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


CONTRAINDICATIONS



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)


RISKS/CONSENT ISSUES



imagesPain (local anesthesia will be administered)


imagesLocal bleeding and hematoma


imagesInfection (sterile technique will be utilized)



imagesGeneral Basic Steps


   imagesVessel localization


   imagesAnalgesia


   imagesInsertion


   imagesSeldinger technique


   imagesDilation


   imagesCatheter placement


   imagesConfirmation


   imagesFlush and secure


LANDMARK TECHNIQUE



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)



images


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.


SUPPLIES



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


   imagesDilator


   imagesScalpel


   imagesSuture


   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)


TECHNIQUE



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.


imagesAnalgesia


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


imagesInsertion


   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


imagesDilation


   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


imagesConfirmation


   imagesManometry


   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)



images


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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