Continuing Education Activity
This activity describes the procedure for scalp vein catheterization, outlining the indications, contraindications, method for the procedure, and potential complications; it also highlights the interprofessional team's role in successfully performing and managing patients who undergo scalp vein catheterization.
- Describe the scalp vein catheterization technique to allow practitioners to successfully utilize this procedure in their patients.
- List the required equipment that should be gathered and used by the interprofessional team to perform scalp vein catheterization.
- Review the indications for scalp vein catheterization.
Peripheral intravenous (IV) catheterization is an essential procedure performed by a variety of interprofessional healthcare team members. IV access can allow for the sampling of blood for laboratory analysis. Also, IV catheterization allows for fluid and medication administration directly to the patient’s circulatory system. Traditionally, IV catheterization is performed in the extremities (arms and hands being more common than legs or feet). This chapter will discuss obtaining peripheral IV access through scalp veins, a less often used but viable alternative to traditional extremity sites. Scalp IVs are an efficient and safe option. Knowing the unique considerations for obtaining IV access in the scalp is essential to successful utilization.
Anatomy and Physiology
Veins are the part of the circulatory system which returns deoxygenated blood to the heart. Peripheral veins offer relatively simple access to the circulatory system, given their superficial location to the skin. Scalp veins are easily accessed due to both this superficiality and their easy visualization. The three most common veins for scalp vein catheterization for peripheral IV access are the posterior auricular veins, superficial temporal veins, and frontal veins.
The frontal veins run up and down along the center of the forehead towards the midline. Superficial temporal veins run along the side of the head and drain the skin and muscles in the temporal region. Posterior auricular veins also drain the skin and superficial muscles of the scalp and run posterior to the ear, also parallel to the cranial-caudal axis.
Similar to other peripheral IV catheterization, the indications for scalp vein catheterization include the sampling of blood for laboratory analysis and direct access to the circulatory system to infuse intravenous fluids, blood products, and/or medications. Generally, extremities will be the first sites to explore for peripheral intravenous catheterization. In patients without limbs (i.e., phocomelia) or inability to successfully obtain peripheral IV access in the arms or legs, scalp veins are another option for obtaining IV access.
Peripheral vein catheterization is generally used for short periods of time (72 hours or less) before necessitating relocation or discontinuation due to expected degradation with use. Whether in the extremities or the scalp veins, these access sites are useful for short term access; in the scalp, generally smaller caliber catheters are ideal.
As with any superficial vein catheterization procedure, considerations must be given that weigh the risks and benefits. In the common peripheral scalp vein sites of the frontal veins, superficial temporal veins, and posterior auricular veins, venous blood flow is robust, and those veins have sufficient alternative routes of venous drainage. Relative contraindications include overlying skin infection and thrombophlebitis at the site of catheterization. Patient discomfort (either with catheterization or continuous presence of hardware to keep the catheter in place) should be considered as well as sensory or motor deficits around the site being chosen.
Peripheral IV catheterization can provide emergent and life-sustaining or saving access to administer medications, fluids, and blood products. In emergency settings, the severity of the clinical situation takes precedence over most relative contraindications.
The following equipment is required:
- Nitrile gloves
- Hair clippers
- Chlorhexidine or alcohol swabs or wipes
- An elastic constricting tourniquet of thin caliber (such as a rubber band)
- An appropriately gauged intravenous catheter
- Transparent film dressing
- Syringe (for blood collection as necessary)
- Saline flush
- Intravenous tubing
- Tubing extension set
- Saline lock
Scalp vein catheterization should be performed by someone authorized to perform intravenous catheterization and with the appropriate experience at accessing scalp veins. Scalp veins are not usually the primary site of attempting access, and when scalp veins are being explored for peripheral IV access, access often is becoming a more urgent need; therefore, it is ideal for maximizing success by using personnel who have more experience. Generally, a tech, medic, nurse, or clinician can perform the procedure as appropriate.
In children, additional trained personnel may be needed for stabilizing the child, and child life specialists can aid in distraction and/or developmentally appropriate support. In peripheral scalp vein catheterization, the ideal positioning of the child includes decreasing mobility at the neck, minimizing body movements that would lead to movement during IV catheter placement, and holding the head at the proper position and angle to maximize a straight path to the scalp vein.
Universal precautions and aseptic techniques should be followed for all procedures. Site selection is the key first step before scalp vein catheterization. After eliminating sites that meet potential contraindications criteria, it is necessary to choose a vein that is visible, of adequate caliber to fit the catheter, and that follows a relatively straight path--tortuous veins make the advancement of the catheter challenging.
Ultrasound guidance by trained personnel may become necessary and may enhance the success of scalp vein catheterization. Utilize an elastic constricting band (like a rubber band) around the scalp. The ideal placement is caudal to the location of the vein being catheterized. Gentle pressure at that site can also be applied with your or an assistant’s hands. If using a circumferential band, it should be placed distal to the catheterization site but superior to the ears and eyes, which should not be compressed. The compression and/or tourniquet will distend veins and improve visualization.
If the scalp vein site identified is within the hair, clipping hair short (or shaving) is indicated to allow for maximal visualization. When possible, a location within the hairline will reduce the risk of visible scars. Once identified, prepare the skin by disinfecting the overlaying area with alcohol or chlorhexidine. If blood cultures are to be obtained, the skin should be prepared according to aseptic protocols at your institution. Continue to utilize aseptic technique throughout the procedure, including but not limited to the use of gloves.
After the site is selected and prepared, unsheath the catheter and place it in line with the vein. While keeping the bevel of the needle up and angled approximately 30 degrees from the surface of the skin, advance as the needle punctures the skin. Continue to advance in the direction of the vein until blood fills the chamber. This flashback indicates the needle has punctured the vein. Flatten the angle of the catheter to approximately 10 degrees above the skin. Then advance the catheter until it is placed in the vein. Once the catheter is sufficiently in the vein, retract the needle while keeping the catheter in place and hold pressure distally on the vein to prevent blood leakage.
A transparent film dressing over the catheter hub is an ideal way to first secure the catheter in place. Attach a syringe if blood is to be sampled or IV tubing or other connectors if medications or fluids are to be administered. Flush the catheter with saline and monitor the catheter site to ensure the extravasation of fluid is not occurring and that the catheter is in its appropriate place. Gauze should be placed under the catheter hub to prevent physical compression or pain on the scalp and taped in the usual style of other peripheral IVs. Given the head's shape, location, and constant movement, stabilization of the scalp vein catheter should be attempted. One example is a simple plastic medicine cup cut and taped over the catheter.
Most complications from scalp vein peripheral catheterization are similar to other peripheral IV access complications: Pain, bleeding, including hematoma, and infection. Rarer complications include extravasation of fluids or medication, phlebitis, thrombophlebitis, penetration of deeper structure or damage to surrounding tissues, nerve damage, or embolism. Specific to scalp vein catheterization are rare complications that are related to the site of IV catheterization. Case reports of intracranial air, epidural infections, and cavernous sinus introduction of air are complications that have been reported.
Intravenous catheterization can be a lifesaving/sustaining procedure required for the administration of drugs and/or fluids. Scalp veins offer a safe, reliable, and comparable alternative site to establish peripheral IV access. In particular in patients without extremities, difficult extremity IV access, or moderate dehydration but stable enough appearance that more invasive access (such as femoral, internal jugular, saphenous cutdown, or intraosseous access) is not indicated.
Enhancing Healthcare Team Outcomes
Intravenous catheterization is an individual skill that can significantly enhance the healthcare team’s ability to care for a patient. Therefore the team must utilize appropriate communication before, during, and after the attempt to optimize outcomes. Closed-loop communication between members of the interprofessional team is important in indicating the need, deciding when to perform scalp vein catheterization, and in the fluids and/or medications being ordered and infused.
Although it is a convenient alternative to extremity IV access, the location, potential lack of experience because it is a rarer site of catheterization, and the look of a patient with a scalp vein may cause distress to the patient, parent (if applicable), and healthcare team, such that indications, contraindications, and decisions on choosing a scalp vein for access must be agreed upon to enhance patient outcomes and satisfaction. Sharing best practices and the creation of clinical practice guidelines are essential to maximizing patient safety and the success of this procedure.