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)

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)

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.

    When 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.

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

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

 Dilation

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

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

    Remove the dilator, leaving the guidewire in place

 Catheter Placement

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

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

    Withdraw the guidewire through the catheter

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

 Confirmation

    Manometry

    Blood gas analysis

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

    Postprocedure chest x-ray (CXR)

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

    Rule out pneumothorax

 Flush and Secure

    Aspirate, flush, and heplock each central line lumen

    Suture the catheter to the skin using silk or nylon sutures

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

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