n engl j med 354;15 www.nejm.org april 13, 2006 e13
The new engl and jour nal of medicine
Placement of an Arterial Line
Ken Tegtmeyer, M.D., Glenn Brady, M.D., Susanna Lai, M.P.H.,
Richard Hodo, and Dana Braner, M.D.
From the Departments of Medical Informatics
and Clinical Epidemiology and
Pediatrics, Oregon Health and Sciences
University, Portland, Oreg. Address reprint
requests to Dr. Braner at 3181 S.W.
Sam Jackson Park Rd., Portland, OR
97239-3098, or at branerd@ohsu.edu.
N Engl J Med 2006;354:e13.
Copyright  2006 Massachusetts Medical Society.
Indications
Radial arterial lines are important tools in the treatment of critically ill patients.
Continuous monitoring of blood pressure is indicated for patients with hemodynamic
instability that requires inotropic or vasopressor medication. An arterial line
allows for consistent and continuous monitoring of blood pressure to facilitate the
reliable titration of supportive medications. In addition, arterial lines allow for reliable
access to the arterial circulation for the measurement of arterial oxygenation
and for frequent blood sampling. The placement of arterial lines is an important
skill for physicians to master as they treat critically ill patients.
An arterial line is also indicated for patients with significant ventilatory deficits.
Measurement of the partial pressures of arterial oxygen and arterial carbon dioxide
provides more information about the status of gas exchange than does arterial
oxygen saturation.
Contraindications
The contraindications to the placement of an arterial line are few but specific.
Placement of an arterial line should not compromise the circulation distal to the
placement site, which means that sites with known deficiencies in collateral circulation
-- such as those involved in Raynauďs phenomenon and thromboangiitis
obliterans or end arteries such as the brachial artery -- should be avoided.
The value of the Allen test, which is used to verify collateral circulation to the
hand through alternate occlusion of the radial and ulnar arteries while the hand
is checked for perfusion, is somewhat controversial. Some studies have been able
to demonstrate adequate perfusion with the use of other techniques that contradict
the results of the Allen test.1,2 Other contraindications include infection of the site
where the catheter is to be placed and traumatic injury proximal to the proposed
insertion site.
Preparation
There are several techniques for the placement of a radial arterial line; two of the
more common are known as "over the wire" and "over the needle." A modified
Seldinger technique can also be used but is not described in this video.
Preparation for both techniques is identical. The equipment needed includes a
sterile preparation solution and a sterile field, a board and tape to secure and
position the wrist, 1 percent lidocaine solution (without epinephrine) and a smallgauge
needle and syringe for delivery, an angiographic catheter and needle, a wire
if the over-the-wire technique is to be used, material such as suture or tape to
secure the line once it has been placed, and a transduction system for monitoring.
After the risks of the procedure have been appropriately assessed and consent
has been obtained from the patient, the hand should be positioned on the wrist
board. The hand should be placed in moderate dorsiflexion, which brings the artery
videos in clinical medicine
Location of the radial artery.
Performance of the Allen test.
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closer to the skin and aids successful placement of the line. A flexible board or
roll placed under the wrist can ease positioning. The site should be cleaned with
a sterile preparation solution and draped appropriately. Sterile gloves should be
used for catheter placement.
Placement of the Line
The radial artery is palpated 1 to 2 cm from the wrist, between the bony head of the
distal radius and the flexor carpi radialis tendon. In a conscious patient, lidocaine may
be infused at the insertion site to help minimize pain on insertion of the line.
For the over-the-wire technique, the artery should be palpated gently with the
nondominant hand proximal to the insertion site. The needle should enter at a
30-to-45-degree angle to the skin directly over the point at which the pulse is
palpated. The catheter should be advanced slowly through the artery; once a flash
of blood is seen in the hub of the catheter, the needle should be advanced a few
millimeters farther through the vessel. The wire should be prepared and the
needle slowly withdrawn until pulsatile blood flow is observed. At this point, the
wire is advanced into the vessel. The wire should thread easily and without resistance.
Once the wire is in the vessel, the needle can be removed; the catheter is then
advanced over the wire. Pressure should be placed over the artery proximal to the
catheter, the wire removed, and the catheter connected to a transduction system.
For the over-the-needle technique, the initial approach is the same. The pulse
should be palpated proximal to the insertion site; the needle should penetrate the
skin at a 30-to-45-degree angle directly over the palpated pulse and then be advanced
slowly toward the pulse. Once pulsatile blood return is seen in the catheter,
the catheter should be advanced slightly farther to ensure that the catheter itself
is within the vessel. The catheter angle should then be lowered to 10 to 15 degrees
and the catheter advanced over the needle into the vessel.
Regardless of technique, the catheter should be secured in place. Suturing is
the preferred method, but many practitioners choose to tape the catheter securely
in place. It is important to ensure that the catheter is not subject to tension from the
tubing or at risk of being removed by the patient.
Perfusion to the hand should be reassessed after placement of the arterial line
and at frequent intervals while the line is in use. Any sign of vascular compromise
at any time should prompt the removal of the line. The line should be removed as
early as possible after it is no longer needed.
Complications
Arterial spasm and an inability on the part of the clinician to pass the wire or
catheter through the artery are the most common difficulties in catheterization. If
spasm is suspected, attempts at catheterizing that artery should be abandoned and
an alternative site selected. If the wire or catheter cannot be passed despite the return
of pulsatile blood, this is either because the angle of the needle in relation to
the vessel is too acute or because the needle tip is not completely within the artery.
With adjustment of the angle, a slight advance, or withdrawal of the needle, placement
may yet be successful.
References
Abu-Omar Y, Mussa S, Anastasiadis K,
Steel S, Hands L, Taggart DP. Duplex ultrasonography
predicts safety of radial
artery harvest in the presence of an abnormal
Allen test. Ann Thorac Surg 2004;
77:116-9.
Fuhrman TM, Pippin WD, Talmage
LA, Reilley TE. Evaluation of collateral
circulation of the hand. J Clin Monit 1992;
8:28-32.
Copyright  2006 Massachusetts Medical Society.
1.
2.
placement of an arterial line
n engl j med 354;15 www.nejm.org april 13, 2006
Over-the-needle technique.
Entry of over-the-wire technique.
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n engl j med 357;24 www.nejm.org december 13, 2007e26
videos in clinical medicine
Central Venous Catheterization --
Subclavian Vein
Dana A.V. Braner, M.D., Susanna Lai, M.P.H., Scott Eman, B.S.,
and Ken Tegtmeyer, M.D.
From the Department of Pediatrics, Oregon
Health & Science University, Portland.
Address reprint requests to Dr. Tegtmeyer
at the Department of Pediatrics, Oregon
Health & Science University, 707 SW
Gaines St., MC: CDRC-P, Portland, OR
97239, or at tegtmeye@ohsu.edu.
N Engl J Med 2007;357:e26.
Copyright  2007 Massachusetts Medical Society.
I n d I c a t I o n s
Central venous catheterization provides for the administration of caustic and critical
medications as well as allowing sampling of blood and measurement of central
venous pressure. Recent evidence and Institute for Healthcare Improvement bundled
guidelines1 suggest that the subclavian vein is the preferred choice for placement
of a central venous catheter.
c o n t r a I n d I c a t I o n s
General contraindications for placement of a central venous catheter include infection
of the area overlying the target vein and thrombosis of the target vein. Specific
contraindications to the subclavian approach include fracture of the ipsilateral
clavicle or anterior proximal ribs, which can distort the anatomy and make placement
difficult. Greater caution should be used when placing a central venous catheter
in coagulopathic patients. The location of the artery (beneath the clavicle) makes
application of direct pressure nearly impossible in attempts to control bleeding.
E q u I p m E n t
Most of the necessary equipment can be found in commercially available kits. These
kits typically include skin-preparation solution and a drape, lidocaine, sterile gauze,
non-Luer lock syringes, a scalpel, a catheter, a dilator, several needles, and a guidewire.
You will also need a sterile gown, sterile gloves, a surgical cap, a mask with a
face shield, and drapes to cover the patienťs entire body. Flush solution is also not
commonly found in the kits. Determine the catheter length and depth of placement
by referring to the patienťs external landmarks. The tip of the catheter should
reach the junction of the superior vena cava and the right atrium. Common catheters
used range from 4-French catheters for infants to 7-French catheters for adults;
11.5-French catheters may be used for dialysis. Because the risk of infection increases
with an increasing number of lumens, a catheter with the fewest number of
lumens required should be used.
p r E p a r a t I o n
Explain the procedure to the patient and obtain written informed consent. Wear a
sterile gown and gloves, a mask with face shield, and a surgical cap. Examine the
patient to be sure that there are no contraindications. Place the patient in the 15degree
Trendelenburg position, which will engorge the vein. If you place a rolled
towel or similar object under the spine to help identify the patienťs external landmarks,
be aware that propping the shoulder or turning the head has been shown to
decrease the size of the vein on ultrasonography.2 Scrub the area thoroughly with
chlorhexidine. Drape the area, covering the patienťs entire body.
The new engl and jour nal of medicine
Copyright  2007 Massachusetts Medical Society. All rights reserved.
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Next, identify anatomic landmarks, beginning with the middle third of the
clavicle. Follow this laterally to the point where the clavicle deviates from the
proximal ribs (Fig. 1). Just medial to this point, the subclavian vein and artery run
just inferior to the clavicle. This is where most successful catheterization occurs.
The insertion site should be somewhat remote from the clavicle, so that the path
of the needle ultimately stays parallel to and just under the clavicle. Typically, the
point of insertion is 2 cm lateral to and 2 cm caudal to the middle third of the
clavicle (Fig. 2). Local anesthesia with 1 to 2 ml of 1 percent lidocaine or equivalent
should be used in this area.
u l t r a s o u n d G u I d a n c E
Several recent articles suggest that ultrasonography can increase the likelihood of
successful placement of a subclavian catheter, despite the presence of bony landmarks.3,4
Because of the greater difficulty in identifying the vein by compression,
Doppler flow should be used to distinguish between the artery and the vein.
t h E p r o c E d u r E
Starting 2 cm lateral to the bend of the clavicle and approximately 2 cm caudal,
insert the catheterization needle through the skin at a 30-degree angle toward the
sternal notch. Place a finger of your nondominant hand in the sternal notch to help
find the landmark. Once the needle is under the skin, lower the needle and syringe
to run parallel to but beneath (posterior to) the clavicle (Fig. 3). Access to the vein
typically occurs just beneath the clavicle, but it may involve a depth of several centimeters
under the skin.
Once you have obtained venous access, carefully stabilize the needle and remove
the syringe. Introduce the J-tipped end of the guidewire into the needle. The
wire should thread easily and without resistance until well beyond the end of the
needle. If you notice ectopic cardiac beats on the monitor, pull the wire back until
the ectopic beats disappear. Then remove the needle, leaving the wire in place.
Maintain control of the wire. A small, 1-to-2-mm incision should be made in the
skin at the insertion point to facilitate dilator passage. Advance the dilator over
the wire into and through the skin and then into the vessel. Once the vessel is
dilated, the dilator can be removed. Use a gauze pad to control increased bleeding,
which usually occurs after dilation. Advance the line over the guidewire, maintaining
control of the wire before passing the catheter into the skin. Remove the
guidewire, check for blood return from all ports, flush all ports, and secure the
catheter in place. Apply a sterile dressing before removing the drapes (Fig. 4).
c o m p l I c a t I o n s
Specific complications associated temporally with placement of a subclavian line
include hemothorax and pneumothorax, air embolism, inadvertent arterial puncture,
and aortic perforation. Obtain a chest radiograph after placement to assess for
complications and for correct placement of the catheter. Common malplacement
locations include placement transverse to the contralateral subclavian vein, retrograde
into the ipsilateral internal jugular vein, or potentially the contralateral internal
jugular vein.
Longer-term complications include thrombosis of the vein and infection. Data
suggest that subclavian placement mitigates but does not eliminate the risk of
infection. Adherence to the Institute for Healthcare Improvement guidelines, including
the use of proper hand hygiene, the use of maximal barrier precautions
during placement, the use of chlorhexidine skin antisepsis, and daily review of
need for the catheter, will help to decrease the risk of infection.1
No potential conflict of interest relevant to this article was reported.
References
Implement the central line bundle.
Cambridge, MA: Institute for Healthcare
Improvement. (Accessed November 16,
2007, at http://www.ihi.org/ihi/topics/
criticalcare/intensivecare/changes/
implementthecentrallinebundle.htm.)
Fortune JB, Feustel P. Effect of patient
position on size and location of the subclavian
vein for percutaneous puncture.
Arch Surg 2003;138:996-1000.
Orihashi K, Imai K, Sato K, Hamamoto
M, Okada K, Sueda T. Extrathoracic
subclavian venipuncture under ultrasound
guidance. Circ J 2005;69:1111-5.
Pirotte T, Veyckemans F. Ultrasoundguided
subclavian vein cannulation in infants
and children: a novel approach. Br J
Anaesth 2007;98:509-14.
Copyright  2007 Massachusetts Medical Society.
1.
2.
3.
4.
Figure 1. Anatomic Landmarks.
Figure 2. Point of Insertion.
Figure 3. Placement of the Needle.
Figure 4. Application of the Dressing.
CENTRAL VENOUS CATHETERIZATION -- SUBCLAVIAN VEIN
n engl j med 357;24 www.nejm.org december 13, 2007
Copyright  2007 Massachusetts Medical Society. All rights reserved.
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n engl j med 356;21 www.nejm.org may 24, 2007 e21
Central Venous Catheterization
Alan S. Graham, M.D., Caroline Ozment, M.D., Ken Tegtmeyer, M.D.,
Susanna Lai, M.P.H., and Dana A.V. Braner, M.D.
From the Department of Pediatrics, Divi-
sionofPediatricCriticalCare,Doernbecher
Children's Hospital, Portland, OR (A.S.G.,
K.T., S.L., D.A.V.B.); and the Department
of Pediatrics, Division of Pediatric Critical
Care, Duke University, Durham, NC (C.O.).
Address reprint requests to Dr. Tegtmeyer
at the Department of Pediatrics, Division
of Pediatric Critical Care, Doernbecher
Children's Hospital, Oregon Health &
Science University, Mail Code: CDRC-P,
707 SW Gaines St., Portland, OR 97239-
2901, or at tegtmeye@ohsu.edu.
N Engl J Med 2007;356:e21.
Copyright  2007 Massachusetts Medical Society.
Indications
Central venous catheterization provides a route for delivery of caustic or critical
medications and allows measurement of central venous pressure.
Contraindications
General contraindications for the placement of a central venous catheter include
infection of the area overlying the target vein and thrombosis of the target vein;
site-specific and relative contraindications include coagulopathy, although this is not
an absolute contraindication. Extreme care must be exercised in patients with coagulopathy
and in other patients for whom complications would be life-threatening.
Equipment
Many institutions stock prepackaged catheter-insertion kits containing the necessary
equipment. The catheter should have the appropriate lumen size to deliver the
required medications, and its length should be appropriate to reach the junction
of the vena cava and the right atrium. Approximate length can be measured against
the patienťs external anatomical landmarks. Seven-French 20-cm catheters are the
most commonly used. Dialysis or rapid fluid resuscitation requires larger-bore
catheters. Each additional lumen decreases the size of the individual lumens, which
will decrease the maximal rate at which fluids can be administered. The catheter
should be flushed, and compatibility between the guide wire and the needle should
be confirmed.
Preparation
Explain the procedure to the patient, and obtain written informed consent. Select the
insertion site on the basis of the comparisons noted in Table 1. Subclavian and intervideos
in clinical medicine
The new engl and jour nal of medicine
Table 1. Risk of Complications Associated with Internal Jugular, Subclavian, and Femoral Central Venous Catheterization.
Complication Risk of Complication at Catheterization Site*
Internal Jugular Vein Subclavian Vein Femoral Vein
Pneumothorax (%) <0.1 to 0.2 1.5 to 3.1 NA
Hemothorax (%) NA 0.4 to 0.6 NA
Infection (rate per 1000 catheter-days) 8.6 4 15.3
Thrombosis (rate per 1000 catheter-days) 1.2 to 3 0 to 13 8 to 34
Arterial puncture (%) 3 0.5 6.25
Malposition Low risk (into inferior vena cava,
passing through right atrium)
High risk (crossing to contralateral subclavian
vein, ascending internal jugular vein)
Low risk (lumbar
venous plexus)
* NA denotes not applicable.
Copyright  2007 Massachusetts Medical Society. All rights reserved.
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nal jugular sites are generally preferred because they present a lower risk of infection
and fewer mechanical complications.1 If the patient has challenging anatomy,
a scar at the insertion site, or any other indication that could result in a difficult
insertion, an expert operator should be in attendance.
Anatomical landmarks for the central approach to internal jugular venous catheterization
begin at the apex of the triangle formed by the heads of the sternocleidomastoid
muscle and the clavicle. A confluence between the internal jugular
vein and the brachiocephalic vein facilitates cannulation at this location. After
identifying the landmarks, sterilize the area with chlorhexidine, using a circular
motion from the center outward, and then apply a sterile drape.
Administer local anesthesia, using 1 to 2 ml of 1% lidocaine or equivalent, with
a 25-gauge needle at the cannulation site. To avoid air embolism, place the patient
with head down, in the Trendelenburg position. The head should be rotated 45
degrees away from the site of cannulation; avoid excessive rotation of the head,
which can cause collapse of the vein. During the procedure, place the index finger
of your nondominant hand on the patienťs carotid artery to diminish the risk of
inadvertent puncture of the artery.
Ultrasound Guidance
In numerous studies, ultrasound guidance has been shown to increase the success
of first-time catheter placement and to decrease the risk of complications.2 When
using ultrasound guidance, enlist an assistant either to handle the probe or to remove
it when it is no longer needed.
The vein and artery appear circular and black on the ultrasound image; the vein
is much more compressible when gentle pressure is applied to the skin via the probe.
The needle appears echogenic and can be followed into the image of the vein on
ultrasound. Newer commercial kits include needles that are more echogenic.
The Procedure
Starting just lateral to the carotid pulse, insert an 18-gauge needle slightly superior
to the apex of the triangle. The needle is maintained at an angle of 20 degrees above
the coronal plane as it is advanced past the apex of the triangle, with the longitudinal
axis in the direction of the ipsilateral nipple. The vein is generally encountered
approximately 0.5 in. (1.3 cm) under the skin,1 though this can vary, depending on
regional adiposity.
After venous access is obtained, hold the needle carefully as you disconnect the
syringe. The J-shaped end of the guide wire is introduced into the needle and
advanced. The wire should thread easily, without resistance, well beyond the end of
the needle. If cardiac rhythm changes are noted, pull the wire back until the rhythm
normalizes. Then remove the needle, leaving the wire in place. Carefully maintain
control of the wire, and make a 1-to-2-mm incision at the site of skin puncture.
Advance the dilator over the guide wire. Once the tract is dilated, remove the dilator
and thread the catheter over the wire and into the vessel. Then remove the guide
wire, confirm blood return, and apply a sterile dressing.
Complications
Risks associated with central venous catheterization include infectious, mechanical,
and thrombotic complications. A chest radiograph should be obtained to confirm
placement and to assess for complications.
Catheter infections occur by means of one of three mechanisms: local insertionsite
infection, which travels down the catheter externally; or hub colonization followed
by infection via the intralumenal route or via hematogenous seeding of the
The new engl and jour nal of medicine
n engl j med 356;21 www.nejm.org may 24, 2007
Sternal notch
Clavicle
Sternal head
Clavicular
head
Sternocleidomastoid
muscle
Sternal notch
Clavicle
Sternal head
Clavicular
head
Sternocleidomastoid
muscle
Subclavian vein
Brachiocephalic
vein
Internal
jugular vein
Superior
vena cava
Right
atrium
Subclavian vein
Brachiocephalic
vein
Internal
jugular vein
Superior
vena cava
Right
atrium
Anatomical landmarks
Site of cannulation
Copyright  2007 Massachusetts Medical Society. All rights reserved.
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central venous catheterization
n engl j med 356;21 www.nejm.org may 24, 2007
References
McGee DC, Gould MK. Preventing complications
of central venous catheterization.
N Engl J Med 2003;348:1123-33.
Hind D, Calvert N, McWilliams R, et al.
Ultrasonic locating devices for central
venous cannulation: meta-analysis. BMJ
2003;327:361.
Implement the Central Line Bundle.
Cambridge, MA: Institute for Healthcare
Improvement. (Accessed April 30, 2007,
at http://www.ihi.org/IHI/Topics/
CriticalCare/IntensiveCare/Changes/
ImplementtheCentralLineBundle.htm.)
Pronovost P, Needham D, Berenholtz
S, et al. An intervention to decrease catheter-related
bloodstream infections in the
ICU. N Engl J Med 2006;355:2725-32.
Merrer J, De Jonghe B, Golliot F, et al.
Complications of femoral and subclavian
venous catheterization in critically ill patients:
a randomized controlled trial. JAMA
2001;286:700-7.
Copyright  2007 Massachusetts Medical Society.
1.
2.
3.
4.
5.
catheter.1 The Institute for Healthcare Improvement recommends five steps to reduce
central-line infections: hand hygiene, adherence to maximal barrier precautions,
chlorhexidine skin antisepsis, selection of an optimal catheter site, and daily review
of the necessity of the catheter, with prompt removal when the catheter is no
longer needed.3 Implementation of these steps has been conclusively shown to decrease
the rate of catheter-related bloodstream infection.4 Scheduled changing of
a catheter over a guide wire or moving a catheter to a new site can increase mechanical
and infectious complications, and neither is recommended.1 Antisepticcontaining
hubs and antimicrobial-impregnated catheters have been shown to decrease
the rate of catheter-related bloodstream infections.1 Topical antibiotic
ointments are ineffective, promote antibiotic-resistant bacteria, and increase fungal
colonization.
Mechanical Complications
Mechanical complications include arterial puncture, hematoma, pneumothorax, hemothorax,
arrhythmia, and improper location of the catheter, whether in an accessory
vein or in the other vessels of the upper vascular system. Insertion of a catheter
into the femoral vein, not shown in this video, has the highest risk of mechanical
complications, but the rates of serious mechanical complications for femoral and
subclavian insertion are similar.5 If an artery is punctured, further attempts at that
site should be abandoned, and access to an alternative site should be attempted.
Internal jugular and subclavian cannulation sites are preferred because of their
lower overall rate of mechanical complications. However, these sites carry a small
risk of hemothorax and pneumothorax.1 Ultrasound guidance for internal jugular
cannulation significantly reduces the number of attempts required and the risk of
complications.2
Thrombotic Complications
Central venous cannulation increases the risk of central venous thrombosis, with
the concomitant potential risk of venous thromboembolism. Thrombosis may occur
as early as the first day after cannulation. The site with the lowest risk for thrombotic
complications is the subclavian vein.1,4 Prompt removal of the catheter when
it is no longer needed decreases the risk of catheter-related thrombosis.
No potential conflict of interest relevant to this article was reported.
Copyright  2007 Massachusetts Medical Society. All rights reserved.
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The new england journal of medicine
n engl j med 358;26 www.nejm.org june 26, 2008
Placement of a Femoral Venous Catheter
Janet Y. Tsui, M.D., Adam B. Collins, M.D., Douglas W. White, B.A.,
Jasmine Lai, B.S., and Jeffrey A. Tabas, M.D.
From the School of Medicine (J.Y.T, A.B.C.,
D.W.W., J.L., J.A.T.), Department of Anesthesia
(A.B.C.), and Department of Medicine,
Division of Emergency Medicine
(J.A.T.), University of California, San Francisco,
San Francisco. Address reprint requests
to Dr. Tabas at San Francisco General
Hospital Emergency Services, 1001
Potrero Ave., Office 1E21, San Francisco,
CA 94110, or at jtabas@sfghed.ucsf.edu.
N Engl J Med 2008;358:e30.
Copyright  2008 Massachusetts Medical Society.
Indications
The insertion of a femoral venous catheter may be necessary when peripheral access
to the circulatory system is compromised and no other sites for placement of a central
catheter are available. Such a catheter may be used to administer large fluid volumes
or potentially irritating medicines, to provide temporary access for emergency dialysis,
for immediate central access during emergency resuscitation, to facilitate cardiac
catheterization, or, in rare instances, for drawing blood, if a patient requires frequent
blood sampling and no other access site is available.
Contr aindications
There are few absolute contraindications to placement of a central catheter, other
than the patienťs not agreeing to the procedure. There are several relative contraindications.
As compared with subclavian or jugular catheters, femoral catheters are
associated with a higher risk of infection, thrombosis, and, in the absence of ultrasound
guidance, arterial puncture.1 If a safer option exists, it should be chosen. It
is important to note that uncooperative patients place both the operator and themselves
at risk for injury. Evident infection at the site where the needle will enter should
prompt the operator to seek another access site. In addition, complications are more
likely to occur if the site is distorted by trauma or is obscured. In patients with uncorrected
bleeding disorders, a central catheter should be placed with caution and only
if necessary. Central catheters should not be placed by inexperienced operators who
lack supervision.
Equipment
Materials required for this procedure include personal protective equipment, a bag
of sterile saline for infusion, intravenous tubing, local anesthetic medications, a central­catheter
kit, and blood­drawing equipment. The central­catheter kit typically includes
a sterile drape, skin preparation solution, sterile gauze, an introducer needle,
a guidewire, a scalpel, a dilator, an intravenous catheter, a mechanism for securing
the catheter to the skin, and a sterile, transparent dressing.
Prepar ation
Explain the procedure to the patient, and obtain written informed consent when possible.
Confirm that you have the correct patient, have selected the correct anatomical
location, and are planning the correct procedure. An assistant should be empowered
to halt the procedure if inappropriate technique or practice occurs.
videos in clinical medicine
e30
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n engl j med 358;26 www.nejm.org june 26, 2008
For optimal exposure of the femoral region, externally rotate and abduct the patienťs
leg away from midline. The femoral vein lies medial to the femoral artery as
it runs distal to the inguinal ligament. Localize the vein by palpating the femoral
artery, or use ultrasonography. Prepare the skin with chlorhexidine, and cover the
area with a sterile drape. Use full sterile dress. Prepare the central­catheter kit, and
flush the catheter ports with sterile saline. If you are using ultrasound localization,
prepare the ultrasound probe for sterile use.
Anesthetize the area with long­acting anesthetic such as lidocaine with epinephrine
or bupivicaine. Adequate analgesia will increase the patienťs comfort and the
operator's likelihood of successful catheter placement.
Placement of the Catheter
After ensuring that the femoral area has been properly anesthetized, reconfirm the
position of the femoral vein by palpating the femoral artery or visualizing it directly
with ultrasonography. Insert the introducer needle at a 45­degree angle from
the skin, directed along the course of the artery, while you pull back the plunger
(Fig. 1). To prevent femoral­artery cannulation, maintain palpation of the artery while
you advance the needle.
Once you see a flash of blood, carefully anchor the needle to avoid dislodging it
from an intraluminal location (Fig. 2). Detach the syringe and thread the guidewire
through the needle. It should pass easily and without resistance into the lumen of the
vessel. While maintaining your grasp of the wire, remove the introducer needle. Incise
the skin at the wire­entry site with a scalpel, keeping the sharp edge away from the
wire. Advance the dilator over the wire to make a tract through the tissues into the
vessel (Fig. 3). Larger catheters may have dilators that fit inside them and must be
advanced together with the catheter. Unless that is the case, remove the dilator and
thread the catheter over the wire. Before advancing the catheter past the skin, firmly
grasp the guidewire protruding from the proximal end of the catheter. It is often
necessary to feed the wire back through the catheter to accomplish this. After the
catheter has been threaded into the vessel, remove the wire. Confirm the intravenous
location of the catheter, flush sterile saline through each port, and secure the catheter
with sutures or staples. Place a sterile dressing over the site before removing the
drapes. Place all sharp and soiled materials in an appropriate receptacle.
Ultrasound Guidance
Several studies have shown that using ultrasonography to assist in central­catheter
placement increases success and reduces complications.2,3 Choose a linear probe rather
than a curved probe for femoral catheter placement. Linear probes emit high­frequency
waves that are optimal for viewing superficial structures, such as the femoral
vessels. Position yourself toward the patienťs feet, and place the ultrasound monitor
in front of you. Orient the probe so that the patienťs right is on the right side of the
screen. Place the probe in a sterile sheath with coupling gel inside. Sterile gel can be
applied to the outside of the protective covering. Placing the patient in a reverse Trendelenberg
position engorges the femoral vein and may aid in visualization. Ultrasound
imaging renders vessel walls brighter than their lumens, which are filled with
blood. The femoral vein is collapsible as compared with the artery. Use of the Doppler
function of the ultrasound machine may help distinguish pulsatile (arterial) from
more continuous (venous) blood flow. Position the vein in the center of the screen,
and insert the needle at the center of the probe (Fig. 4). After the ultrasound images
indicate that the needle is in an appropriate position for entering the vein, you will
also note the intravenous location by observing a flash of blood into the syringe.
Figure 1. Inserting the Introducer
Needle.
Figure 2. Anchoring the Needle.
Figure 3. Advancing the Dilator
to Make a Tract.
Figure 4. Inserting the Needle
at the Center of the Probe.
videos in clinical medicine
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n engl j med 358;26 www.nejm.org june 26, 2008
Complications
Potential complications include infection, thromboembolism, arterial puncture, and
hematoma. It is important to be aware of these possible problems and to keep them
in mind as you monitor the patient. Less common complications include arteriovenous
fistula and pseudoaneurysm. Most of these complications can be prevented by
following proper sterile technique, using ultrasonography for placing the catheter,
limiting the number of attempts at placing the catheter, and removing it as soon as
possible.
If the femoral artery has been punctured, apply pressure to the site for at least
10 minutes. Small hematomas may be managed conservatively, but continuing hemorrhage
may require surgical intervention.
Dr. Collins reports receiving lecture fees from General Electric Ultrasound. No other potential conflict of
interest relevant to this article was reported.
Videos in Clinical Medicine
References
McGee DC, Gould MK. Preventing
complications of central venous catheterization.
N Engl J Med 2003;348:1123­33.
Hind D, Calvert N, McWilliams R, et
al. Ultrasonic locating devices for central
venous cannulation: meta­analysis. BMJ
2003;327:361.
Rothschild JM. Ultrasound guidance
of central vein catheterization: evidence
report/technology assessment. In: Making
health care safer: a critical analysis of
patient safety practices. No. 43. Rockville,
MD: Agency for Healthcare Research and
Quality, 2001:245­53. (AHRQ publication
no. 01­E058.)
Copyright  2008 Massachusetts Medical Society.
1.
2.
3.
Copyright  2008 Massachusetts Medical Society. All rights reserved.
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n engl j med 357;15 www.nejm.org october 11, 2007 e15
videos in clinical medicine
The new engl and jour nal of medicine
Chest-Tube Insertion
Shelly P. Dev, M.D., Bartolomeu Nascimiento, Jr., M.D.,
Carmine Simone, M.D., and Vincent Chien, M.D.
FromtheDepartmentofCriticalCareMedicine,
Sunnybrook Health Sciences Centre,
University of Toronto, Toronto. Address
reprint requests to Dr. Dev at the Department
of Critical Care, Sunnybrook Health
Sciences Centre, 2075 Bayview Ave., Office
D­112, Toronto, ON M4N 3M5, Canada,
or shelly.dev@sunnybrook.ca.
N Engl J Med 2007;357:e15.
Copyright  2007 Massachusetts Medical Society.
Indications
Insertion of a chest tube is indicated in either emergency or nonemergency situations.
Specific indications are listed in Table 1.1-3
Contraindications
Published guidelines state that there are no absolute contraindications for drainage
by means of a chest tube1 except when a lung is completely adherent to the chest
wall throughout the hemithorax.2 Relative contraindications include a risk of bleeding
in patients taking anticoagulant medication or in patients with a predisposition
to bleeding or abnormal clotting profiles. Whenever possible, coagulopathies and
platelet defects should be corrected with the infusion of blood products, such as
fresh frozen plasma and platelets.
Equipment
Most hospitals have presterilized, packaged chest-tube­insertion trays. The key components
of the tray are a scalpel with size 11 blade; several dissecting instruments,
such as curved Kelly clamps or artery forceps; a 10-ml syringe and a 20-ml syringe;
one small-gauge needle (size 25) and one larger-gauge needle for deeper anesthetic
infiltration (size 18­21); a needle driver; scissors; one packet of strong, nonabsorbable,
curved sutures of size 1.0 or larger, made from silk or nylon4; and a chest tube
of appropriate size (see below). A commercially available pleural drainage system,
such as the Pleur-evac (Teleflex Medical), should also be ready for connection after
the chest tube is inserted.
Table 1. Indications for Chest-Tube Insertion.
Emergency
Pneumothorax
In all patients on mechanical ventilation
When pneumothorax is large
In a clinically unstable patient
For tension pneumothorax after needle decompression
When pneumothorax is recurrent or persistent
When pneumothorax is secondary to chest trauma
When pneumothorax is iatrogenic, if large and clinically significant
Hemopneumothorax
Esophageal rupture with gastric leak into pleural space
Nonemergency
Malignant pleural effusion
Treatment with sclerosing agents or pleurodesis
Recurrent pleural effusion
Parapneumonic effusion or empyema
Chylothorax
Postoperative care (e.g., after coronary bypass, thoracotomy, or lobectomy)
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Grasp the proximal free end of the chest tube with a clamp or forceps. Using another
clamp or forceps, grasp the distal tip of the tube to prepare it for insertion.4
Chest-Tube Size
The size of the chest tube that is needed depends on the indication for the insertion
of a chest tube. Table 2 provides a summary of size recommendations based on
indication.5-11
Preparation
If time permits, explain the procedure to the patient or next of kin and obtain written
consent; this may not be possible when the need for chest-tube insertion is urgent.
Position the patient in either a supine or a semirecumbent position. Maximally
abduct the ipsilateral arm or place it behind the patienťs head. The area for insertion
is approximated by the fourth to fifth intercostal space in the anterior axillary
line at the horizontal level of the nipple. This area corresponds to the anterior
border of the latissimus dorsi, the lateral border of the pectoralis major muscle,
the apex just below the axilla, and a line above the horizontal level of the nippleoften
referred to as the "triangle of safety."2 You can isolate this area by palpating
the ipsilateral clavicle, then working downward along the ribcage, counting down
the rib spaces. Once the fourth to fifth intercostal space is felt, move your hand
laterally toward the anterior axillary line (Fig. 1). This is the area for incision; the
actual insertion site should be one intercostal space above the chest-tube incision
site. Mark the spot for incision on the skin with a pen or the back of a needle.
Use full barrier precautions (wash your hands and wear a sterile gown and
gloves, protective eyewear, and a face mask). Create a large, sterile field on the patienťs
skin, using sterile gauze and 2% chlorhexidine solution. Drape the patient,
exposing only the marked area. Using a 1% or 2% lidocaine solution and a 25-gauge
needle, create a wheal of anesthetic in the cutaneous tissue at the marked spot. Draw
up more lidocaine solution in a 20-ml syringe. Using a 21-gauge needle, anesthetize
the deeper subcutaneous tissues and intercostal muscles. Locate the rib lying below
the intercostal space where the tube will be inserted, and continue to anesthetize
the periosteal surface. Ten to 20 ml of lidocaine solution may be used to
ensure optimal analgesia.1 While anesthetizing the rib, find the superior aspect
of the rib and use this to bevel or "march" the needle on top of it. Using continued
negative suction as the needle advances, with the needle beveled on top of the rib,
confirm entry into the pleural space when a flash of pleural fluid enters the chamThe
new england journal of medicine
n engl j med 357;15 www.nejm.org october 11, 2007
Figure 1. Locating Landmarks.
Table 2. Sizing of Chest Tubes on the Basis of Indication.
Indication for Chest Tube Recommended Size of Chest Tube
Pneumothorax
Large pneumothorax in patient in stable condition 16­French to 22­French
14­French or smaller (insert by Seldinger method)*
Large pneumothorax in patient in unstable condition
Patient receiving mechanical ventilation
Secondary pneumothorax
24­French to 28­French
Pleural collections
Malignant pleural effusion
Transudative effusion
Consider smaller­bore, 8­French to 16­French first*
If ineffective, try larger­bore (22­French or larger)
Parapneumonic effusion
Empyema
No firm recommendations
20­French or larger may be tried
* The Seldinger method of chest­tube insertion is performed with the use of 14­French or smaller chest drains usually under ultrasound guidance
either at the bedside or in a radiology suite. This method is not covered in this review.
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ber of the syringe. If a pneumothorax is being evacuated, the syringe may only fill
with air. Stop advancing the needle and inject any remaining lidocaine to fully
anesthetize the parietal pleura. Withdraw the needle and syringe completely.
Incision and Dissection
An incision 1.5 to 2.0 cm in length should be made parallel to the rib. Use the
Kelly clamp or artery forceps to cut through the subcutaneous layers and intercostal
muscles (Fig. 2). The path should traverse diagonally up toward the next superior
intercostal space. Once you have dissected through the subcutaneous tissues,
find the surface of the rib lying below this space with the dissecting instrument.
Then slide the instrument straight up, until you find the top edge of the rib. Use
this to bevel or balance the dissecting instrument as you dissect the intercostal muscles
(Fig. 3). Once you reach the parietal pleura, gently push the dissecting instrument
through it. You may also digitally penetrate the pleura to avoid puncturing
adjacent lung tissue,3,4 using your index finger to explore the tract. Once your finger
enters the pleura, withdraw the Kelly clamp. Use your finger to palpate within
the pleural layer and ensure that the lung falls away from the pleura.1 If it does
not, this may indicate the presence of an adhesion, so tube insertion may be difficult.
(Trocar insertion, considered dangerous, is no longer advised.4)
Tube Insertion
Once the distal tip of the tube has passed through the incision, unclamp the Kelly
clamps or forceps and advance the tube manually. Aim the tube apically for evacuation
of a pneumothorax and basally for evacuation of any fluid.1-3
Securing the Tube
Mattress or interrupted sutures should be used on both sides of the incision to close
the ends. Use the loose ends of the sutures to wrap around the tube and tie them
off, anchoring the tube to the chest wall.1 Tape the tube to the side of the patient
and wrap a petroleum-based gauze dressing around the tube. Cover this gauze with
several pieces of regular sterile gauze, and secure the site with multiple pressure
dressings.
Purse-string sutures are not recommended owing to poor cosmetic results and
increased risk of skin necrosis; the seal they provide does not prevent air leaks.3
Connect the distal end of the chest tube to a sterile pleural drainage system,
such as the commercially available Pleur-evac. Once the tube is connected, unclamp
the distal end; if there is a pneumothorax, bubbling may be seen. If there
is a large pleural effusion, it will begin collecting. Do not reclamp the chest tube,
once released, unless the pleural drainage system is being changed. Reclamping the
tube may lead to the redevelopment of a pneumothorax and may create a tension
pneumothorax.
Chest Radiograph Confirmation
Once you have secured the chest tube, obtain an anterior-posterior chest radiograph
to confirm placement, which can be done by identifying the radio-opaque
line along the tube. If the proximal drainage hole is outside the pleural space,
drainage may be ineffective and an air leak may result. In this circumstance, the
tube should be removed and a new chest tube inserted.
Complications
The most important complications associated with chest-tube insertion1-3,9 include
bleeding and hemothorax due to intercostal artery perforation, perforation of visceral
organs (lung, heart, diaphragm, or intraabdominal organs), perforation of machest-tube
insertion
n engl j med 357;15 www.nejm.org october 11, 2007
Figure 2. Dissection.
Figure 3. Positioning the Dissection
Instrument.
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jor vascular structures such as the aorta or subclavian vessels, intercostal neuralgia
due to trauma of neurovascular bundles, subcutaneous emphysema, reexpansion pulmonary
edema, infection of the drainage site, pneumonia, and empyema. There may
be technical problems such as intermittent tube blockage from clotted blood, pus,
or debris, or incorrect positioning of the tube, which causes ineffective drainage.
Timing of Chest-Tube Removal
The timing of chest-tube removal depends on the indication for insertion of the
chest tube.
For a pneumothorax, bubbling must have ceased and the lung must be fully
expanded on chest radiograph before the tube can be removed. If suction is being
used to evacuate a pneumothorax, most physicians will use a trial of underwater
seal to ensure that the lung stays expanded without suction. Practice differs greatly
among physicians with regard to duration of observation after air leak cessation
and before removal of the tube and whether or not to clamp the tube before removal
to rule out a persistent air leak.11 On the basis of available data, most physicians
would obtain a chest radiograph 12 to 24 hours after the last observed
evidence of an air leak to ensure that the lung stays fully expanded before tube
removal. Because opinion and practice are clearly divided on the need for clamping
the drain before tube removal, no strong recommendation can be made here.
If placement was for any pleural fluid drainage, once the drainage volume is less
than 200 ml in a 24-hour period,3,5 the fluid is serous, the lung has re-expanded on
the chest film, and the patienťs clinical status has improved, the chest tube may
be removed.
If the patienťs condition fails to improve after chest-tube insertion, a respirologist
or a thoracic surgeon should be consulted for more definitive management,
such as fibrinolytic therapy or surgical decortication.8,9
Technique of Tube Removal
The major concern with removal of a chest tube is the risk of pneumothorax during
removal. Again, physician practice differs with respect to the point in the respiratory
cycle at which the tube is removed: during end-inspiration or end-expiration.
Neither has been shown to be superior in the prevention of pneumothorax.5 When
preparing to remove the tube, two people may need to participate so that one can instruct
the spontaneously breathing patient and pull the tube while the other can quickly
occlude the insertion site. Cut the skin sutures, using sterile technique. Have
additional strong nylon or silk sutures ready in case additional sutures are required
to seal the hole. Sterile petroleum-based and regular gauze should also be ready.
Instruct the spontaneously breathing patient to perform a forced Valsalva maneuver
or to inhale to total lung capacity after a full exhalation. If the patient is being
fully mechanically ventilated, removal should be timed to end-expiration. One operator
can pull the tube out while the other quickly occludes the site with gauze,
adds additional sutures to close the opening, and secures the site with a pressure
dressing. A chest radiograph 12 to 24 hours after removal is recommended1,3; this
should be done sooner if there is clinical suspicion of a residual air leak or a new
pneumothorax.
Caution must be exercised when removing a chest tube from any patient receiving
mechanical ventilation. This is of particular importance for patients with high
oxygen or positive end-expiratory pressure requirements, chronic lung disease, or
any additional reasons for persistent air leaks or recurrent pneumothoraces. In
these cases, highly experienced physicians should supervise the decision to remove
a chest tube.
No potential conflict of interest relevant to this article was reported.
chest-tube insertion
n engl j med 357;15 www.nejm.org october 11, 2007
References
Miller KS, Sahn SA. Chest tubes: indications,
technique, management and
complications. Chest 1987;91:258-64.
Laws D, Neville E, Duffy J. BTS guidelines
for the insertion of a chest drain.
Thorax 2003;58:Suppl 2:ii53-ii59.
Tang ATM, Velissaris TJ, Weeden DF.
An evidence-based approach to drainage
of the pleural cavity: evaluation of best
practice. J Eval Clin Pract 2002;8:333-40.
Hyde J, Sykes T, Graham T. Reducing
morbidity from chest drains. BMJ 1997;
314:914-5.
Baumann MH. What size chest tube?
What drainage system is ideal? And other
chest tube management questions. Curr
Opin Pulm Med 2003;9:276-81.
Parulekar W, Di Primo G, Matzinger
F, Dennie C, Bociek G. Use of small-bore
vs large-bore chest tubes for treatment of
malignant pleural effusions. Chest 2001;
120:19-25.
Antunes G, Neville E, Duffy J, Ali N.
BTS guidelines for the management of
malignant pleural effusions. Thorax 2003;
58:Suppl 2:ii29-ii38.
American Thoracic Society. Management
of malignant pleural effusions. Am
J Respir Crit Care Med 2000;162:1987-
2001.
Light RW. Parapneumonic effusions
and empyema. Proc Am Thorac Soc 2006;
3:75-80.
Davies CWH, Gleeson FV, Davies RJO.
BTS guidelines for the management of
pleural infection. Thorax 2003;58:Suppl
2:ii18-ii28.
Baumann MH, Strange C, Heffner JE,
et al. Management of spontaneous pneumothorax:
an American College of Chest
Physicians Delphi consensus statement.
Chest 2001;119:590-602.
Copyright  2007 Massachusetts Medical Society.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Copyright  2007 Massachusetts Medical Society. All rights reserved.
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n engl j med 356;17 www.nejm.org april 26, 2007 e15
The new engl and jour nal of medicine
Orotracheal Intubation
Christopher Kabrhel, M.D., Todd W. Thomsen, M.D., Gary S. Setnik, M.D.,
and Ron M. Walls, M.D.
From the Department of Emergency Medicine,
Massachusetts General Hospital,
Boston (C.K.); the Department of Emergency
Medicine, Mount Auburn Hospital,
Cambridge, MA (T.W.T., G.S.S.); the De-
partmentofEmergencyMedicine,Brigham
and Women's Hospital, Boston (R.M.W.);
and the Division of Emergency Medicine,
Harvard Medical School, Boston (C.K.,
T.W.T., G.S.S., R.M.W.).
N Engl J Med 2007;356:e15.
Copyright  2007 Massachusetts Medical Society.
INDICATIONS
Orotracheal intubation is indicated in any situation that requires definitive control
of the airway. Orotracheal intubation is commonly performed to facilitate control
of the airway in a patient undergoing general anesthesia. It is also performed as
part of the care of critically ill patients with multisystem disease or injuries. Emergency
indications include cardiac or respiratory arrest, failure to protect the airway
from aspiration, inadequate oxygenation or ventilation, and existing or anticipated
airway obstruction.
CONTRAINDICATIONS
In urgent situations or emergencies, such as when a patient is in cardiac arrest,
airway management is of paramount importance, and there are very few contraindications
to orotracheal intubation. Orotracheal intubation by direct laryngoscopy
is somewhat contraindicated in a patient with partial transection of the trachea,
because the procedure can cause complete tracheal transection and loss of the airway.
In these cases, surgical airway management may be necessary. Unstable cervical
spine injury is not a contraindication, but strict, in-line stabilization of the cervical
spine must be maintained during intubation. An assistant should stand at the side
of the bed and hold the patienťs head, neck, and shoulders in an anatomically
neutral position. The anterior portion of the cervical collar is opened or removed to
permit the patienťs mouth to be fully opened.
When immediate intubation is not required, the difficulty of intubation should
first be assessed. This assessment is discussed in detail in the Preparation section,
under Sedation and Paralysis.
EQUIPMENT
You will need the following equipment: gloves, a protective face shield, a working
suction system, a bag-valve mask attached to an oxygen source, an endotracheal tube
with stylet, a 10-ml syringe, an endotracheal-tube holder (cloth tape may be used if
a tube holder is not available), an end-tidal carbon dioxide detector, a stethoscope,
and laryngoscopes with appropriate blades. The two main types of laryngoscope
blades are the Macintosh blade, which is curved, and the Miller blade, which is
straight. Each is available in various sizes, and each requires a slightly different
technique. The choice of blade depends on the operator's experience and personal
preference. A size 3 or 4 Macintosh blade or size 2 or 3 Miller blade can be used in
most adult patients.
Endotracheal tubes are sized according to the internal diameter of the tube;
7.0-, 7.5-, or 8.0-mm tubes are appropriate for most adults.1-3 The appropriate tube
size for use in children can be determined by adding 4 to the patienťs age in years
and then dividing by 4 ([age in years+4]÷4=tube size), by matching the external
videos in clinical medicine
Figure 1. In-line stabilization of the
cervical spine
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diameter of the tube to the width of the patienťs little fingernail, or by using a
system based on the chilďs height or length (such as the Broslow­Luten resuscitation
tape).1
Tubes can be cuffed or uncuffed. Cuffed tubes are appropriate for adults and
older children. Uncuffed tubes are used for younger patients (those requiring a
tube smaller than 5.5 mm).1,2 After inserting a cuffed tube, you must inflate the
balloon on the distal end to create a seal between the tube and the tracheal lumen.
This seal will prevent leakage of air and aspiration of gastric contents.
PREPARATION
Before proceeding, be sure that all equipment is readily accessible and functioning,
that personnel are properly prepared, and that written informed consent has been
obtained from the patient or the patienťs health care proxy if the clinical situation
permits. Inflate the cuff of the endotracheal tube to check for leaks. Insert the
stylet into the endotracheal tube, maintaining the tube's natural curve. Make sure
the tip of the stylet does not extend beyond the end of the tube. If necessary, the stylet
can be used to reshape the endotracheal tube, as in the "hockey stick" maneuver, to
facilitate intubation of an anterior larynx. Ensure that the suction catheter is secure
and within easy reach. Obtain intravenous access, and place the patient on a monitor
if time and conditions permit. Assign an assistant to watch the monitor during the
procedure and to report any changes.
Adjust the height of the bed so that the patienťs head is level with the lower
portion of your sternum. Unless there are contraindications, move the patient into
the "sniffing" position by placing a pillow or folded towel under the patienťs occiput.
This combination of flexion of the neck and extension of the head improves the
alignment of the axes of the oral cavity, pharynx, and larynx, facilitating optimal
visualization of the vocal cords.1,3 When intubating an infant, you typically do not
need to provide additional head support, because the infanťs large occiput naturally
causes the head to assume the sniffing position.
If the clinical situation allows, preoxygenate the patient with a non-rebreather
mask or by having the patient breathe 100% oxygen through a bag-valve mask for
at least 3 minutes before intubation.3 Preoxygenation replaces the primarily nitrogenous
mixture of ambient air, which constitutes the patienťs functional residual
capacity, with oxygen. This increases the interval before desaturation in a patient
who is hypoventilating or apneic. This preliminary step is essential to minimize
the need for positive-pressure ventilation during intubation, thus reducing the risk
of aspiration of gastric contents.3
Remove the patienťs upper and lower dentures, if present, immediately before
laryngoscopy. Re-insert the patienťs dentures to improve the mask seal if bagvalve­mask
ventilation is required.
If the patienťs mental status is diminished or if the patient is pharmacologically
sedated, an assistant should apply firm pressure to the cricoid cartilage. This
maneuver (the Sellick maneuver) compresses the soft-walled esophagus between
the cricoid cartilage and the cervical vertebrae, theoretically preventing passive
regurgitation of gastric contents.2 If the airway becomes distorted, releasing cricoid
pressure may improve visualization of the glottis.
Sedation and Paralysis
In many cases, a neuromuscular-blocking agent and a potent sedative are needed to
facilitate intubation. These agents will improve your visualization of the vocal cords
and prevent the patient from vomiting and aspirating gastric contents.3 If you plan
The new england journal of medicine
n engl j med 356;17 www.nejm.org april 26, 2007
Figure 2. The "sniffing" position
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Orotracheal Intubation
n engl j med 356;17 www.nejm.org april 26, 2007
to use such agents, you must assess the difficulty of intubation before proceeding.3
You can generally predict that intubation will be difficult if the patient has a history
of difficult intubation, limited neck mobility, a small mandible, pharyngeal structures
that are poorly visible through the open mouth with tongue extruded, a limited
ability to open his or her mouth, or a laryngeal prominence that is close to the
mentum.1,3 Anatomical distortion (such as by tumors, trauma, or infection), edema,
or obstruction of the airway may also lead to difficult orotracheal intubation. When
faced with a potentially difficult intubation, you should make contingency plans,
including preparation for an alternative intubation technique, such as using a gumelastic
bougie, a laryngeal mask airway, a fiberoptic intubating bronchoscope, or a
surgical technique.
The Procedure
Position your body so that your eyes are far enough from the patient to facilitate
binocular vision. While holding the laryngoscope in your left hand, open the patienťs
mouth with your right hand. Insert the laryngoscope blade to the right of the
patienťs tongue. Gradually move the blade to the center of the mouth, pushing the
tongue to the left. Slowly advance the blade and locate the epiglottis. Ideal placement
of the laryngoscope blade depends on whether a curved or a straight blade is used.
If you are using a curved blade, place the tip into the vallecula epiglottica, which is
between the base of the tongue and the epiglottis. If you are using a straight blade,
place the tip of the blade posterior to the epiglottis.
With the tip of the blade correctly positioned, lift the laryngoscope upward and
forward at a 45-degree angle to expose the vocal cords. Direct the force of your
lifting action along the axis of the laryngoscope's handle, in the direction of the
ceiling, over the patienťs feet. Avoid bending your wrist or rocking the blade against
the patienťs teeth, since this can result in dental or soft-tissue injury (and will not
enhance the view of the glottis).
While holding the endotracheal tube in your right hand and maintaining your
view of the vocal cords, insert the endotracheal tube into the right side of the
patienťs mouth. The tube should not obstruct your view of the vocal cords during
this critical part of the procedure. Pass the tube through the vocal cords until the
balloon disappears into the trachea.
Remove the stylet, and advance the tube until the balloon is 3 to 4 cm beyond
the vocal cords. Inflate the endotracheal balloon with air to the minimum pressure
required to prevent air leakage during tidal-volume ventilation with a bag. This
usually requires less than 10 ml of air. Have an assistant maintain cricoid pressure
until you have confirmed that the tube is in the trachea.
Troubleshooting
If you cannot see the vocal cords or epiglottis after positioning the laryngoscope
blade, you have probably inserted the blade too far or have not placed the blade
precisely in the midline. Withdrawing the blade gradually in the midline will often
allow the epiglottis or larynx to drop into view. Manipulating the larynx with your
right hand or having an assistant apply firm backward, upward, and rightward pressure
(the so-called BURP maneuver) to the larynx can also facilitate visualization of
the vocal cords.2 An assistant can gently pull the right side of the patienťs lip and
cheek to enhance visibility of the glottis. If you still cannot see the cords clearly, an
assistant should gently release the cricoid pressure, since this compression can sometimes
compromise the view. You should always achieve the best possible view of the
vocal cords before attempting to insert the endotracheal tube.
A
B
Figure 3. Proper placement of the
curved (Panel A) and straight
(Panel B) laryngoscope blades
Figure 4. Proper orientation of the lifting
action
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Confirmation
The end of the endotracheal tube should lie in the mid-trachea, 3 to 7 cm above the
carina. A good general rule is to align the 22-cm marking on the tube with the front
teeth of an average-sized adult.2 For children, you can use the following formula to
estimate the proper depth of tube insertion1: tube depth (in centimeters)=[(chilďs age
in years)÷2]+12. Place the end-tidal carbon dioxide detector onto the endotracheal
tube and attach the ventilation bag, administering a few tidal-volume breaths. Proper
tube placement cannot be confirmed solely on the basis of a physical examination
or by a finding of fogging of the tube. Other techniques must be used to confirm
this most critical aspect of management. Carbon dioxide will be reliably and consistently
detected within the first six breaths after orotracheal intubation and with
each exhalation thereafter.4 In some patients in cardiac arrest, gas exchange does
not occur. Thus, carbon dioxide may not be present, even when the tube is in the
trachea.4 In such cases, you may use a self-inflating bulb (esophageal-detector device)
or a fiberoptic endoscope to visualize the tracheal rings.
Perform a secondary assessment to confirm proper esophageal-tube placement
by auscultating over the stomach during positive-pressure ventilation. Auscultate
both lungs in the midaxillary line to confirm that there is equal, bilateral air movement.
If breath sounds are diminished on the left side after intubation, the right
main bronchus has probably been intubated. Gradually withdraw the endotracheal
tube until symmetrical (i.e., bilateral) breath sounds are auscultated.
Use chest radiography to assess the patienťs pulmonary status after intubation
and to ensure that the tip of the radio-opaque line embedded in the endotracheal
tube is positioned at the level of the mid-trachea and not in either main bronchus.
Radiography is not a reliable means of detecting esophageal intubation.
Securing the Tube
Secure the endotracheal tube to the patienťs head once you have confirmed that the
tube is in the proper position. You should use an endotracheal-tube holder to secure
the tube, because this device helps prevent accidental displacement.1,2 If such a device
is not available, you may use adhesive tape or cloth endotracheal-tube tape. Pharmacologic
sedation and hand restraints may be used to prevent the patient from inadvertently
removing the tube.
COMPLICATIONS
The most serious complication of endotracheal intubation is unrecognized esophageal
intubation, which may lead to hypoxemia, hypercapnia, and death. Laryngoscopy
can provoke vomiting and aspiration of gastric contents, causing pneumonitis or
pneumonia. Additional complications include bradycardia, laryngospasm, bronchospasm,
and apnea owing to pharyngeal stimulation. Trauma to teeth, lips, and vocal
cords and exacerbation of cervical spine injuries can also occur.
The new england journal of medicine
n engl j med 356;17 www.nejm.org april 26, 2007
References
Lutes M, Hopson LR. Tracheal intubation.
In: Roberts JR, Hedges JR, ed. Clinical
procedures in emergency medicine. 4th
ed. Philadelphia: Saunders, 2004:69-99.
Schneider RE. Basic airway management.
In: Walls RM, ed. Manual of emergency
airway management. Philadelphia:
Lippincott Williams & Wilkins, 2000:43-57.
Walls RM. Rapid sequence intubation.
In: Walls RM, ed. Manual of emergency
airway management. Philadelphia: Lippincott
Williams & Wilkins, 2000:8-15.
Idem. Confirmation of endotracheal
tube placement. In: Walls RM, ed. Manual
of emergency airway management. Philadelphia:
Lippincott Williams & Wilkins,
2000:27-30.
Copyright  2007 Massachusetts Medical Society.
1.
2.
3.
4.
Copyright  2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at NSW HEALTH AND HEALTH TECHNOLOGY on June 2, 2008 .
New England Journal of Medicine
CORRECTION
Orotracheal Intubation
Orotracheal Intubation . In the PDF summary of the video, the third
sentence under ``Confirmation´´ should have read, ``For children, you
can use the following formula to estimate the proper depth of tube
insertion1
: tube depth (in centimeters)=[(chilďs age in years)÷2]+12,´´
rather than ``tube depth=[(chilďs age in years)+2]÷12.´´ The text has
been corrected on the Journaľs Web site at www.nejm.org.
N Engl J Med 2007;356:2228
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n engl j med 358;22 www.nejm.org may 29, 2008 e25
videos in clinical medicine
The new engl and jour nal of medicine
Cricothyroidotomy
James Hsiao, M.D., and Victor Pacheco-Fowler, M.D.
From the Department of Emergency
Medicine, New York­Presbyterian Hospital,
New York. Address reprint requests
to Dr. Hsiao at 445 East 68th St., #7H,
New York, NY 10065, or at james_j_
hsiao@yahoo.com.
N Engl J Med 2008;358:e25.
Copyright  2008 Massachusetts Medical Society.
Indications
Cricothyroidotomy is an emergency procedure performed on patients with severe
respiratory distress in whom attempts at orotracheal or nasotracheal intubation either
have failed or were deemed to have an unacceptable level of risk. The procedure involves
making an incision in the cricothyroid membrane, which lies between the
thyroid and cricoid cartilages, and inserting a tracheostomy tube into the trachea
to allow ventilation.
The major indication for cricothyroidotomy is the inability to establish an airway
through orotracheal or nasotracheal intubation, which may be due to difficult patient
anatomy, excessive blood in the mouth or nose, massive facial trauma, or airway
obstruction resulting from angioedema, trauma, burns, or a foreign body obstructing
the airway.
The rate of failed emergency department intubations and subsequent surgical
airway management is lower than 0.6%.1 In the emergency department, cricothyroidotomy
has been used for 1.0 to 2.8% of all intubation attempts in patients with
trauma.2-4 Whenever possible, cricothyroidotomy should be performed by physicians
fully trained and skilled in carrying out the procedure, such as emergency physicians,
surgeons, and intensivists.
A tracheostomy tube placed during a cricothyroidotomy performed under emergency
conditions can be left in place for up to 72 hours. Because of the potential
complications of cricothyroidotomy, including subglottic stenosis and damage to
the thyroid and cricoid cartilages, a cricothyroidotomy should be converted to a tracheostomy
if airway access is needed for more than 72 hours.5 Although tracheostomy
is preferred for long-term management, it should be performed in the controlled
setting of the operating room. In urgent situations, cricothyroidotomy should
be performed.
Surgical cricothyroidotomy involves inserting a tracheostomy tube into the trachea
through an incision in the cricothyroid membrane. In needle cricothyroidotomy,
a catheter is placed over a needle that penetrates the membrane, allowing ventilation
by a pressurized stream of oxygen. Because the catheter has a smaller
diameter, it is less effective in providing adequate ventilation and should be used
only as a temporizing measure while preparation is made for surgical cricothyroidotomy
or tracheostomy. Needle cricothyroidotomy is the preferred method of establishing
an emergency airway in children younger than 10 to 12 years, since the larynx
is more easily damaged by surgical cricothyroidotomy in this age group, with a
higher incidence of postoperative airway complications.6
Contr aindications
Cricothyroidotomy should not be performed when there is massive trauma to the larynx
or cricoid cartilage. When orotracheal and nasotracheal intubation are viable
options, they should be attempted before cricothyroidotomy is considered.
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Prepar ation
Since cricothyroidotomy is an emergency procedure, there may not be time to obtain
informed consent, and the patient may not be able to provide consent. The
procedure should be performed in emergency situations even in the absence of
informed consent.
For sterilization and local anesthesia, the following are needed: gloves, a protective
gown, a face shield, chlorhexidine or povidone iodine (Betadine, Purdue Pharma),
gauze pads, 1% or 2% lidocaine with epinephrine, and a 6-ml syringe with a 25gauge
needle. To perform the procedure, the following are needed: a tracheostomy
tube, a scalpel with a number 10 or 11 blade, a curved hemostat, a Trousseau dilator,
a tracheal hook, a 10-ml syringe, and suture or tying material. A bag-valve device
and an oxygen source should be available to ventilate the patient once the procedure
has been performed.
A tracheostomy tube with an internal diameter of 6 mm should be used. A tube
with an internal diameter larger than 7 mm would be difficult to insert into the
cricothyroid membrane.
The tracheostomy tube comprises three parts (Fig. 1). The outer cannula has a
neck plate extending from the sides that allows the tube to be secured to the neck
with sutures or a cloth tie. The inner cannula has an adaptor at the end that attaches
to a bag-valve device or mechanical ventilator. The obturator provides a smooth
surface to guide insertion of the tube (Fig. 1).
A 6-mm endotracheal tube can be used as an alternative to the tracheostomy tube,
but this option is much less preferable because an endotracheal tube is more difficult
to secure to the patienťs neck. Endotracheal tube holders or other devices
may be used to help secure an endotracheal tube to the neck. Another advantage
of the tracheostomy tube is that it is shorter than an endotracheal tube and therefore
easier to suction.7
Procedure
Place the patient in the supine position. Since this procedure is performed in extremely
urgent circumstances, there is usually not time to drape the patient. Chlorhexidine
or povidone iodine should be applied if time permits. If the patient is awake, administer
local anesthesia.
Directions are given for a right-handed operator. Side-specific designations should
be reversed for left-handed operators.
To perform cricothyroidotomy, stand on the patienťs right side. Stabilize the
larynx with your left thumb and middle finger, and use your index finger to palpate
the thyroid cartilage. Move your index finger down until you palpate the cricoid
cartilage. The space between the thyroid and cricoid cartilages is the cricothyroid
membrane. This is where you will make the incision (Fig. 2).
Use the scalpel to make a 2.5-cm vertical incision through the skin and subcutaneous
tissue. Use the curved hemostat to make a blunt dissection in the subcutaneous
tissue. The initial incision should be vertical for two reasons: first, a vertical
incision will avoid injury to the recurrent laryngeal nerves, which run parallel to
the trachea, and second, an initial incision above or below the cricothyroid membrane,
if vertical, will allow extension of the incision as needed. Starting with a
horizontal incision that is too low or too high would necessitate a new incision in
the correct location.
Next, use the scalpel to make a horizontal incision through the cricothyroid membrane.
You may feel a pop as you enter the trachea. Extend the incision laterally,
turn the blade, and extend it in the opposite direction.
The new england journal of medicine
n engl j med 358;22 www.nejm.org may 29, 2008
Figure 1. Components of the Tracheotomy
Tube.
Shown from left to right are the inner
cannula, outer cannula, and obturator.
Figure 2. Landmarks for Cricothyroid-
otomy.
The incision is made in the cricothyroid
membrane.
Copyright  2008 Massachusetts Medical Society. All rights reserved.
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To avoid penetrating too deeply and perforating the esophagus, which lies posterior
to the trachea, do not go more than 1.3 cm (1/2 inch) deep (Fig. 3). To
minimize the risk of esophageal perforation, hold the scalpel between your thumb
and index finger, and allow your middle finger to extend down the side of the
scalpel, leaving the distal 1.3 cm of the blade exposed. If the patient is trying to
breathe, once you enter the trachea, airflow should be audible and may also be
visible.
Once the trachea has been entered, make sure the blade stays within the incision,
so that communication with the trachea is never lost. Insert a tracheal hook,
and pull upward on the distal portion of the incision, elevating the larynx. Once
the tracheal hook is in place, you may remove the blade.
Insert a Trousseau dilator and open the membrane vertically, then insert the
tracheostomy tube. Holding the cannula in place, remove the obturator and attach
the adaptor. Inflate the cuff with a 10-ml syringe. Attach a bag-valve unit and ventilate
the patient. Look for symmetric chest rise and auscultate for symmetric breath
sounds. Tie or suture the tracheostomy tube in place. Dispose of needles and sharps
in an appropriate container.
If an endotracheal tube is used in place of a tracheostomy tube, make sure the
tube is not inserted to a depth of more than 2 to 3 cm. Deeper placement of the
tube may cause it to go down the right mainstem bronchus.
Complications
There are three major complications of cricothyroidotomy. First, esophageal perforation
occurs when the blade penetrates too deeply. To prevent this, allow only the
distal 1.3 cm of the blade to enter the trachea. Second, subcutaneous emphysema
may occur if the horizontal incision is too wide, allowing air to become trapped in
the subcutaneous tissue. Third, excessive bleeding or hemorrhage may occur if a
vessel is ruptured. If minor vessels are injured, the bleeding can be controlled with
direct pressure. If there is rupture of major vessels, such as the carotid artery or
internal jugular vein, ligation may be required.
Postprocedur al Care
After the procedure, obtain a chest x-ray film to confirm placement of the tracheostomy
tube. Call for respiratory therapy so the patient can be mechanically ventilated.
Obtain a surgical consult so that definitive tracheostomy can be performed,
if necessary. A tracheostomy tube placed during an emergency cricothyroidotomy
can be left in place for up to 72 hours.
No potential conflict of interest relevant to this article was reported.
Cricothyroidotomy
n engl j med 358;22 www.nejm.org may 29, 2008
Figure 3. Cross-Sectional View of Trachea
and Esophagus.
References
Bair AE, Filbin MR, Kulkarni RG,
Walls RM. The failed intubation attempt
in the emergency department: analysis of
prevalence, rescue techniques, and personnel.
J Emerg Med 2002;23:131-40. [Erratum,
J Emerg Med 2002;23:325.]
Bushra JS, McNeil B, Wald DA,
Schwell A, Karras DJ. A comparison of
trauma intubations managed by anesthesiologists
and emergency physicians.
Acad Emerg Med 2004;11:66-70.
Erlandson MJ, Clinton JE, Ruiz E, Cohen
J. Cricothyrotomy in the emergency
department revisited. J Emerg Med 1989;7:
115-8.
Bair AE, Panacek EA, Wisner DH,
Bales R, Sakles JC. Cricothyrotomy: a 5-year
experience at one institution. J Emerg Med
2003;24:151-6.
Esses BA, Jafek BW. Cricothyroidotomy:
a decade of experience in Denver.
Ann Otol Rhinol Laryngol 1987;96:519-
24.
Sise MJ, Shackford SR, Cruickshank
JC, Murphy G, Fridlund PH. Cricothyroidotomy
for long-term tracheal access:
a prospective analysis of morbidity and
mortality in 76 patients. Ann Surg 1984;
200:13-7.
Gens DR. Surgical airway management.
In: Tintinalli JE, Kelen GD, Stapczynski
JS, eds. Emergency medicine: a comprehensive
study guide. 6th ed. New York:
McGraw-Hill, 2004:119-24.
Copyright  2008 Massachusetts Medical Society.
1.
2.
3.
4.
5.
6.
7.
Copyright  2008 Massachusetts Medical Society. All rights reserved.
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