Vascular Access: Theory and Techniques in the Small Animal Emergency Patient

Matthew W. B e a l , D V M and Dez Hughes, BVSc MRCVS, Diplomate, ACVECC

Acquisition of vascular access in the emergent small animal patient is one of the keys to successful management of a population of patients that are often unstable with regard to their major body systems. Venous and intraosseus cannulat~on allow for the administration of a variety of fluids and potentially hfe-saving medications. In addition, central venous and arterial access also serve as condu~ts for atraumatic blood sampling and intravascular pressure monitoring. A thorough knowledge of vascular access theory, the dynamms of flutd flow, vascular anatomy, catheter selection cnterta, and placement techniques are critical to the proper and safe use of the vascular access options available today to the small animal clinician. Copynght 2000 by W.B. Saunders Company

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scular access is the lifeline for the small animal emerency patient. Vascular access may be used for the delivery of intravenous fluids, blood components, or medications; venous and arterial blood samphng; or intravascular pressure monitoring. Selection of an appropriate catheter and knowledge of placement techniques, maintenance, and use of the various methods of vascular access is essential to the small animal emergency and critical care veterinarian. Most veterinarians are familiar with over-the-needle catheters and their use in peripheral veins; however, technological developments have yielded many options for vascular access. These include mtraosseous catheters, single- and multilumen central venous catheters, percutaneous catheter introducers, and peripherally inserted central venous catheters. Access sites include peripheral and central veins and arteries and even the marrow cavity of bones. Numerous placement techniques have also been developed including through-the-needle catheters, catheters introduced using the Seldinger technique, and surgical cutdown procedures.

Catheter Selection
The intended purpose of the catheter is usually the main determinant of the type of catheter selected as well as its
From the Section of Crttical Care, Department of Chntcal StudiesPhiladelphia, School of Veterinary Medtcme, Untversttyof Pennsylvanta, Philadelphia, PA. Address reprmt requests to Matthew W Beal, DVM, Sectton of Crittcal Care, Department of Chnical Studtes, School of Vetermary Medtcme, Universttyof Pennsylvanta,3850 Spruce St, Philadelphta,PA 19104-6010. E-marl: mabeal@vet upenn.edu NOTE. Porttons of this arttcle appeared in a previous work by the authors ("Emergency VascularAccess"), first published m The Veterinary Climcs of North America: Small Animal Practice (Volume 30, Number 3, May 2000). Copyrtght 2000 by W B. Saunders Company 1096-2867/00/1502-0009510.00/0 dot:10.1053/svms.2000.6802

placement site. In an emergency situation the primary goal is simply to gain vascular access so that ease of placement is of paramount importance. The emergency patient often has respiratory and/or cardiovascular compromise, and even relatively noninvasive procedures can be unduly stressful and hazardous. Mimmizing restraint and stress to the patient via a quick and simple catheter placement is of great benefit. The cephalic vein is often the easiest site to use, and the patient can be restrained while sitting or standing, rather than in lateral recumbency. In contrast, central venous catheterization or other vascular access techniques requiring prolonged patient restraint may be extremely stressful and should usually be avoided in the unstable emergency patient. Oxygen therapy should always be considered durmg catheter placement in patients with respiratory or cardiovascular compromise. However, an unstable patient may not tolerate a face mask. Alternatively, oxygen can be delivered by positioning an oxygen hose in front of the face (flow-by oxygen) or by placing a clear, vented, plastic bag over the head. Over-the-needle catheters placed in peripheral veins are used most often because of ease of insertion, low cost, safety, and versatility. Contram&cations for placement of these catheters are few, but include disease or infection of the skin or subcutaneous tissue at the insertion site and fractures or venous disruption proximal to the site. Peripheral venous catheters cannot be used for central venous pressure monitoring, or the administration of total parenteral nutrition or other hypertonic solutions because of the risk of causing thrombophlebins. For administration of irritant solutions, or for frequent blood sampling, central venous catheterization is more appropriate. Multilumen central venous catheters can be used to enable concurrent infusion of multiple intravenous solutions or me&cations. Before placement of a central venous catheter, the coagulation status of the patient should be assessed. Patients with coagulopathy, thrombocytopenia, or thrombocytopathia can experience potenually hfe-threatening hemorrhage after jugular venous catheterization. Ideally, the prothrombin time, activated partial thromboplastin ume, platelet count, and a buccal mucosal bleeding time (BMBT) should be assessed. An activated clotting time and a blood smear to estimate platelet numbers may suffice in the emergency situation. A BMBT should be performed in patients at higher risk for thrombocytopathla, eg, in breeds with a high incidence of Von Willebrand's disease or in ammals receiving nonsteroidal antiinflammatory medicatmns. In contrast to patmnts at high risk for bleeding during central venous catheterization, patients with disease processes that are associated with hypercoagulability, such as Cushing's &sease, parvoviral enteritis, or proteinlosing nephropathy may be at risk for local thrombosis or

Clinical Techmques in SmallAnimal Practice, Vol 15, No 2 (May), 2000: pp 101-109

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pulmonary thromboembolism after central venous catheterization. Because of their length, central venous catheters can be inappropriate for the rapid administration of large volumes of fluids: the rate of fluid flow through a tube is inversely proportional to the length of the tube. Flow rate is also inversely proportional to the viscosity of the solution administered, so infusion of fluids with a higher viscosity, such as blood products, will be especially difficult. Flow is also directly proportional to the fourth power of the radius of the tube and the pressure differential across the tube. This means that if the radius of the catheter is doubled, the flow rate increases 16-fold. One study showed that increasing the diameter of intravenous tubing from 3.2 to 4.4 mm reduced the ume for infusion of 1 L of crystallmd solution from 6 to 2.7 minutes in vitro.1 Furthermore, when the catheter size was increased from 16 to 14 gauge, infusion time decreased further to 1.8 minutes. Increasing the pressure differential can be achieved by raising the height of the fluid bag above the patient or by applying pressure to the fluid bag, either manually or through use of a pneumatic cuff (Clear-Cuff pressure infuser; Medex Inc, Hilllard, OH). Short, large-bore catheters in large vessels should therefore be used for rapid delivery of large volumes of fired. A short 14- or 16-gauge over-the-needle catheter, or a percutaneous catheter introducer placed in the jugular vein allows extremely rapid fluid administration. When venous access is not possible because of small patient size, severe hypovolemia, contraindications to placement, or technical difficulty, intraosseous (IO) catheter placement can be used. IO acess is a rapid, relatively easy, and inexpensive means of vascular access that is especially useful in very small patients and neonates. 2 The rich sinusoidal network that exists within the marrow cavity of long bones allows rapid absorption of both intravenous fluids and medications. Contraindications to the placement of IO catheters are few, but include disease at the proposed site of insertion, sepsis (because of the risk of osteomyelitis), and fractures of the bone in which the catheter is to be inserted. 2 Arterial catheterization, usually using a short, over-theneedle catheter placed in the dorsal pedal artery, is a relatively simple and safe way to directly monitor arterial blood pressures and obtain serial arterial blood samples. Contraindications to placement of arterial catheters include severe thrombocytopenia or coagulopathy and disease at the proposed site of catheter insertion.

Patient Preparation and Catheter Maintenance

Strict aseptic technique should be used when possible to minimize the risk of catheter-related infection. A surgical preparation of more than 2 minutes with iodine scrub followed by alcohol and tincture of iodine compared with alcohol and tincture of iodine alone has been shown to lower significantly the incidence of phlebitis and positive catheter tip cultures in dogs. 3 Ideal catheter placement comprises a thorough clipping of hair, full surgical scrub, and use of a surgical drape and sterile gloves. When venous access must be rapidly established, local clipping, a rapid skin scrub, and catheter placement without sterile gloves can suffice. The choice of dressing material for securing and covering intravenous catheters is influenced by their effect on catheterrelated infection rate, cost effectiveness, and overall staff
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satisfaction. A decreased incidence of infection was seen in veterinary patients when use of sterile, individually packaged dressings was compared with non-individually packed dressings placed in a sterile container. 4 Studies examining the relationship between catheter-related mfections and dressing type in people have yielded conflicting results. 5-r It seems prudent to cover the catheter site with a sterile dressing such as a gauze square, Band-Aid (Johnson and Johnson Consumer Products Co, Skillman, NJ), or nonadherent dressing. In people, the incidence of peripheral catheter-related bacterial infection was lower using ointment containing polymyxln, neomycin, and bacitracin compared with iodophore ointment or no topical treatment; however, there was no difference in the incidence of catheter-related septicemia. 8 The catheter should be examined at least every 6 hours to ensure that it remains securely in place and that the dressing is clean. Changes of the sterile dressing and examination of the catheter site should be performed daily or more frequently if necessary. The catheter should he removed and a new catheter inserted at an alternative site if there is any pain, redness, swelling, or discharge at the catheter site. Additionally, in an animal that develops a fever without another apparent cause, the catheter site should always be considered a likely nidus of infection. The procedure of routine flushing of intravenous catheters and the use of heparin in the flush solution has been challenged in human medicine in recent years. Catheter patency and incidence of phlebitis appears to be unaffected by heparin in the flush solution, or flushing the catheter twice a day compared with three times a day. 9-1 It has also been suggested that frequent invasion of the catheter hub may increase the occurrence of catheter-related infection.ll There is also some controversy regarding the appropriate length of ume that an intravenous catheter should be left in place. Some have suggested that catheters placed before arrival in the hospital or in the emergency room should be considered contaminated and replaced within 24 hours. I2 In veterinary patients, an increase in catheter-related infections was not shown when peripheral catheters left in place for more than 72 hours were compared with those removed before 72 hours. 4 In a study of the use of central venous catheters, pulmonary artery catheters, and arterial catheters in people, the incidence of catheter-related sepsis was similar when catheters were removed every 7 days (and a new catheter placed at another site), when there was no weekly change (but a new site was used when the catheter change was necessary), or when a new catheter was placed in the same site every 7 days. 13 This study concluded that these types of catheters can be left in place provided they remain functional and no complications exist. 13 Multiple guide wire exchanges for central venous catheters (see Seldinger technique, below) in patients with no evidence of sepsis seem safe in people. 12 It has also been advocated that catheters can be left in place indefinitely as long as proper surveillance is performed.

Peripheral Venous Access

Potential sites of catheter placement include the cephalic vein or the accessory cephalic vein (ie, distal to the carpus), the saphenous vein, the branches of the medial saphenous vein, the dorsal common digital vein (over the metatarsal bones), or the medial or lateral auricular veins (occasionally useful in dogs with large ears such as the Bassett Hound, Bloodhound, and Dachshund) (Figs 1 through 4). Placement techniques for
BEAL AND HUGHES

Cephalic

v.

Median cubital 3rachlol ~edion v.

v.

i~

Cephalic

v..

~epholic AccessoQj cephahc

v.-

v.

vein. With an assistant holding the intravascular portion of the catheter (to keep it in place and to minimize blood loss), the stylet is then withdrawn the catheter hub is attached to an intravenous fluid line or an injection cap and secured in place. The percutaneous facilitative approach was designed to decrease resistance to passage of the catheter (thus minimizing burring). 15 The skin is tented over the vein and a small skin incision is made using a needle or a No. l i scalpel blade. The catheter IS then placed as described above. The percutaneous facilitative method is especially useful for the insertion of large-bore catheters in small animals or in animals with thick skin such as tom cats and ferrets. In animals in whom percutaneous placement is likely to be difficult, such as those with severe hypoperfusion or subcutaneous edema, a surgical cut-down can be performed. After routine surgical preparation, an incision is made just lateral to the vein and the incision is then rolled from side to side to allow direct visualization of the vein. Importantly, the incision should just penetrate the skin because with deeper incisions the vein will tend to move with the overlying skin when the incision is manipulated. A brief blunt &ssection may be necessary to allow better access to the vein. An over-the-needle catheter is then carefully inserted through the thin wall of the vein, and the catheter is advanced over the stylet. The catheter can then be sutured to the subcutaneous tissues around the vein, to the vein itself, or to the skin overlying the vein. The wound can be flushed if necessary, then closed in a routine fashion and covered with a sterile dressing.

Dorsal common digital v/V-

Central Venous Access

Central venous access refers to catheters that terminate in the cranial or thoracic caudal vena cava. There are many catheter types and placement techniques available for establishing central venous access. These include through-the-needle catheters; long, over-the-needle catheters, and single- or multilnmen catheters placed using the Seldinger technique (see below). Additionally, although they are not actually central venous catheters, short (1 to 2 in), large bore (14- to 18-gauge) catheters can be placed in the jugular vein to allow rapid infusion rates as described above. Placement of central venous catheters can be facilitated using percutaneous, percutaneous facilitative, or surgical cut-down techniques. The jugular vein is used most often for central venous access, although alternative sites include the femoral vein, maxillary vein, and medial saphenous vein. 15 Central venous access can also be established via peripheral veins using extremely long intravenous catheters (Accuguard Peripherally Inserted Central Catheter Tray, Braun Medical Inc, Bethlehem, PA). The jugular vein always lies along a line drawn between the angle of the jaw and the thoracic inlet (Fig 5). To avoid losing the anatomical landmarks, it is very important to extend the neck and to minimize motion of the neck. To promote jugular venous &stension, an assistant can occlude the vein at the thoracic inlet. A small skin incision is especially helpful when attempting jugular venous access because of the thickness of the skin in the neck region. Because the jugular vein is a large, thin-walled, and moderately mobile structure, a quick, controlled, stabbing motion can facilitate entry into the vein lumen. The technique for placing short over-the-needle catheters for rapid volume infusion is similar to that for placement of

Fig 1. Venous anatomy of the right antebrachium. (Reprinted with permission from Evans, Miller's Anatomy of the Dog, 1993,14 p 694.) v., vein.
catheters in all of these sites are nearly identical, although highly mobile sites may necessitate stabilizing the catheter using a splint (accessory cephalic vein, dorsal common digital vein, and auricular veins) or suturing the catheter in place. Peripheral venous catheters can be placed via one of three methods: the percutaneous approach, percutaneous facilitative approach, or via a surgical cut-down. 15 Successful percutaneous placement necessitates a thorough knowledge of local anatomy and is easmr when the vein can be directly visualized or palpated. Beginning at the most distal point at which the vein can be identified allows subsequent proximal attempts at catheter placement should the initial attempt be unsuccessful. Tensing the skin during insertion facilitates catheter placement by minimizing subcutaneous motion of the vein, especially when using the saphenous vein. The catheter is inserted through the skm at an angle of approximately 15 to 30 with the bevel facing up, taking care not to burr the tip of the catheter. If penetration of the skin is very difficult or the tip of the catheter becomes burred, it is better to use a percutaneous facilitative approach (see below). When blood appears in the flash chamber, the catheter and stylet are advanced together for 1 to 3 m m and the catheter is then fed over the styler into the
EMERGENCY VASCULAR ACCESS

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Pophteol I~jmph node-

Let. sophenous v.. . . . . .

C a u d a l br o[ Iot.sophenous v.-

. .Cranial bc of lot.. sophenous v.

sCranial br of reed sophenous v. i ....... Anostornof'lc br. - - - D O t ' S o l common dr~ i t el v. H

Fig 2. Venous anatomy of the right hindlimb; lateral aspect. (Reprinted with permission from Evans, Miller's Anatomy of the Dog, 1993,14 p 701 .) lat., lateral; v., vein; br., branch; med., medial.

P l a n t a r common dt gl t o l v.lV- -

- o r s a / c o m m o n d l f f l t o l v. III

peripheral catheters. Once blood is seen within the flash chamber, the catheter and stylet are advanced together for about 1 to 3 mm, then the catheter is fed over the stylet until the hub reaches the skin. The catheters are temporarily secured with a single suture or via a tape butterfly that is sutured to the skin. A longer (4 to 6 in) 14-gauge catheter (Angiocath, Becton Dickinson, Sandy, UT) can be placed m the jugular vein using xdenncal technique and advanced down into the cranial vena cava. Because of their relative lack of flexibility, these longer catheters may be prone to collapse. Through-the-needle central venous catheters are a widely used method of central venous access because of their low cost and relative ease of placement (L-Cath; Lumed, Santa Ana, CA, Intracath; Becton Dickinson). Placement of these catheters involves puncturing the vein with a needle and then feeding a slightly smaller catheter into the vein. Blood may or may not be seen m the catheter lumen. After catheter placement, the needle is then backed out of the vein and either removed by breakaway (L-Cath) or covered with a needle guard (Intracath). The catheter can then be sutured in place. One disadvantage of through-the-needle catheters is that the hole in the vein caused by the needle is larger than the catheter itself, whmh can lead to hemorrhage, especially in patients with abnormal hemostasis. The Seldinger technique is a method for the insertion of catheters into vascular structures or body cavities and can be used to place single- or multilumen central venous catheters (Arrow International, Reading, PA), percutaneous catheter introducers, or even peritoneal dialysis catheters. 16 Percutaneous catheter introducers are large-bore, relatively short catheters with a valve attached to the catheter hub. Once placed, they allow placement and removal of various catheters through
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the valve. They are most commonly used with pulmonary arterial catheters that must be advanced and withdrawn during use. In the emergency setting, they can serve as extremely large-bore conduits that can be used for rapid mtravascular volume restoration. The Seldinger technique can also be used to change catheters while maintaining direct vascular access at the site. Catheter placement via the Seldinger technique is as follows: 1. 2. 3. 4. 5. 6. Surgical preparation. Optional local anesthetic infiltration. Small 2 to 4 mm incision with No. 15 blade over vessel. Insert needle into blood vessel. Blood should flow freely from the needle. Feed flexible J-tip guide wire through needle into the blood vessel. Withdraw needle over guide wire. At thts point, there will usually be some hemorrhage from the placement site. Direct pressure can be applied to the site to minimize hematoma formation. Advance dilator or combinatmn dilator/catheter over grade wire into vascular structure. The guide wire should be held throughout thts procedure to avoid the risk of it slipping out of or down the vein. Remove dilator over guide wire and advance saline-filled catheter over wire into vessel. Remove guide wire. Flush all ports with saline or heparimzed saline. Suture catheter in place. Apply sterile dressing.

7.

8. 9. 10. 11. 12.

When placing catheters into the jugular vein using the Seldinger technique, the approximate distance to the heart
BEAL AND HUGHES

Femoral

v.--

M. Sortortus-

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Middle - Coudofemoral v,

Med. 3ophenous

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-

-M. ~raclhs

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- - -Popliteal lymph node - Caudal br. armed saphenous v

Fig 3. Venous anatomy of the right hindlimb; medial aspect. (Reprinted with permission from Evans, M i l l e r ' s A n a t o m y o f t h e D o g , 1993,14 p 702.) v., vein; m., muscle; med., medial; br., branch; lat., lateral; caud., caudal.

Cranlal br. of reed, saphenous v.. . . . .

anastornosts with Crontcd b~ of lat 3ophenouS v.. . . . .

DorSal common d i g i t a l v.II- -Plantar c o m m o n d i g i t a l v 11

should be measured to avoid advancement of the guide wire or catheter into the heart, which can result in cardiac arrhythmias or atrial injury. If a central venous catheter must be changed, the site should be aseptically prepared and a guide wire exchange performed. The guide wire is advanced through the catheter, then the catheter may be removed over the wire, which remains in the vein. A new catheter is placed in the same site over the guide wire. Jugular venous access can also be performed by surgical cut-down. This is generally reserved for animals with cardiovascular collapse, in whom peripheral access is difficult or impossible. If time allows, surgical cut-down should be performed using strict aseptic technique, otherwise the skin over the jugular vein is clipped and then wiped with an antiseptic solution. Sterile gloves should be worn. An incision is made through the skin parallel to or over the anatomic location of the jugular vein. Blunt manual dissection with both index fingers is used to strip away subcutaneous fat and connective tissue surrounding the vessel (Fig 6). Holding off the jugular vein at the thoracic inlet can aid visualization. It is much easier to successfully place a catheter if most (if not all) tissue covering the vein is removed before attempting to Insert the catheter. Furthermore, if much tissue remains over the vein, an unsuccessful catheterization attempt results in bleeding into the overlying tissue and hematoma formation that can obscure the vein. Following an unsuccessful attempt after the jugular vein has been exposed, bleeding is easily controlled by
EMERGENCY VASCULAR ACCESS

applying pressure above and below the puncture and a catheter can often be placed directly into the inadvertent venotomy. After successful introduction of the catheter, it should be immediately held in place by an assistant and sutured to tissue surrounding the vessel or the vessel itself. The site can then be flushed and closed. If strict aseptic technique was not practiced, the catheter should be removed within 24 hours and drainage established for the site if necessary.

Intraosseous Access
Intraosseous access can be achieved using a hypodermic needle, spinal needle, or bone marrow aspiration needle (in larger patients). 2 Commercially available IO catheters are also available (Cook Veterinary Products, Bloomington, IN) but are rarely necessary. The most commonly used sites are the trochanteric fossa of the femur and the fiat, medial aspect of the tibia just distal to the tiblal tuberosity. Alternative sites include the ilium, ischium, and greater tubercle of the humerus. The site should be clipped and a surgical scrub performed. In a conscious patient, the site should be infiltrated with a local anesthetic from the skin down to and including the periosteum. A stab incision in the skin will minimize any blunting of the needle. The needle should be advanced to the periosteum and then rotated clockwise and counterclockwise in 30 increments while applying controlled pressure. The abrupt
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Fig 4. Venous anatomy of the ear. (Reprinted with permission from Evans, Miller's Anatomy of the Dog, 1993,14 p 688.) med., medial; auric., auricular; lat., lateral; superf., superficial; int., internal; ext., external; In, lymph node; br., branch; super., superior; vent., ventral; dor., dorsal.

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Facial

From rnandlbular" 91and' I 11 ~ Phorslngeal br I l I Cranial loryngeal I I Lingual

~ ~ 5ubmenia~ bular olveolar" MOndJ 'l

~Hyold venous aFCh

decrease in resistance that often occurs when the cortex is penetrated should be antmlpated. The needle should then be advanced into the bone to the hub, and the limb can then be flexed and extended to help assess correct placement (the catheter should move with the limb). If using a spinal or bone marrow needle, the stylet is then removed and the needle is aspirated and then flushed to ensure patency.

If the catheter is not patent, it can be rotated to ensure that the bevel is not apposed to the tuner cortex and flushed forcefully. If this is unsuccessful, the needle should be removed and another placed through the same site. Flmd infusion sets or injection caps can then be attached. To secure the needle, a tape butterfly can be attached to the hub of the needle, then sutured to the skin. A sterile dressing at the skin entry site and

Fig 5. Anatomic localization of the left jugular vein between the angle of the jaw and the thoracic inlet (head is located to the left of the image). Visualization of the vein is facilitated by applying digital pressure at the thoracic inlet.

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BEAL AND HUGHES

Fig 6. Jugular cut-down: Tissue overlying the jugular vein can be rapidly stripped away with the index fingers to expose the jugular vein.

a wrap will minimize chances of contaminauon and decrease motion at the site. The risk of sciatic nerve injury can be minimized, when using the trochanteric fossa, by gradually walking the needle off the medial aspect of the greater trochanter. 2 Additionally, care should be taken to avoid damage to the growth plates of the tibial tuberosity and proximal tibia when using the tibial site in young animals} 7

Arterial Access
Arterial access is used for monitoring intra-arterial blood pressure and arterial blood sampling. The most common site of catheter placement is the dorsal pedal artery, but the radial artery, brachial artery, femoral artery, and auricular artery can also be used in special circumstances. Arterial catheters in sites other than the dorsal pedal artery are more difficult to maintain, largely because of motion in these areas. Dorsal metatarsal (pedal) arterial cannulation is not technically difficult, but requires a thorough knowledge of regional anatomy. The course of the artery should be identified by careful and thorough palpation before an attempt at catheterization. Once the artery has been penetrated by the catheter, it will often undergo spasm. This means that an unsuccessful attempt will render further attempts much more difficult, so it is vital to be sure of the anatomical course before attempting placement. The artery can be palpated most easily just proximal to the point where it passes in a plantar direction between metatarsals II and III located just distal to the hock. Palpating over the metatarsal bones, the artery usually runs proximally at an angle of - 3 0 to the long axis of the limb in a medial to lateral direction. Catheterization is accomphshed via a percutaneous or percutaneous facilitative approach. If skin penetrauon seems difficult, the catheter should be withdrawn and checked for burring of the tip before attempting arterial catheterization because a damaged catheter will be unlikely to feed into the arter)~. The artery is best accessed from the craniomedial aspect of the metatarsus (with the patient in lateral recumbency),
EMERGENCY VASCULAR ACCESS

directing the catheter toward the craniolateral metatarsus at an angle of N30 to the sagital plane of the limb. In the authors' experience, failing to direct the catheter at an appropriate angle is the most common reason for inability to feed a catheter after successful arterial puncture. With the skin pulled taught, a 20to 24-gauge over-the-needle catheter is placed through the skin (at an angle of approximately 10 to 20 to it) and directed toward the artery. Once arterial blood is seen in the flash chamber, the catheter is fed over the styler and into the artery. Upon withdrawal of the stylet, pulsatile blood flow should be seen from the catheter. If catheterization is unsuccessful, a firm pressure bandage should be applied to the site for 15 to 20 minutes to minimize hematoma formation. If a catheterization attempt is successful, an injection cap, T-style catheter adapter, or arterial pressure tubing can then be attached. The catheter can be secured using suture material, tape, or a combination thereof. The entry site should be covered with a sterile dressing, and the catheter should be protected from potential contaminants. In cases in which percutaneous catheterization of the dorsal pedal artery is unsuccessful, a surgical approach to catheterization can be attempted. The dorsal aspect of the metatarsus should be prepared routinely for surgery and draped. Aseptic technique should be practiced. A 1-inch skin incision should be made from the proximal third metatarsal bone dlstally to the lateral border of the second metatarsal bone. Blunt dissection of the underlying soft tissues should be accomplished until the artery can be visualized. Distally, the artery will lie nearly flush with the dorsal surface of the metatarsals. Once the superficial tissues have been removed, the artery can be cannulated with a 20- to 24-gauge over-the-needle catheter (Fig 7A). The catheter should be secured to the skin with suture around the sewing groove on the catheter, and the wound should be flushed and closed routinely (Fig 7B). A sterile dressing should be applied to the surgical site. In cases in which metatarsal cannulation is not possible, the femoral artery can be cannulated percutaneously using the Seldinger technique as described above.

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Fig 7. (A) Cannulation of the right dorsal pedal artery by cut-down approach. (B) Cannulation of the right dorsal pedal artery by cut-down approach, The catheter should be secured to the surrounding skin or soft tissues, Numbers show location of metatarsal bones two and three. Tarsus is located at the top of the illustration,

In a recumbent animal, patency of an arterial catheter is best mamtamed by connection to a pressurized, continuous flushmg system, although intermittent flushing with heparimzed sahne every 4 hours is acceptable. Other routine catheter care should be performed as for venous cannulae. Flmds and medications should not be admimstered via the arterial route (excepting small volumes of flush solution) and preaspiration samples taken durmg blood sampling should be returned to the panent through a venous access route

Acknowledgment
The authors thank Mr. Doug Thayer for his invaluable assistance and expertise in preparation of the photographs for this article.

References
1. Rottman SJ, Larmon B, Manlx T Rapid volume infusion m prehosp~tal care. Prehospital Disaster Med 5:225-229, 1990 2. Otto CM Kaufman GM, Crowe DT: Intraosseous infusion of fluids and therapeutics. Comp Contin Educ Pract Vet 11 421-430, 1989

3. Burrows CF: Inadequate skin preparation as a cause of intravenous catheter-related infection in the dog. J Am Vet Med Assoc 180.747749, 1982 4. Matthews KA, Brooks MJ, Valhant AE: A prospective study of intravenous catheter contamination. J Vet Emerg Cnt Care 6:33-43, 1996 5. Makl DG, Stolz SS, Wheeler S, et al A prospective, randomized trial of gauze and two polyurethane dressings for site care of pulmonary artery catheters Implications for catheter management. Crit Care Med 22:1729-1737, 1994 6. Treston-Aurand J, Olmsted RN, Allen-Brldson K, et al: Impact of dressing materials on central venous catheter infection rates. J Intraven Nurs 20:201-206, 1997 7. Hoffman KK, Weber DJ, Samsa GP, et at Transparent polyurethane film as an intravenous catheter dressing: A meta-analys~s of the infection risks J Am Med Assoc 267 2072-2076, 1992 8. Maki DG, Band JD Acomparative study of polyantlblotlc and Iodophor ointments in prevention of vascular catheter-related infection Am J Med 70 739-744, 1981 9. Peterson FY, Kirchhoff KT. Analysis of the research about heparmJzed versus non-heparinlzed intravascular lines Heart Lung 20:631-640, 1991 10. Dunn DL, Lenihan SF: The case for the saline flush. Am J Nurs 87:798-799, 1987 11. Lmares J, Sitges-Serra A, Garau J, et al: Pathogenesis of catheter sepsis. A prospective study with quantitative and semi-quantitative cultures of catheter hub and segments. J Chn Microblol 21:357-360, 1985

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12. Norwood S, Ruby A, Cwetta J, et al: Catheter-related ~nfections and associated septicemia. Chest 99:968-975, 1991 13. Eyer S, Brummitt C, Crossley K, et al: Catheter-related seps~s: prospective, randomized study of three methods of long-term catheter maintenance. Cnt Care Med 18:1073-1079, 1990 14. Evans HE. Miller's Anatomy of the Dog, ed 3. Philadelphia, PA, Saunders, 1993

15. Crowe DT: Performing life-saving cardiovascular surgery. Vet Med 84:77-96, 1989 16. Sacchettt A: Large-bore infusion catheters (Seldinger technique for vascular access), in Roberts JR, Hedges JR (eds)" Clinical Procedures in Emergency Medicine. Philadelphia, PA, Saunders, 1984, pp 289-293 17. Poundstone M: Intraosseous infusion of fluids in small animals. Vet Tech 13:407-412, 1992

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