Internal Medicine: Venous Anatomy

Peripheral Venous Line Placement

• Convenient and immediate access for IV administration of fluids, medications, blood products, and/or nutritional support
• Indication: administration of fluids, medications, blood products, and/or nutritional support
• No absolute contraindications, but relative contraindications include local infections and burns on the intended site of insertion, and arteriovenous fistula formation or deep vein thrombosis on the affected limb
• Non-dominant upper extremity is usually used for convenience and less risk of extravasation/dislodgement

Steps for Peripheral Venous Line Placement

• Prepare all materials, including IV cannula, gloves, tourniquet, sterile cotton, medical adhesive tape/dressings, sharps disposal, and IV fluid/medications
• Practice universal precaution, perform hand hygiene, and use gloves
• Locate the target vein, ideally the most prominent, non-branched vein
• Stabilize the vein by applying traction to the skin using the non-dominant hand
• Hold the cannula, with the needle pointing proximally to the target vein, and insert at a 45-degree angle
• Advance the needle slowly until a flashback of blood appears in the chamber
• Slightly decrease the angle and carefully advance through the vein, following the contour, until the bushing is on the insertion site
• Apply pressure proximal to the insertion as the needle is carefully retracted with the dominant hand

Central Venous Line Placement

• Used for patients who require long-term access for IV administration, monitoring, and/or blood draws
• Sites include the subclavian vein, internal jugular vein, and femoral vein
• Subclavian vein provides a direct route to the right atrium but has a higher risk for pneumothorax and bleeding
• Femoral vein is used for patients who have a high risk of bleeding but is usually avoided due to increased risk of catheter-related deep vein thrombosis unless the other sites are unavailable

Steps for Central Venous Line Placement (Intrajugular)

• Prepare materials, including sterile gloves, drapes, gown, mask, antiseptic solution, sterile saline flush, and local anesthetic
• Locate the target vein using an ultrasound or landmarks between the clavicular and sternal heads of the sternocleidomastoid muscle at the base of the neck
• Infiltrate the skin with 1% Lidocaine around the insertion site
• Insert the introducer needle at a 45-degree angle
• Secure the catheter with suture and sterile dressing over the site
• Observe for any untoward reactions, and then confirm placement of the catheter tip with chest radiography

ECG Interpretation

• ECG placement involves limb leads and chest leads
• Limb leads include standard limb leads (I, II, III) and augmented limb leads (aVR, aVL, aVF)
• Chest leads include V1-V6, with V1 located at the 4th ICS, right parasternal border, and V2 located at the 4th ICS, left parasternal border
• How to read an ECG:
  • Heart rate (HR): normal (60-100bpm), tachycardic (>100bpm), bradycardic (<60bpm)
  • Second degree AV block (Mobitz I): progressive prolongation of PR interval then sudden beat drop (P-wave not followed by QRS complex)
  • Second degree AV block (Mobitz II): R/S in V5 or V6
  • Intervals: P-wave (0.5V), QRS complex (0.12s), and PR interval (0.12-0.2s)
  • Ischemia/infarction: incomplete QRS complex

Peripheral Venous Line Placement

• Convenient and immediate access for IV administration of fluids, medications, blood products, and/or nutritional support
• Indications: administration of fluids, medications, blood products, and/or nutritional support
• Stabilize vein by applying traction to skin using your nondominant hand
• Use anesthetic - Lidocaine 1%, Scalpel – blade II, Central line kit, Fr 6 to 8 catheter and dilator, Guidewire, Syringes, Needles 18- and 22- gauge, and polypropylene suture 4-0

Central Venous Line Placement

• Steps:
  • Prepare materials (Sterile gloves, drapes, gown, mask, antiseptic solution, sterile saline flush, Local anesthetic)
  • Place patient in Trendelenburg position, head facing the contralateral side of insertion site
  • Locate target vein using an ultrasound or the landmarks: between the clavicular and sternal heads of the sternocleidomastoid (SCM) muscle at the base of the neck
  • Observe strict aseptic technique (proper handwashing, gowning, draping, sterile preparation of access site)
  • Infiltrate the skin with 1% Lidocaine around the insertion site
  • Insert 18-gauge introducer needle at a 45-degree angle
  • Remove the introducer needle while still holding the guidewire in place
  • Make an incision around the guidewire enough to insert the dilator over the guidewire
  • Advance the dilator up to ~3-4cm (for Right IJV) while still securing the position of the guidewire
  • Withdraw the dilator while maintaining guidewire position then apply immediate pressure onto the exit site
  • Advance the central venous line catheter over the guidewire until desired length is achieved (~16-18cm for Right IJV)
  • Carefully remove the guidewire
• Indications: hemodynamic monitoring of critically ill patients, hemodialysis- and plasmapharesis-requiring patients, long-term access for parenteral nutrition
• Contraindications: no absolute contraindications, relative contraindications include distorted local anatomy, local infection on intended site, severe coagulopathy and bleeding disorders, thrombosed veins or proximal vascular injury
• Potential sites: Internal jugular vein (Right IJV is often the preferred site), Subclavian Vein, Femoral vein

ECG Interpretation

• ECG placement: Limb leads (Standard limb leads: I, II, III, Augmented limb leads: aVR, aVL, aVF), Chest leads (V1 – 4th ICS, right parasternal border)
• How to read?: Discard the needle properly, Remove the tourniquet, Secure the cannula onto the skin using medical adhesive tape/dressing, Observe for any untoward reactions, and then confirm placement of catheter tip with chest radiography