Femoral Vein—Central Venous Access

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

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

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

Access site for transvenous pacemaker

Nonemergent venous access due to inadequate peripheral IV sites

CONTRAINDICATIONS

No absolute contraindications

Relative Contraindications

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

Combative or uncooperative patients

Overlying infection, burn, or skin damage at puncture site

Trauma to the ipsilateral groin or lower extremity

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

Ipsilateral renal transplant (risk of venous thrombosis)

RISKS/CONSENT ISSUES

Pain (local anesthesia will be administered)

Local bleeding and hematoma

Infection (sterile technique will be utilized)

General Basic Steps

Vessel localization

Analgesia

Insertion

Seldinger technique

Dilation

Catheter placement

Confirmation

Flush 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)

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

Central Venous Catheter Kit

Drapes, chlorhexidine prep (2), gauze

Catheter (multiport, cordis, or hemodialysis)

Guidewire within plastic sheath

Lidocaine, anesthesia syringe, and small-gauge needle

Three-inch introducer needle and syringe

Dilator

Scalpel

Suture

Sterile gloves, sterile gown, sterile cap and mask

Sterile drapes

Sterile saline flushes

Sterile port caps

Ultrasound machine (optional)

Sterile ultrasound probe cover with sterile gel (optional)

TECHNIQUE

Patient Preparation

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

Supplemental oxygen and continuous pulse oximetry monitoring

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

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

Sterilize the entire groin with chlorhexidine or povidone–iodine solution

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

Drape with sterile sheets, covering the body liberally

If 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.

Vessel Localization

If 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.

Analgesia

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

Insertion

Attach a syringe to the introducer needle

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

Apply 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

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

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

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

Stabilize and hold the introducer needle

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

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

Seldinger Technique

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

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

If 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.