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The Case
A 500-pound morbidly obese male presents to your ED complaining of mild shortness of breath and palpitations. A quick ECG shows SVT with a rate over 200 bpm. His BP is in the 130s systolic, and he is otherwise stable. You know you have a bit of time. Meanwhile, the nurses begin searching for veins to start an IV.

The Problem
Multiple nurses try and fail to place a peripheral IV due to the patient’s obesity.  You know that you will need to push adenosine, so you will need a proximal line. His neck is so thick that finding an external jugular vein will be difficult. You think about central access, but he cannot lie flat to tolerate placement of an internal jugular line. Additionally, he has a massive inguinal hernia and sizable pannus, making a femoral line essentially out of the question. A subclavian line will be equally difficult given his size and lack of landmarks.

You attempt ultrasound-guided peripheral IV placement with a long (1.88 inch) angiocatheter, but it keeps decannulating. It is just not long enough to stay in the vein. You contemplate placing an intraosseous line into his humerus, but even his shoulder is obese, making landmarks difficult to identify. Plus, you’d rather not have to drill into the bone of an awake patient unless absolutely necessary.

How can you secure vascular access in this patient?

Quick Trick
Use a pediatric central venous catheter (CVC) placed under ultrasound guidance using the Seldinger technique into a deep arm vein.

The pediatric CVC is 8 cm (3.15 in) in length, which gives the extra length you need to get from the patient’s skin into the vein. As an extra bonus, this is a double lumen catheter with 18- and 20- gauge lumens. This conveniently allows you to push the adenosine through one port and the saline flush through the second port. After placement, the line was secured in place with a tissue adhesive glue and some steri-strips. Twelve milligrams of adenosine later, the patient was comfortably back in sinus rhythm.

Placing this line is essentially like placing a short peripherally inserted central catheter (PICC). Instead, you can call it a PIPP catheter – a peripherally inserted peripheral pediatric catheter!

Note of Caution
Specifically for adenosine injection, ensure that the catheter is in a vein rather than an artery. A case report in a 14 year-old patient, who received intra-arterial adenosine from an angiocatheter inadvertently placed in the radial artery, described the unique complication of transient hand pain and hyperemia. Ultrasound guided placement of a deep vessel angiocatheter as described above will hopefully help minimize the risk of intra-arterial placement.1

 



References
1. Patil MB, Patil SM. Accidental Intra-arterial Injection of Adenosine in a Child with Supraventricular Tachycardia. Iran J Pediatr. 2013 Jun;23(3):368-9.

Noah Sugerman is an emergency medicine resident at the UCLA/Olive View EM residency.
Eric Silman, MD is the assistant program director at the UCLA/Olive View EM residency


more on the web
This article was originally published on the blog Academic Life in Emergency Medicine
AcademicLifeinEM.com

from the comment stream

This looks like a great idea. It seems with a lot of these alternative techniques we are blurring the lines between traditional peripheral and traditional central access. This line would not reach a large central vein but what about risk of infection or thrombosis? Do you place this line with sterile technique (like a PICC) or under “clean” conditions like a peripheral? Obviously this is a solution to a problem in a pinch (and a great idea.) Just some issues I wonder about.
-Stewart Sanford, MD


We put this line in under semi-sterile conditions (sterile gloves, US probe cover, chlorhexidined area). It very much blurs the line between a peripheral IV and a PICC – more technically between a peripheral IV and a midline IV. Both are associated with a very low rate of infection and thrombosis. Specifically in our patient, the length of catheter inside the vein was no more than about 1.5 in. Truthfully, I would treat this the same as a peripheral IV. So I wouldn’t leave it in more than 3-4 days. Here’s a nice nursing document that examines the differences between all these lines with some references to papers on infection rates, etc:
http://picclinenursing.com/MidlineCatheters2ndedition.pdf

-Noah Sugerman, MD


Great trick. I’ve been trying this out and I do like it, although to be honest, I sometimes find the femoral artery arterial line catheter to be even easier to place and you can put IV contrast through them. So far, it seems to depend on the patient, as the Seldinger technique is better for some of them. I feel like I have 2-3 of these a day, so these types of alternative access are becoming more and more important as our patients are growing in size!
-Dan Colby, MD


The femoral arterial line was actually my first thought, but ours are not labeled as “pressure injectable” and I needed the longest line possible for the adenosine. For any other indication I would have used the femoral arterial line, and this is a viable alternative. I used to like the built-in, wire-in-needle setups for radial arterial lines when I was in residency, but they are only about as long as a “long IV catheter” mentioned in our post. They are great for standard deep brachial lines.
-Eric Silman, MD


Great idea! What about injecting contrast though?
-Jeff Wiswell, MD


Good thought, Jeff. I looked into this. The short answer appears to be no; but in actuality maybe. It appears there are 2 issues at play:
1. Being able to see contrast extravasation. This is why traditional peripherals (i.e. 20g in the AC) are OK for power-injection of contrast. The CT tech should theoretically check for contrast extravasation after a few minutes and stop the scan if the line infiltrates. The worry with a line in a deep vein is that it may go unnoticed. I would argue that infiltration of even a superficial peripheral in the morbidly obese may go unnoticed.
2. The catheter’s ability to withstand high pressures without breaking. Arrow actually makes a separate (and I’m sure more expensive) line of catheters that is certified for pressure-injection. This one technically isn’t and is only tested to withstand pressures up to 50 psi. However, there appear to be at least some studies that show small-bore CVCs can withstand the pressures during power-injection of contrast. http://www.ncbi.nlm.nih.gov/pubmed/9169679

-Noah Sugerman, MD

 

 

Comments   

# Femoral Arterial Line Works well tooAdan Atriham 2013-10-23 18:43
The first time I needed a pediatric central line catheter the nurses looked at me as if I had 3 heads, then I asked for an arterial femoral line and they became normal again.
Reply
# NicePaul M 2013-10-30 11:39
Great idea - will be using this in the future. With regards to the ability to pressure inject for CT - it seems likely that the patient is going to be past the weight limit on your CT table..so VQ/LE dopplers will be more the play.

One question regarding using Seldinger technique - when you use the dilator after wire is placed - do you go all the way similar to placing a central line? (in other words, how far do you push the dilater in?) I would be fearful of disrupting the deep arm vein due to its size. Not sure if my fear is real or perceived.

Thanks
Reply

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