II. Approach: Peripheral Access
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Peripheral IV Access (default initial line)
- Gauge 18 or larger is preferred
- Initial Resuscitation with fluids
- Fluid infusion via 18 gauge peripheral IV is faster than via a triple lumen central catheter
- Medication administration including antibiotics
- Intravenous Contrast administration (reliable 18 gauge IV needed for CTA, PE studies)
- Initial Vasopressors may be used peripherally if reliable large bore IV (until central access is obtained)
- Allows for venous lab samples on placement and later
- Requires wasting part of sample, and then Flushing line
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Intraosseous Access
- Rapid landmark based placement with multiple available sites (e.g. proximal tibia, Humerus)
- Emergent Vascular Access for Resuscitation when peripheral IV cannot be immediately placed
- Allows for infusion of most fluids and medications including Vasopressors (but not Sodium Bicarbonate)
-
Midline Venous Catheter (Ultrasound-Guided Antecubital Line)
- Alternative to central venous access when standard peripheral lines are difficult
- Extravasation is more common with deep brachial vein IVs
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Rapid Infusion Catheter (RIC Line)
- Converts a 18-20 gauge peripheral IV into a large bore line (8 Fr)
- Seldinger wire is threaded through peripheral line and peripheral IV is removed
- Skin is nicked at IV entry site and dilator is threaded over wire and through skin
- Catheter is threaded over wire and into vein and wire is removed
- Allows for high flow rates via peripheral line
- Risk of destroying peripheral vein by threading it with too large of a catheter
- Converts a 18-20 gauge peripheral IV into a large bore line (8 Fr)
III. Approach: Central Access
- See Central IV Access
- Background
- Central Lines are sewn in place and typically more secure than peripheral lines which may be dislodged
- Internal Jugular Veins are preferred central access points
- However, in Resuscitation, consider femoral lines which are out of way of Resuscitation efforts
- Convert femoral lines to other sites in first 48 hours
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Central Line Types
- Triple Lumen Catheters
- Best for infusing multiple medications (including Vasopressors)
- Slower infusion rates (under pressure) than 18 gauge peripheral IVs
- Introducer Catheters
- Largest bore of the central catheter options offering high infusion rates
- Weingart recommends bypassing side port with commercially available product
- Hemodialysis Catheters
- Large bore catheter (12-13 french) with 2 ports
- Triple Lumen Catheters
IV. References
- Weingart and Swaminathan in Herbert (2021) EM:Rap 21(4): 5-7