Central line: femoral

Indications

• High volume/flow resuscitation
• Emergency venous access
• Inability to obtain peripheral venous access
• Repetitive blood sampling
• Administering hyperalimentation, caustic agents, or other concentrated fluids
• Hemodialysis or plasmapheresis

Contraindications

• Infection over the placement site
• Distortion of landmarks by trauma or congenital anomalies
• Current venous thrombosis in target vessel
• Prior vessel injury or procedures
• Morbid obesity
• Uncooperative patient
• Intraabdominal hemorrhage
• Injury to pelvis

Central line if coagulopathic

• Preferentially use a compressible site such as the femoral location (avoid the IJ and subclavian if possible, though IJ preferred over subclavian)
• No benefit to giving FFP unless artery is punctured
  • However, consider giving FFP if patient has hemophilia

Equipment Needed

• CVC kit: typical contents:
  • Clorhexidine
  • Sterile drape
  • 1% lidocaine without epinephrine
  • 5 mL syringe (for lidocaine)
  • 22-ga and 25-ga needles (for lidocaine)
  • 5 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, sterile gloves
• For ultrasound guided placement
  • Ultrasound machine and probe (vascular probe)
  • Sterile probe cover with sterile gel
• Biopatch
• Sterile caps for lumen ports
• Tegaderm
• Sterile saline

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

• Central lines

Sources

Roberts & Hedges 6e, pp 397-431