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Vascular Access — CVC Types, US-Guided IJ, IO, CLABSI Bundle
TEXTEquipment · 7 min read
Pick the right line for the duration, place it with ultrasound, follow the bundle, and pull it when it's no longer needed. CLABSI is preventable; pneumothorax is preventable; femoral catheters are mostly avoidable.
After this lesson you can
3 min read6 sectionsCatheter types by indication + duration
- short-term (<1 week)
- can't run vasopressors continuously
- no central drugs (vesicants, hypertonic, parenteral nutrition >900 mOsm)
- 1-4 week dwell
- tip in axillary vein — bridges between peripheral and central
- can't run vesicants
- short-term (days to weeks)
- ICU/OR
- multiple infusions + vesicants + monitoring
Tunneled CVC (Hickman, Broviac): months, lower infection rate from subcutaneous tunnel.
Implanted port (Port-a-Cath): months to years, intermittent access (chemotherapy), lowest infection rate.
Site selection — IJ vs subclavian vs femoral
- straight-shot to SVC
- easiest US visualization
- low pneumothorax risk — first-line for emergent + most elective CVCs
- more curve
- higher mis-position
- slightly more PTX risk
Subclavian: LOWEST infection rate (best for long-term ICU lines), but highest pneumothorax + arterial puncture (non-compressible artery — bleeding can be catastrophic) — favored in trauma/hemodynamic-instability when pneumothorax is acceptable; avoid in coagulopathy.
Femoral: HIGHEST infection rate + DVT risk + immobilization — use only when IJ/SC not feasible (e.g., trauma, code situations); pull as soon as alternative available.
Ultrasound-guided IJ technique
Scan transverse first to identify carotid (pulsatile, non-compressible) medial + IJ (compressible, larger, more lateral).
Confirm patency by light probe pressure compressing the vein.
- supine
- slight Trendelenburg distends the vein
- head turned slightly contralateral
Vein depth typically 1-2 cm.
Real-time needle-tip visualization throughout — do NOT advance without seeing the tip.
Aspirate dark venous blood, advance wire (no resistance — Seldinger), confirm wire in vein on US (not in carotid!), dilate, advance catheter.
Confirm CVC tip position with chest X-ray (tip at SVC/RA junction, above the pericardial reflection); some centers use TEE or saline-bubble contrast intraop.
Intraosseous access
- proximal humerus (highest flow rates, ~5 L/hr, preferred for adults)
- proximal tibia (anteromedial flat surface, 2 cm distal + 1 cm medial to tibial tuberosity)
- distal tibia (above medial malleolus)
- sternum (specific device required — manubrium, avoids vital structures)
EZ-IO drill is standard.
ALL IV drugs work at IO at full IV doses, including epinephrine, amiodarone, fluids, blood, contrast.
Lidocaine 40 mg IO before flushing in awake patients — IO infusion is painful.
Limit dwell to 24 hr to minimize osteomyelitis risk; convert to definitive access as soon as feasible.
CLABSI prevention bundle
Chlorhexidine-impregnated dressing for adult ICU lines.
Dressings changed q7d (transparent) or q2d (gauze) or sooner if soiled.
Scrub the hub for 15 sec with alcohol before every access.
Document the bundle elements — required for accreditation + many payer requirements.
Complications recognition + management
- thrombosis (DVT, especially femoral + PICC)
- CLABSI
- catheter mis-position (mediastinal placement, vertebral vein, etc.)
- erosion through SVC
Catheter-tip culture if line removed for suspected CLABSI: matched peripheral + line cultures with differential time-to-positivity >2 hr is diagnostic.
End of lecture
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