To the Editor:—
Occasionally, patients for ambulatory surgery present with difficult peripheral venous access. Because only short-term access is needed, I prefer to avoid central venous cannulation and the associated risks. In these cases, I have begun using ultrasound guidance and a simplified Seldinger1technique for upper extremity peripheral venous access. A description of the technique and the results of a series of 10 procedures follows.
In this technique, a tourniquet is applied to the upper arm. Alcohol or povidone iodine is used to prepare the antecubital fossa and distal upper arm. Disposable, nonsterile gloves are worn, and draping is unnecessary. A 10-5 MHz ultrasound probe (Sonosite Titan, L38; Sonosite, Bothell, WA) is covered with gel, an occlusive dressing (3M Tegaderm 10 × 12 cm; 3M, St. Paul, MN), and then additional sterile gel. Using a transverse view, an appropriate, nonthrombosed vein is identified. This may be the cephalic, basilic, or brachial vein. The brachial artery and median nerve are identified, so they can be avoided. Lidocaine is infiltrated 1–2 cm distal to the planned insertion site. I then use a spring-wire guide/catheter over needle assembly, usually used for arterial catheterization (Arrow arterial catheterization set FA-0420; Arrow International, Reading, PA). It consists of a 10.8-cm, 20-gauge catheter over a 22-gauge thin wall needle with an integral 0.46-mm-diameter spring wire guide. Using a transverse or longitudinal view and a free hand technique, the needle is inserted into the selected vein under real-time imaging. When ultrasound imaging shows the needle in the vein and venous blood flashback appears, I ask an assistant to advance the spring wire guide. Alternately, I drop the ultrasound probe and advance the wire myself. Next, the catheter is advanced over the wire, the tourniquet is released, and the needle/wire assembly is removed.
Table 1shows the results of a series of 10 consecutive ultrasound-guided peripheral venous access procedures performed by the author. Patients were included in this series if at least two attempts at standard peripheral venous access failed or no adequate sized veins were visible or palpable in the upper extremity. Success was defined by the ultrasound view of the catheter in the vein and free flow of venous-appearing blood from the catheter. Each separate skin puncture was considered an attempt. Time was defined as the interval from initial skin puncture until success was achieved or the procedure was aborted. Nine of 10 catheter insertions were successful. There was an average of 1.3 attempts per procedure. The time required for a procedure averaged 140 s.
Ultrasound guidance is used commonly for peripherally inserted central catheters2and occasionally for standard peripheral venous access. In emergency medicine applications, Keyes et al. 3found that a 5-cm catheter over needle infiltrated 8% of the time, and therefore, a longer catheter might be useful for these deeper veins. Sandhu and Sidhu4recommended long needle-mounted catheters or a Seldinger technique for deep veins. Using a guide wire may help to ensure that an advancing catheter enters the vein properly. However, a standard Seldinger technique takes more time and requires sterile gloves, draping, and a table to hold the wire, tissue dilator, and catheter.
Ultrasound guidance for peripheral venous access may be improved by the use of a simplified Seldinger technique. The Arrow catheter set is commonly used for arterial catheterization, so anesthesiologists should be familiar with its use. The series described here demonstrates that this technique has a good success rate and the procedure takes a relatively short time to complete. Ultrasound guidance using this catheter may prevent multiple puncture attempts and decrease the use of unnecessary central venous catheters.
Asheville Surgery Center, Asheville, North Carolina. email@example.com