;9:190192. 3. Gausche M, Tadeo RE, Zane MC, et al. Out-of-hospital intravenous access: unnecessary procedures and excessive cost. Acad Emerg Med. 1998;5:878-882. 4. Göransson KE, Johansson E. Prehospital peripheral venous catheters: a prospective study of patient complications. J Vasc Access. 2012;13:16-21.
282
5. Davis DP, Ramanujam P. Central venous access by air medical personnel. Prehosp Emerg Care. 2007;11:204-206. 6. Powar M, Nguyen-Van-Tam J, Pearson J, Dove A. Hidden impact of paramedic interventions. J Accid Emerg Med. 1996;13:383-385. 7. Pepe PE, Wyatt CH, Bickell WH, Bailey ML, Mattox KL. The relationship between total pre-hospital time and out-come in hypotensive victims of penetrating injuries. Ann Emerg Med. 1987;16:293-297. 8. Demetriades D, Chan L, Cornwell E, et al. Paramedic vs. private transportation of trauma patients. Effect on outcome. Arch Surg. 1996;131:133-138. 9. Leidal BA, Kirchhoff C, Bogner V, et al. Is the intraosseous access route fast and efficacious compared to conventional central venous catheterization in adult patients under resuscitation in the emergency department? A prospective observational pilot study. Patient Saf Surg. 2009;3:24. 10. Harrington LL, Rehbolz C, Mitchell PM, et al. Out-of-hospital placement of adult intraosseous access using EZ-IO device. Ann Emerg Med. 2007;50:s81. 11. Frascone RJ. Consecutive field trials using two different intraosseous devices. Prehosp Emerg Care. 2007;11:164-171. 12. Sunde G, Heradstveit BE, Vikenes BH, Heltne JK. Emergency intraosseous access in a helicopter emergency medical service: a retrospective study. Scand J Trauma Resusc Emerg Med. 2010;18:52. 13. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. MMWR Recomm Rep. 2002;51:1-29.
Air Medical Journal 33:6
