Central line: femoral

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Background

  • Incidence of septicemia from femoral vein catheters is no different than the incidence for subclavian and internal jugular veins.[1][2]
  • Good site for access during resuscitation as does not interfere with compressions. It is not an ideal line for ACLS drugs due to length from heart, but good for post-resuscitation pressors and blood products.

Indications

  • Central venous pressure monitoring
  • High volume/flow resuscitation
  • Emergency venous access
  • Inability to obtain peripheral venous access
  • Repetitive blood sampling
  • Administering hyperalimentation, caustic agents, or other concentrated fluids
  • Insertion of transvenous cardiac pacemakers
  • Hemodialysis or plasmapheresis
  • Insertion of pulmonary artery catheters

Contraindications

Absolute[3]

  • Infection over the placement site
  • Anatomic obstruction (thrombosis of target vein, other anatomic variance)
  • Site-specific
    • Subclavian - trauma/fracture to ipsilateral clavicle or proximal ribs

Relative

  • Coagulopathy (see below)
  • Distortion of landmarks by trauma or congenital anomalies
  • Prior vessel injury or procedures
  • Morbid obesity
  • Uncooperative/combative patient

Central line if coagulopathic

  • Preferentially use a compressible site such as the femoral location (avoid the IJ and subclavian if possible)
  • No benefit to giving FFP unless artery is punctured[4]

Equipment Needed

  • CVC kit typically contains:
    • Chlorhexidine
    • Sterile drape
    • 1% lidocaine without epinephrine
    • 5 mL syringe (for lidocaine)
    • 22-ga and 25-ga needles (for lidocaine)
    • 5-10 mL syringe (for venipuncture)
    • 18-ga needle (for venipuncture)
    • Guidewire
    • Scalpel with 11-blade
    • Dilator
    • Triple-lumen catheter (or introducer catheter/Cordis)
    • Catheter clamp
    • Silk suture
  • Sterile gown, cap, mask, gloves
  • Biopatch
  • Tegaderm
  • Sterile saline flush
  • Sterile caps for lumen ports

Procedure

Ultrasound-guided

  1. Obtain informed consent when possible
  2. Supine position
  3. Ultrasound survey to identify anatomy before beginning
  4. Thoroughly cleanse area
  5. Don cap, mask, sterile gown and gloves
  6. Chlorhexidine prep the skin. Wide area. (If obese, may need assistant to retract pannus)
  7. Place sterile drape over target area
  8. With assistant, place sterile cover over ultrasound probe, with some gel inside, secured with rubber bands from probe cover package
  9. Anesthetize insertion site
  10. Prepare catheter by flushing each lumen with sterile saline
  11. Prepare the guide wire by sliding the plastic sleeve slightly forward to straighten the curved wire tip
  12. Using ultrasound, identify femoral vein/artery - large bore vessels, inferior to inguinal ligament. Vein is compressible and (usually) medial, artery non-compressible and lateral.
  13. Align femoral vein in center of ultrasound screen
  14. Insert needle with syringe under ultrasound guidance, while applying negative pressure on the syringe
  15. When the needle enters the lumen, blood will be aspirated freely
  16. Stabilize the needle hub, carefully remove the syringe from the needle
  17. Confirm blood flow is non-pulsatile. Cap needle hub with thumb to avoid air embolism
  18. Insert the guidewire in through the needle hub, never letting go of the wire. If resistance is met, remove the wire and aspirate with syringe to confirm placement still in the vessel
  19. Remove the needle, keeping the wire in the vessel
  20. Make a small incision to facilitate dilator passage through the skin
  21. Thread the dilator over the wire, and advance several centimeters into the vessel, then remove, while keeping the wire in the vessel
  22. Advance the catheter over the wire, until the wire protrudes from a distal port (For introducer catheters, the dilator and larger single-lumen catheter are inserted as a dilator-sheath unit, assembled prior)
  23. Grasp the wire where it emerged from the port and advance the catheter into the vessel
  24. Remove the wire
  25. Place end cap on port
  26. Withdraw blood then flush each port/lumen with saline
  27. Suture the catheter in place
  28. Place Biopatch
  29. Cover with Tegaderm

Landmark technique

  • Same preparation as above, differences from ultrasound method highlighted below
  • Palpate femoral pulse 2 finger breadths below inguinal ligament
  • Release pressure but keep fingers in place over femoral pulse
  • Insert needle at a 45 deg angle medial to femoral pulse
  • If unable to palpate femoral pulse (and ultrasound unavailable):
    • Palpate ASIS and midpoint of the pubic symphysis, imagine a line between them
    • Femoral artery lies at junction of medial and middle thirds of this line
    • Femoral vein is one finger breadth medial

Complications

  • Arterial puncture and hematoma
  • Vessel injury
  • Air embolism
  • Cardiac dysrhythmia
  • Nerve injury
  • Infection
  • Thrombosis
  • Catheter misplacement

See Also

References

  1. ↑ Parienti J-J, Thirion M, Megarbane B, et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy. JAMA 2008; 299:2413–2422.
  2. ↑ Deshpande K, Hatem C, Ulrich H, et al. The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population. Crit Care Med 2005; 33:13–20.
  3. ↑ Graham, A.S., et al. Central Venous Catheterization. N Engl J Med 2007;356:e21
  4. ↑ Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit. Intens Care Med 1999; 25:5
  5. ↑ Morado M.et al. Complications of central venous catheters in patients with haemophilia and inhibitors. Haemophilia 2001; 7:551–556
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