Venous access introduces a needle into a vein, usually for the purpose of withdrawing blood or administering medication.
Purpose
Venous access is necessary for fluid administration, medication administration, and obtaining blood for chemical analysis. Sites for access include veins located in the peripheral arms or legs, scalp, neck, and bone.
Venous access in children may pose special problems since finding appropriate veins and immobilization may be difficult but essential. For complicated procedures sedation may be indicated. Venous access can be performed during emergency situations, for outpatients, inpatients, and those who require long term chemotherapy.
Precautions
There are no major precautions for access during emergency procedures. The main concern during an emergency would be to secure a portal of entry to infuse potentially life saving medications and fluids. For all methods of access the main precautionary measures include attention to accurate procedures. Proper procedures are necessary to minimize the possibility of infection, embolism, phlebitis, or destruction of neighboring tissue.
Description
For peripheral venipuncture the common site is usually a vein in the arm (the anticubital fossa located on the opposite side of the elbow) or on the flat bony area of the hand (dorsum of the hand). Scalp veins are accessible in infants under one year of age. The selected vein should be long and straight for needle accommodation. It should be identified by straightness, lack of pulsation (characteristic of an artery), and filling with blood form above (arteries fill from below). Internal jugular catheterization is performed in the neck using special bone and muscle landmarks. The external jugular vein can be cannulized by immobilizing tilted and rotating the head. The subclavian approach is a complicated procedure and emergency access can be performed if attempts for access a vein in other areas have failed. Intraosseous venous access is usually accomplished through a leg bone. Catheters implanted in the front of the chest (anterior chest wall) can accomplish long-term venous access. A large leg vein is preferably used and isolated by dissection. A catheter is inserted into the vein and they are tied together.
Preparation
For peripheral vein access in the arm, a tourniquet is applied a few inches over the puncture site. The skin over the puncture site is sterilized with an alcohol pad. The needle is inserted and either blood is drawn and the needle is removed, or a catheter is inserted to place an intravenous line. Scalp veins can be accessible by immobilizing the head, shaving the area from hair, and using a rubber band as a tourniquet. Internal jugular vein catheterization is accomplished by extending the patient's head over the edge of a table or cart and rotating away from the intended puncture site. Immobilizing the head and extending it 15–20 degrees over the edge of a bed or cart and rotating away from the puncture site can cannalize the external jugular vein. The subclavian vein access is a complicated procedure and requires sedation and special positioning (Trendelenburg). A towel should be place in the back of the area. The skin should be cleansed and the puncture site is anesthetized. For the femoral approach the leg is externally rotated. The artery should be felt and along with specific anatomical landmarks the vein can be localized. The skin should be cleaned and anesthetized. During venous cutdown a large vein near the anklebone is careful dissected away from underlying tissues. The area must be properly cleaned and anaesthetize prior to making an incision. A catheter is inserted and secured in place with sutures.
Aftercare
For simple procedures such as peripheral venous access, applying simple pressure (to stop bleeding) and a bandage may be sufficient. For more complicated procedures, the primary cause for access should be treated as well as care to avoid or treat potential complications that may arise from access.
Risks
For access into a peripheral vein, care must be taken not to puncture both sides of the vein. After removal of the needle or catheter, a piece of cotton and pressure should be applied over the puncture site to prevent unwanted bleeding. Access with a scalp vein should be preformed with care to avoid hematoma formation (localized blood clot), accidental puncture of an artery, or infection. Access into the internal jugular vein in the neck can cause laceration of an artery or nerve. This procedure can also cause hematoma (blood clot) formation; damage to local nerves within the area, pneumothorax, or misplaced catheterization. Venous access into the external jugular vein can cause hematoma or placement outside the thorax. Subclavian vein access can cause air to enter a vein (resulting in an air embolus) or pneumothorax. Cannulation of the femoral vein in the groin area can cause infection or thrombophlebitis. Intraosseous venous access commonly performed in a leg bone can cause hematomas, infection or damage to bone marrow. This procedure should not be performed if the attempts in one leg is unsuccessful, the skin over the legs is diseased (from a burn or infection), or there is a broken leg bone or bone disease. Venous cutdown can cause infection, loss of the catheter in the vein, phlebitis, or nerve damage.
BOOKS
Pfenninger, John L., et al, eds. Procedures for Primary Care Physicians. 1st ed. Mosby-Year Book, Inc., 1994.
ORGANIZATION
American College of Angiology. 295 Northern Blvd, Ste. 104, Great Neck, NY 11021-4701.
Laith Farid Gulli, M.D.
Bilal Nasser, M.Sc.
KEY TERMS
Cannula—Insertion of a tube.
Catheterization— The process of inserting a tubular instrument into a body cavity to permit passage of fluid.
