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Central Venus Line Placement: Femoral Vein Access

Jason Jones, MD; Rohit Patel, MD

Keywords: central venous line, hypotension, heart failure, sepsis, femoral central venous line

Indications:

• Volume replacement

• Emergent venous access

• Administration of caustic medications: vasopressors, calcium chloride, hypertonic saline, high dose of potassium

• Dialysis catheter placement (hemodialysis)

• Pulmonary artery catheterization (not preferred but can do if necessary)

• Nutritional support (TPN)

• Long term antibiotics

• Chemotherapy

• Plasmapheresis

• Frequent or persistent blood draws or intravenous therapy when unable to establish peripheral access due to edema or other causes

Contraindications:

Absolute:

• Infection at site of insertion

• Distorted anatomy/landmarks (prior surgery, radiation, or history of thrombus in the specified vein)

Relative:

• Morbid obesity

• Agitated or moving patient

• Intra-abdominal (or retroperitoneal) hemorrhage

• Children less than 2 years (higher complication rates)

• Coagulopathy (although out of all the sites, this might be the preferred due to compressibility)

Materials and Medications (some of these items may be located in tray or bundle):

• Central Venous Catheter tray or bundle (single/double/triple/quad lumen, dialysis catheter, large bore introducer)

• Sterile gloves

• Sterile drapes or towels

• Sterile gown

• Hat/hair cap and mask with eye protection

• Antiseptic solution with skin swabs (ie chlorhexidine)

• Sterile saline flushes (three 10 ml syringes)

• Lidocaine 1%

• Sterile gauze

• No. 11 blade scalpel

• Dressing (sterile waterproof transparent dressing or sterile 4x4 gauze with tape)

• Sterile biopatch

• Suture material with needle driver if needed

• Transducing line (optional)

• Sterile probe cover (if using ultrasound guidance)

Femoral vein access:

1. Palpate the patient’s femoral artery below the inguinal ligament. This is usually found 1/2 of the distance between the anterior superior iliac spine (ASIS) and the midline of the symphysis pubis.

2. Trim overlying hair as necessary.

3. If ultrasound-guided approach is desired, use the linear probe (same as internal jugular) to detect the femoral vein at this location. The femoral vein will be easily compressible, while the femoral artery will be less compressible and pulsatile (see Figure 1)

4. Wash hands and use sterile technique to apply iodine or chlorhexidine solution (various forms available)

5. Open your femoral central venous line kit and don cap, mask, sterile gown, and sterile gloves. Non-sterile assistants should wear a cap, mask, sterile gown, and sterile gloves. Flush all ports of your CVL kit with saline flushes and check for leaks or malfunction of catheter.

6. Under sterile technique, apply the drape over the area of insertion, and have an assistant extend the drape the length of the bed. Reapply sterile iodine or chlorhexidine at the site.

7. Anesthetize the skin overlying the femoral vein with lidocaine.

8. If ultrasound-guided approach is desired, have an assistant hold up the vascular ultrasound probe. Place your gloved hand through a sterile ultrasound sleeve and grasp the top of the ultrasound probe. Without breaking sterile technique, pull and invert the sterile ultrasound sleeve over the probe and cable. See below for more detailed ultrasound guided cannulation technique.

9. Insert the needle at a 45º angle, bevel down, directed superiorly, 1 cm medial to the palpable femoral artery pulse. Once the needle has broken through the skin, aspirate by applying small amount of traction on the plunger continuously on the attached syringe.

10. Advance smoothly and slowly until blood appears in the syringe. Stop once blood is aspirated. If femoral vein is not cannulated, withdraw your needle until just beneath the skin and redirect.

11. Hold the hub of the needle with thumb and forefinger to immobilize in place. Remove the syringe carefully. If blood appears arterial or pulsatile, remove the needle and hold pressure for 5 to 10 minutes.

• Use the palm of your hand on the thigh to stabilize your hand. Not having your hand stable is a common mistake leading to needle movement out of the vein.

12. If blood appears venous (dark color, emerges as a continuous trickle, or transduced), cannulate the needle with the guide-wire. Maintain a two-finger grip on the guide-wire at all times. Advance the guide-wire until approximately 15 cm remains.

• Must keep handle of guidewire at ALL times and can be done through proper technique

13. If guide-wire does not advance easily, remove guide-wire and reposition needle until blood aspirates easily. The J-tip can be straightened using a pinching motion if needed (see Figure 2)

• Alternatively, one can use the catheter/syringe found in most kits to use as a bridge to guidewire placement. For the author this has improved success when there is difficulty in wire placement. Use the same steps above with the catheter (see Figure 3) and when you have return of blood advance the angiocath into the vein followed by insertion of the guidewire through the angiocath. This is especially useful in moving/agitated patients, patients who have collapsible veins due to hypovolema, and patients who have abnormal anatomy and may have veins that take an abnormal angle shortly past the needle tip.

14. Using your scalpel, make a single 1/2 cm stab incision at the site of needle insertion to assist with dilator placement.

• You can do the stab incision with or without the needle in place, but from experience most novice have difficulty locating the correct stab location due to small amount of blood accumulation when the needle is taken out.

15. Remove your needle, carefully leaving guide-wire in place. Apply dilator over guide-wire and advance into the body with gentle pressure and a twisting motion in the same plane that you used to direct the needle.

16. Holding pressure at the insertion site with sterile gauze 4x4 pads, remove the dilator from the guide-wire, leaving the guide-wire in place. Insert the central venous catheter over the guide-wire until it fits snugly against the skin. Use the markings on the catheter to determine proper length placed (usually with femoral site you can ‘hub’ the catheter) (see Figure 4).

17. Using a sterile saline flush, ensure that each lumen of the central venous line draws blood easily and flushes easily. Carefully note any that do not and consider repositioning as needed. You can attempt moving catheter in or out a few centimeters or rotating the catheter and recheck. Apply caps to each open lumen of your central venous line.

• Remember to cover the introducer port if not using immediately. If you do not, it poses an infection and air embolism risk to the patient.

18. Suture the line in place.

19. Place an antibiotic biopatch or similar antimicrobial dressing.

20. Enclose central venous line site with sterile waterproof transparent dressing.

Pearls and Pitfalls:

• Femoral central venous lines cannot accurately transduce central venous pressures.

• Asking the patient to perform a valsalva maneuver has been shown to increase the width of the femoral vein by 1/3.

• The mnemonic NAVEL (Nerve Artery Vein Empty space Lymphatics) assists in remembering the order of femoral structures from lateral to medial.

• Traditionally, femoral venous lines were felt to have higher rates of infection than subclavian or internal jugular lines. However, more recent analyses are challenging this belief. Obesity is more important of a risk factor for infection in femoral sites.

Complications:

1. Arterial puncture: the femoral artery site can be compressed, so if punctured hold pressure

2. Hematoma: usually requires monitoring only

3. Thrombosis: this complication may lead to pulmonary embolism

4. Catheter embolization:

• Prevention: Never withdraw a catheter past a needle bevel which might shear off the catheter.

• Management: x-ray the patient and contact specialist who can remove the embolized catheter

5. Lost guide wire. If the operator is not careful about maintaining control of the guide wire, it may be lost into the vein. This requires retrieval by interventional radiology or surgery and is an emergency.

6. Local site or systemic infection: using maximal sterile precautions has been shown to greatly decrease rate of infection

Ultrasound guided cannulation (general tips for each approach)

• Venous anatomy is best visualized using high frequency (5-10 MHz) linear probe. Higher frequencies generate less penetration but better resolution.

• You can use the ultrasound to identify the location of the vessel prior to the procedure and utilize external landmarks during the procedure itself (static technique), or you can use the ultrasound to visualize cannulation of the vessel during the procedure (dynamic technique).

• Static view is advantageous is that the ultrasound transducer is not needed during the sterile portion of the procedure, but it does not allow for direct visualization of cannulation and guidance during the procedure.

• Dynamic view (preferred) allows for direct visualization during the procedure, but requires more technique and requires use of transducer during the sterile portion of the procedure.

• The dynamic technique can be used in either a short axis view, where a cross sectional view of the vessel and needle is used, or a long axis view, where a longitudinal view of vessel and needle is used (see Figure 5).

• The long axis view allows for full visualization of the needle throughout the procedure and allows for better visualization and adjustment of needle depth. It is more difficult for lateral changes in positioning and tends to be technically more difficult.

• Key in this view is that once a good section of vein is obtained, do not move probe to visualize the needle, move the needle into the ultrasound view by slightly adjusting trajectory.

• The short axis view allows for lateral changes in position but is not as good at visualizing depth throughout the procedure, as visualization of the needle is in cross-sectional imaging. Perforation of the posterior wall is more common in this view.

• When using the short axis view, remember to position the ultrasound probe such that the field of the ultrasound intersects the vessel (IJ, femoral, subclavian) at the anticipated site of insertion of the needle into the vein. Remember that the needle is only visualized as it intersects the plane of the ultrasound.

• When using the long axis view, make sure to visualize the vessel with the ultrasound such that you can see the greatest diameter of the vessel along the entire length of the ultrasound probe. Keep the ultrasound steady during the procedure and insert the needle at an angle at the lateral edge of the ultrasound probe. Using this technique, one can visualize the entire length of the needle

Removing a Central Line:

1. Place patient in supine or Trendelenburg position (for femoral removal can help decrease bleeding)

2. Remove suturing and dressing.

3. Hold pressure for approximately one minute to stop bleeding.

4. Dress with a sterile dressing.

5. If central line-related infection is suspected, cut off the tip with sterile scissors and send for culture.

References

Femoral:

1. Dailey RH. Femoral Vein Cannulation: A Review. The Journal of Emergency Medicine 1985; (2):367-372.

2. Swanson RS, Uhlig PN, Gross PL, et al. Emergency Intravenous Access Through the Femoral Vein. Annals of Emergency Medicine 1984; 13(4):244-247.

3. Lim T, Ryu H-G, et al. Effect of the Bevel Direction of Puncture Needle on Success Rate and Complications During Internal Jugular Vein Catheterization. Critical Care Medicine 2012; 40 (October 6): epub ahead of print.

4. McGee DC, Gould MK. Preventing Complications of Central Venous Catheterization. The New England Journal of Medicine 2003; 348:1123-33.

5. Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: A systemic review of the literature and meta-analysis. Critical Care Medicine 2012; 40(8):2479-2485.

Figure 1: Ultrasound showing internal jugular vein and artery with and without compression

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Figure 2: J tip straightening using pinch/stretch method

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Figure 3: Angiocath that can be used in difficult to cannulate/wire patients

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Figure 4: Length: marking seen on typical central venous catheters, number indicates in centimeters from distal tip

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Figure 5: Short and Long axis views of Internal jugular vein

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