Placement of a central venous catheter in the antecubital vein using a modified seldinger technique

To describe a case of a patient requiring inotropic support without central venous access in which the central venous catheter (CVC) was placed in the antecubital vein using a modified seldinger technique.

Placement of CVC in the field in retrieval medicine can be time consuming and is not without risk of complication. Minimizing time in the field can lead to better outcomes for patients who are seriously medically ill or traumatically injured. The ED also offers a more controlled environment for the safe and accurate placement of CVCs. However, there are times in the prehospital environment when more secure access than peripheral is needed in order to administer the appropriate treatment. Herein, a modified seldinger technique is described for the peripheral placement of a CVC.

A 53-year-old man presented to a remote health clinic in the outback of Australia with complaints of weakness, persistent vomiting and chest pain. He subsequently arrested for a brief period (∼3 minutes) from suspected hyperkalemia complicated by MI and upon resuscitation was bradycardic, obtunded and hypotensive. Clinic staff were only able to gain an 18G left antecubital IV. The patient required an adrenaline infusion, IVF and other medications. Using the angiocatherter already in place, a guide wire was placed through and a quadruple lumen CVC was placed without complication allowing for infusion of medications (adrenaline drip, meropenem) and IVF. The catheter was removed after a CVC was placed under US guidance and sterile conditions in the ICU 12 hours later.

This case represents a dilemma faced in the prehospital environment by retrieval teams and offers a novel technique as a temporizing solution until appropriate CVC access can be gained.