Femoral Vein—Central Venous Access

imagesEmergency venous access for fluid resuscitation, drug infusion, and renal dialysis

imagesInfusions requiring central venous administration (vasopressors, calcium chloride, hyperosmolar solutions, hyperalimentation)

imagesCritically ill patients who cannot be placed flat or in Trendelenburg position due to respiratory distress

imagesAccess site for transvenous pacemaker

imagesNonemergent venous access due to inadequate peripheral IV sites


imagesNo absolute contraindications

imagesRelative Contraindications

   imagesCoagulopathic patients (femoral approach is preferred over the subclavian and internal jugular approaches because it is more easily compressed)

   imagesCombative or uncooperative patients

   imagesOverlying infection, burn, or skin damage at puncture site

   imagesTrauma to the ipsilateral groin or lower extremity

   imagesSuspected proximal vascular injury, particularly of inferior vena cava (IVC)

   imagesIpsilateral renal transplant (risk of venous thrombosis)


imagesPain (local anesthesia will be administered)

imagesLocal bleeding and hematoma

imagesInfection (sterile technique will be utilized)

imagesGeneral Basic Steps

   imagesVessel localization



   imagesSeldinger technique


   imagesCatheter placement


   imagesFlush and secure


Site of insertion is 2 to 3 cm inferior to the midpoint of inguinal ligament and 1 fingerbreadth medial to the femoral artery (FA) pulse (Figure 22.1). Anatomically, the structures underlying the inguinal ligament, from lateral to medial, are recalled by the mnemonic NAVEL.

    Femoral Nerve

    Common Femoral Artery

    Common Femoral Vein

    Empty Space

    Lymphatics (FIGURE 22.1)


FIGURE 22.1 The thin line represents the pulsatile common femoral artery. The thick line 1 fingerbreadth medial to it represents the common femoral vein.


imagesCentral Venous Catheter Kit

   imagesDrapes, chlorhexidine prep (2), gauze

   imagesCatheter (multiport, cordis, or hemodialysis)

   imagesGuidewire within plastic sheath

   imagesLidocaine, anesthesia syringe, and small-gauge needle

   imagesThree-inch introducer needle and syringe




   imagesSterile gloves, sterile gown, sterile cap and mask

   imagesSterile drapes

   imagesSterile saline flushes

   imagesSterile port caps

   imagesUltrasound machine (optional)

   imagesSterile ultrasound probe cover with sterile gel (optional)


imagesPatient Preparation

   imagesCardiac monitoring to detect dysrhythmias triggered by wire advancement into the right ventricle

   imagesSupplemental oxygen and continuous pulse oximetry monitoring

   imagesExternally rotate the leg and slightly bend the knee to expose the groin

   imagesIf using ultrasound guidance, evaluate the right and left femoral veins (FVs) before prepping to confirm ideal vein location and compressibility

   imagesSterilize the entire groin with chlorhexidine or povidone–iodine solution

   imagesWear surgical cap, eye protection, mask, sterile gown and gloves

   imagesDrape with sterile sheets, covering the body liberally

   imagesIf using ultrasound guidance, have an assistant place the probe (with gel applied) inside the sterile probe sheath

Note: Unless immediate emergent access is warranted, the physicians attempting the procedure must wear cap, eye protection, and mask, along with sterile gown and gloves.

imagesVessel Localization

   imagesIf attempting to localize the right FV, use the right hand to hold the introducer needle and syringe. With the left hand, palpate the FA to avoid arterial puncture while guiding needle insertion. If attempting to localize the left FV, reverse hands.


   imagesUse a small-gauge needle to anesthetize skin and subcutaneous tissue with 1% lidocaine


   imagesAttach a syringe to the introducer needle

   imagesUsing the above landmarks, insert the introducer needle at a 30- to 60-degree angle to skin just medial to the palpated FA pulse

   imagesApply negative pressure to the syringe plunger while advancing the needle 3 to 5 cm or until a flash of blood is seen in the syringe

   imagesIf no flash is obtained, withdraw the needle slowly while continuing to aspirate

   imagesIf redirecting the needle, always withdraw the needle to the level of skin before advancing again

   imagesOnce the needle enters vessel, blood will flow freely into the syringe

   imagesStabilize and hold the introducer needle

   imagesRemove the syringe and ensure that venous blood continues to flow easily

   imagesUse a finger to occlude the needle hub to prevent air embolism

imagesSeldinger Technique

   imagesAdvance the guidewire through the introducer needle. The wire should pass easily. Do not force it.

   imagesAlways hold on to the guidewire with one hand. Never let go of the guidewire.

   imagesIf resistance is met, withdraw the wire and rotate it, adjust the angle of needle entry, or remove the wire and reaspirate with the syringe to ensure the needle is still in the vessel.

   imagesWhen at least half of the guidewire is advanced through the needle, remove the needle over wire. Keep one hand holding the wire at all times.

   imagesMake a superficial skin incision with the bevel of the scalpel blade angled away from wire

   imagesEnsure the incision is large enough to allow easy passage for the dilator


   imagesThread the dilator over the guidewire, always holding on to the wire

   imagesAdvance the dilator through the skin into the vessel with a firm, twisting motion while holding the guidewire with the nondominant hand

   imagesRemove the dilator, leaving the guidewire in place

imagesCatheter Placement

   imagesThread the catheter over the guidewire and retract the guidewire until it emerges from the catheter’s port

   imagesWhile holding the guidewire, advance the catheter through the skin into the vessel to the desired length

   imagesWithdraw the guidewire through the catheter

   imagesUse a syringe to aspirate blood from the catheter to confirm placement in the vein



   imagesBlood gas analysis

   imagesSonographic confirmation of the catheter in the vein (Figure 22.2)

   imagesPostprocedure chest x-ray (CXR)

   imagesConfirm the catheter tip in the superior vena cava just proximal to the right atrium

   imagesRule out pneumothorax

imagesFlush and Secure

   imagesAspirate, flush, and heplock each central line lumen

   imagesSuture the catheter to the skin using silk or nylon sutures

   imagesCover the skin insertion site with a sterile dressing (bacteriostatic if available) (FIGURE 22.2)


FIGURE 22.2 Longitudinal view of a catheter in the femoral vein.

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Femoral Vein—Central Venous Access
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