Introduction

Vascular access is one of the most basic required skills of the critical care physician. Many factors – including body habitus, volume depletion, shock, history of intravenous drug abuse, prior cannulation, scarring, thromboses, congenital deformity, and cardiac arrest – can make it difficult to obtain vascular access in patients who are critically ill or injured. Traditionally, surface anatomy and anatomic landmarks have served as the only guides for locating central veins. The incorporation of ultrasound into the procedure allows for more precise assessment of vein and artery location, vessel patency, and real-time visualization of needle placement.

The paradigm for radiology is to perform invasive procedures such as vascular access under real-time direct visualization so as to reduce complications. Although patients may have complicating medical problems, those scheduled for procedures in radiology are usually hemodynamically stable. Why then would critical care physicians perform invasive procedures on more unstable patients without the same tools and techniques to increase safety?

Real-time bedside ultrasonography facilitates rapid and successful vascular access (1–6). Indeed, there is increasing institutional and literature support for performing cannulation under direct visualization as the technology spreads throughout the hospital. This is not limited to the ED but is applicable to any critical care unit or patient care area in the hospital.

Focused questions for vascular access

The questions for vascular access are as follows:

1. Where is the target vein?

2. Is it patent?

This chapter covers techniques to make this assessment seem second nature.