Chapter 33

Vascular access enables the administration of analgesia and antibiotics, vasoactive medications during cardiac arrest, crystalloid solutions in severe dehydration and hypovolemia, blood transfusion for hemorrhagic shock from trauma or GI bleeding, and therapy-guiding central venous pressure measurements in sepsis and heart failure.1 Multiple factors determine the route and site for venous access.

Infusion rate is of critical importance in the resuscitation of severe hypovolemia or hemorrhage.1,2 Infusion rates through a medical catheter behave according to Poiseuille’s law:

The rate of flow is directly proportional to the catheter radius and the pressure gradient, and inversely proportional to the dynamic fluid viscosity and catheter length. Flow rates are increased by increasing the catheter radius, increasing the pressure gradient (use of gravity, manual push-pull devices, pressure bag application, or commercial rapid infusing devices), decreasing viscosity (coadministration of crystalloid with viscous blood products), and/or decreasing catheter length (peripheral angiocatheter vs. triple lumen catheter). Flow rates are maximized by using the largest internal diameter catheter possible.

Peripheral Venous Anatomy of the Upper Extremity

The most commonly accessed veins for peripheral catheterization of the upper extremity are the dorsal hand veins and the veins of the antecubital fossa. The venous anatomy of the upper extremity can be seen in Figure 33-1.

Figure 33-1.

Venous anatomy of the upper extremity.

Peripheral Venous Anatomy of the Lower Extremity

Peripheral catheterization of the superficial veins of the lower extremity is more difficult and often requires venous cutdown of the great and small saphenous veins.

The great saphenous vein receives contributions from the medial aspect of the foot and originates at its medial dorsal aspect. The saphenous vein traverses the lower leg anterior and superior to the medial malleolus. It courses posterior to the medial condyle of the femur and along the medial thigh where it terminates into the femoral vein approximately 3 cm below the inguinal ligament.

The small saphenous vein originates posterior to the lateral malleolus as a continuation of the lateral dorsal foot veins. It traverses to the middle of the posterior lower leg, ascends directly cephalad, terminating in the popliteal vein.

The femoral vein is the primary deep vein of the lower extremity. It is located medial to the femoral artery. The vessels course together through the proximal thigh.

The cephalic vein originates at the radial aspect of the dorsal hand vein network, coursing the lateral aspect of the forearm, then medially over the anterior forearm approaching the antecubital fossa. The cephalic vein communicates with the basilic vein via the median cubital vein located in the antecubital fossa. It ascends the upper arm in the groove along the lateral border of the biceps muscle, passing between the deltoid and ...

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