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Circulation - Central Venous Access (femoral)

Indications

Infusion of irritant and vasoactive substances

Inadequate peripheral venous access

Extracorporeal therapies (haemodialysis or apheresis)

Central venous pressure monitoring

Transvenous pacing

Contraindications (absolute in bold)

Proximal vascular injury

Obstructed vein

Coagulopathy (APTT >50 seconds, INR >1.5, platelets <50,000/mm3)

Antiplatelet medications or NOACs

Overlying infection

Uncooperative patient

Alternatives

Internal jugular central venous access

Peripheral IV access (consider reduced concentrations for infusions)

Intraosseous access

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Failure (failed cannulation, catheter misplacement)

Bleeding and haematoma

Arterial puncture

Air embolus

Shearing or loss of guidewire

Nerve damage

Vascular damage (erosion and stenosis)

Thrombosis

Infection (local and systemic)

Procedural hygiene

Standard precautions

Surgical aseptic non-touch technique

PPE: sterile gloves and gown, surgical mask, eye protection, sterile ultrasound probe cover

Area

Resuscitation bay

Staff

Procedural clinician and nurse

Equipment

Ultrasound and sterile probe cover

Catheter: multi-lumen, ideally rated for contrast injection under pressure

Catheter set: syringe and needle, guidewire, dilator, fixation, saline and syringe, suture and set

Swappable capless valves for each lumen

Drawing up needle and 25g needle with 5ml syringe for lignocaine

Sterile transparent semipermeable dressing

Positioning

Supine on incline with head elevated

External rotation at the hip and leg extension

Insertion site: lateral to the pubic tubercle, 1cm medial to the femoral artery (location of the pulse)

Medication

10ml lignocaine 1%

Consider analgesia and sedation

Sequence

Set up equipment and flushes all lumens with 0.9% Saline

ultrasound identification of femoral vein (confirm vein is compressible and locate artery)

Anaesthetise skin and soft tissue with lignocaine

Insert needle for guidewire under ultrasound guidance, aspirating until you withdraw blood

Remove syringe and thread guidewire through needle (or pass through syringe with some kits)

Insert guidewire to a depth of 15cm

Removing needle after wire placement and confirm that the guidewire is in a vein (using ultrasound)

Use scalpel to lance a tract (through skin only) next to the guidewire

Thread dilator 6-8cm over wire into the vein

Thread the catheter over the wire, making sure you always visualise and hold the guidewire

Remove wire and lock catheter to prevent flow of blood

Confirm that the guidewire is complete, and the tip has not been damaged

Aspirate and flush all lumens

Suture at the skin and at the anchor point (if present)

Apply sterile transparent semipermeable dressing

Post-procedure care

Use line as required

Monitor insertion site for bleeding

Documentation (completion, technique, attempts, guidewire removal, complications)

Tips

Maintain light pressure only with ultrasound probe to avoid vessel compression

Cannulate just below the inguinal ligament to avoid arterial puncture (artery superficial to vein distally)

Catheters placed in an artery, should be discussed with vascular before removal (correct clotting, direct pressure)

Discussion

The internal jugular route has the least acute complications (after PICC) and more often result in a satisfactory catheter location. It is our preferred site for central venous catheter insertion.

The femoral route is commonly useful when the patient cannot lie supine on an incline with the head down. The subclavian route has the lowest rates of infection, but the greatest risks of pneumothorax and serious haemorrhage. Although sometimes useful for emergency vascular access in an arrest, we do not recommend the routine use of this route for initial central lines.

This contrasts to the Australian and New Zealand Intensive Care Society which generally preferences the subclavian route due to the low infection rates.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Australian and New Zealand Intensive Care Society [Internet]. Melbourne; 2012. ANZICS Safety and Quality Committee. 18pp. Available from: www.clabsi.com.au and www.anzics.com.au

American Society of Anesthesiologists Task Force on Central Venous Access, Rupp SM, Apfelbaum JL, et al. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2012;116(3):539-573. doi:10.1097/ALN.0b013e31823c9569

Murgo M, Spencer T, Breeding J, Alexandrou E, Baliotis B, Hallett T, Guihermino M, Martinich I, Frogley M, Denham J, Whyte R, Ray-Barruel B and Richard C. Central venous access device – post insertion management. Sydney: ACI; 2014. 978-1-74187-953-7

Smith RN, Nolan JP. Central venous catheters. BMJ. 2013;347:f6570. Published 2013 Nov 11. doi:10.1136/bmj.f6570

Saugel B, Scheeren TWL, Teboul JL. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care. 2017;21(1):225. Published 2017 Aug 28. doi:10.1186/s13054-017-1814-y

Czepizak CA, O'Callaghan JM, Venus B. Evaluation of formulas for optimal positioning of central venous catheters. Chest. 1995;107(6):1662-1664. doi:10.1378/chest.107.6.1662

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Chopra V. Central venous access devices and approach to device and site selection in adults. In: UpToDate. Waltham (MA): UpToDate. 2019. Available from: https://www.uptodate.com/contents/central-venous-access-devices-and-approach-to-device-and-site-selection-in-adults

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