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F
emoral vein catheters are used
in the rural setting to gain rap -
id intravenous access during
trauma and cardiopulmonary resuscita-
tion. The advantages of using the femoral
vein are its large diameter and noninter-
ference with cardiac compressions or
intubation.1Additionally, there are no
risks of pneumothorax with cath eter
insertion into a femoral vein, and it is
easily compressed if bleeding occurs.2
This article outlines the steps required to
gain central venous access via the fem -
oral vein.
INDICATIONS
• Obtaining vascular access quickly
and efciently when peripheral veins
are inaccessible.3
• Infusing uids or blood products in
critically ill patients.3
• Administering potent vasoactive
drugs, such as norepinephrine and
dopamine, as well as solutions that
are irritating or hypertonic, such as
potassium chloride.3
• Measuring central venous pressure
(e.g., during sepsis, congestive heart
failure or pericardial effusion).
• Performing acute and subacute he -
mo dialysis, as well as hemoltration
and cardiac pacing.3
• Administering nutritional therapy
(total parenteral nutrition).
CONTRAINDICATION
The only contraindication to this poten-
tially life-saving procedure is refusal by
a competent patient.
RELATIVE
CONTRAINDICATIONS
• Femoral vein catheters should not
be used if a safer option exists.
• Sites with anatomic distortion, cuta-
neous burns, proximal vascular in -
jury (e.g., thrombus) and infection
should be avoided when inserting the
femoral catheter, because complica-
tions are more likely to occur.
• Patients with coagulopathies are at
higher risk of hemorrhage.4
• Do not use the femoral vein as a site
for central venous access in cases of
penetrating abdominal trauma or
known vena cava disruption.
COMPLICATIONS
One study reports that more than 15% of
patients who undergo venous catheteriza-
tion for central venous access experience
complications.1The most common com-
plications include arterial puncture, infec-
tion, thrombosis and hematoma. Femoral
vein catheters are associated with a higher
thrombosis rate than all other central
venous access sites.1Despite the femoral
line’s reputation as a “dirty” site, a recent
study has shown no difference between
catheter-insertion sites in the rate of
catheter-related bloodstream infections.5
Femoral vein catheterization is recom-
mended for short-term use, and femoral
venous lines should be removed when no
longer needed to avoid complications.2
THEORY
The femoral vein travels in the femoral
101
The occasional femoral line
The Practitioner
Le praticien
Dominique R. Ansell,
MSc, MD
Sarah M. Giles, MD,
CCFP, DTM&H
Department of Family
Medicine, Faculty of
Medicine, University of
Ottawa, Ottawa, Ont.
Correspondence to: Sarah
Giles; smgiles@dal.ca
This article has been peer
reviewed.
© 2013 Society of Rural Physicians of Canada Can J Rural Med 2013;18(3)
sheath with the femoral artery, nerve and lymphatics.
Anatomically, the femoral vein lies behind the inguinal
ligament, about 1 cm below it, and just medial to the
femoral artery. It is located very close to the skin and
is easily accessible.6
EQUIPMENT
• Sterile personal protective gear (e.g., gloves, gown
and mask)
• Sterile drape and towels
• Sterile preparation solution (e.g., chlorhexidine)
• Three 10-mL syringes containing sterile normal
saline ush
• 3 intravenous caps
• Ultrasound machine (if available)
• Sterile sheath for ultrasound probe
• Coupling gel for ultrasound probe
• Central venous catheter set containing
- 1% lidocaine, small-gauge needle and 10-mL
syringe
- 18-gauge introducer needle
- Guidewire
- #11-blade scalpel
- Venodilator
- Single- or multilumen catheter
- Gauze pads measuring 4" × 4"
- 3–0 or 4–0 silk suture with straight needle or
needle driver
- Sterile transparent dressing
ULTRASOUND GUIDANCE
If available, ultrasound guidance is highly recom-
mended during central venous catheterization.
As reported by Rothschild7and by Cheung and
colleagues,8ultrasound guidance of central lines
improves success rates for catheter insertion. Ultra-
sound guidance also reduces the number of veni -
puncture attempts before successful line insertion,
and reduces the risk of complications.7,8
CONSENT
Before attempting the procedure, explain it to the
patient and discuss possible complications. Obtain
consent after ensuring the patient understands the
risks and benets of femoral vein catheterization. In
an emergency situation, consent is implied.
THE PROCEDURE
1. The insertion of a femoral catheter should be
performed under sterile conditions. Ensure that
you are gowned and gloved, and wearing a facial
mask and hair cover before beginning. After
Multilumen catheter
Hubs to secure catheter
Guidewire
Central line kit
IV caps
18-gauge introducer needle
Venodilator
Fig. 1. A standard central venous catheter kit by Arrow Medical Products. IV = intravenous.
Can J Rural Med 2013;18(3)
102
donning protective gear, open the standard kit
(Fig. 1).
2. Expose the patient’s femoral region by externally
rotating and abducting the patient’s leg away
from the midline. Clean the groin area with dis-
infectant (chlorhexidine) 3 times with 3 different
sterile sponges. Place a large sterile sheet on the
patient’s upper body and legs to create a sterile
eld. Palpate for the femoral artery to anatom -
ically locate the femoral vein, which will be me -
dial to the femoral artery. Inject 1–2 mL of 1%
lidocaine subcutaneously using the small (25-
gauge) needle to freeze the skin.
3. If bedside ultrasonography is available, use a lin-
ear probe to localize the femoral vein (Fig. 2).
Orient the probe so that the patient’s right side is
on the right of the ultrasound monitor. If possi-
ble, place the probe in a sterile sheath with coup -
ling gel inside. The femoral vein is collapsible,
whereas the artery is not. Position the vein in the
centre of the ultrasound monitor (Fig. 3).
4. Insert the 18-gauge introducer needle at a 30-
degree angle from the skin while pulling back on
the plunger of the syringe (Fig. 4). Conrm that
the needle is in an appropriate position, with the
help of the ultrasound images. Ultrasonography,
venous manometry, pressure-waveform analysis
or venous blood gas measurement can be used to
conrm placement of the catheter. Once you
observe a return of blood in the syringe, manu -
ally anchor the needle to avoid dislodging it. The
blood seen in the syringe should be dark and
nonpulsatile.
5. Detach the syringe and thread the guidewire
through the needle (Fig. 5). The guidewire
comes wrapped in a circular tube and has a plas-
tic adaptor that feeds it into your needle. The
guidewire has a folded tip that prevents it from
lacerating the vein. It should pass smoothly and
without resistance into the femoral vein. If you
feel resistance, stop and evaluate the source.
Once the guidewire is in the femoral vein, grasp
Fig. 2. Localization of the femoral vein using ultrasonography.
103
Can J Rural Med 2013;18(3)
the guidewire rmly and remove the introducer
needle (Fig. 6). Secure the guidewire to ensure it
does not get lost inside the body (Fig. 7).
6. Pass the venodilator over the guidewire. At the
skin, use the scalpel to make a small (0.5 cm)
incision at the wire-entry site while maintaining
a hold of your guidewire. Next, advance the
veno dilator over the wire to create a tract for the
catheter.
7. Remove the venodilator from the femoral vein
while continuing to hold on to the guidewire.
Next, place the multilumen catheter on the
guidewire and advance it into the femoral vein
(Fig. 8). The guidewire will be pushed out of the
port of the multilumen catheter. Remove the
guidewire. Once the guidewire is removed,
blood will ow up from the lumen of the
catheter. The ow of blood will clear the air
from the line. You can now attach the intra-
venous cap to a 10-mL syringe and ush normal
Fig. 3. Ultrasound images of the femoral vein (FV) and femoral artery (FA). The image on the left shows the
femoral vein uncompressed, and the image on the right shows the femoral vein being compressed by the
ultrasound probe. Images courtesy of A. Smith and B. Metcalfe at Memorial University.
Fig. 4. Insertion of the introducer needle with ultrasound guidance.
Fig. 5. Feeding of the guidewire through the introducer needle.
Can J Rural Med 2013;18(3)
104
saline through the cap. Do the same for the
other lumens of the catheter: bleed them back,
attach the intravenous cap and then ush.
8. Secure the catheter by placing sutures through
the hub openings on each side of the catheter
(Fig. 9).
AFTER FEMORAL LINE INSERTION
After completion of the procedure, conrm venous
placement of the wire before use of the line. Also
conrm the nal position of the catheter tip, which
should lie in the inferior vena cava below the renal
veins and above the conuence of the iliac veins.
This last step can be done with abdominal radiogra-
phy, uoroscopy or continuous electrocardiography.
However, radiography would be the likely method
of choice in a rural location.9
CONCLUSION
The femoral vein provides a reliable site for central
venous access and is relatively easy to catheterize. It
is an advantageous site because it does not cause
lung collapse or carotid punctures during insertion.
Good aseptic technique and ultrasonographic assis-
tance have led to successful femoral line insertions
Fig. 6. Feeding of the guidewire into the femoral vein.
Can J Rural Med 2013;18(3)
Fig. 7. Securing of the guidewire.
Fig. 8. Insertion of the multilumen catheter.
105
and minimal complications.4Remember to remove
central venous catheters as soon as possible to avoid
complications and to reassess daily the need for
keeping the catheter in place.2
PROCEDURE SUMMARY
1. Sterile preparation and equipment set-up
2.Positioning of the patient and locating of the
femoral vein
3. Anesthesia
4. Location of the vein with ultrasonography
5. Placement of the introducer needle in the vein
6.Assessment of catheter placement with ultra-
sonography
7. Insertion of the guidewire
8. Removal of the introducer needle
9. Skin incision
10.Insertion of the venodilator and catheter
11.Removal of the dilator and guidewire
12.Flushing and capping of the lumens
13.Securing of the catheter
14.Conrmation of catheter tip position before use
of the central line
Acknowledgements: The authors thank Andrew Smith and
Brian Metcalfe at Memorial University for providing the ultra-
sound images of the femoral vein and artery. We also thank
James Crispo for his help with the images in the paper. Lastly,
we thank the University of Ottawa Skills and Simulation Cen-
tre for the use of their equipment to generate the images.
Competing interests: None declared.
REFERENCES
1. Emerman CL, Bellon EM, Lukens TW, et al. A prospective study
of femoral versus subclavian vein catheterization during cardiac
arrest. Ann Emerg Med 1990;19:26-30.
2. Burchell PL, Powers KA. Focus on central venous pressure moni-
toring in an acute care setting. Nursing 2011;41:38-43.
3. Taylor RW, Ashok V, Palagiri V. Central venous catheterization.
Crit Care Med 2007;35:1390-6.
4. McGee DC, Gould MK. Preventing complications of central
venous catheterization. N Engl J Med 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 systematic
review of the literature and meta-analysis. Crit Care Med 2012; 40:
2479-85.
6. Tsui JY, Collins AB, White DW, et al. Placement of a femoral
venous catheter. N Engl J Med 2008;358:e30.
7. Rothschild JM. Ultrasound guidance of central vein catheteriza-
tion. In: Shojania KG, Duncan BW, McDonald KM, et al., editors.
Making health care safer: a critical analysis of patient safety prac-
tices. Rockville (MD): Agency for Healthcare Research Quality
Archives; 2001. p. 245-53. Available: http://archive .ahrq .gov /clinic
/ptsafety /chap21 .htm (accessed 2013 Mar. 16).
8. Cheung E, Baerlocher MO, Asch M, et al. Venous access: a prac -
tical review for 2009. Can Fam Physician 2009;55:494-6.
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American Society of Anesthesiologists Task Force on Central
Venous Access. Anesthesiology 2012;116:539-73.
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Can J Rural Med 2013;18(3)
Fig. 9. Securing of the catheter.