Chapter 43

• Intravenous hemodynamic monitoring.
• Central venous sampling.
• Parenteral nutrition.
• Hemodialysis.
• Transvenous pacing.
• Placement of pulmonary artery catheters.

• Significant coagulopathy, especially with platelet counts < 50,000/μL.

### Potential Risks

• Infection.
• Pneumothorax.
• Dysrhythmia.
• Arterial puncture.
• Guidewire loss.
• Pseudoaneurysm.
• Thrombosis.
• Retroperitoneal dissection.
• Arteriovenous fistula.

• Chlorhexidine skin preparation solution.
• Sterile gown, gloves, and drapes.
• 1% lidocaine.
• 22-gauge finder needle.
• 18-gauge introducer needle.
• J-tip guidewire.
• Transduction tubing.
• Tissue dilator.
• Sterile saline for flushing the line.
• Catheter.
• 2-0 silk sutures.
• Sterile dressing.

• Short-acting antianxiety or pain medications as needed in consultation with the patient's nurse.

• The patient should be supine, in Trendelenburg (head-down) position for subclavian and internal jugular lines, and in reverse Trendelenburg (head-up) position for femoral lines.
• For infraclavicular subclavian vein access in larger patients, and those in whom the clavicle is difficult to palpate, a rolled towel can be placed between the shoulder blades to facilitate access.
• For femoral lines the patient should be placed supine with the leg slightly abducted and externally rotated.
• The patient should be placed on continuous monitoring.
• The area chosen should be widely exposed and all necessary hair trimmed.
• The area is prepared with a chlorhexidine-based skin solution and sterile drapes are applied.

### Femoral Vein Access

• Figure 43–1: Landmarks used for placement are the anterior iliac spine and the symphysis pubis.
• The vein is found halfway between these landmarks just below the inguinal ligament, lateral to the artery and medial to the nerve.
• One hand is placed over the femoral pulse, and the syringe is held in the other with the needle at a 30–40-degree angle to the skin and the bevel up.
• The needle typically encounters the vein within 2–4 cm but may be hubbed before encountering the vein in an obese patient.
• If there is no return of blood, the needle should be withdrawn slowly as the vein may be entered on withdrawal.
• The needle should be moved medially to laterally in a systematic manner until the vein is encountered.

### Subclavian Vein Access

• Figure 43–2A, B: The axillary vein continues as the subclavian vein at the lateral border of the first rib.
• It arches superiorly behind the medial clavicle and then joins the internal jugular vein to become the brachiocephalic vein posterior to the sternoclavicular joint.
• The subclavian artery runs with the vein, separated by the anterior scalene muscle, in a superior and posterior position (Figure 43–2A).
• The apex of the lung can rise above the level of the first rib on the left but is usually situated more inferiorly on the right. It lies deep and inferior to the subclavian vein.
• The subclavian vein can be accessed along the length of the clavicle, but the ...

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