ArticlePDF Available

The occasional femoral line

Authors:

Figures

Content may be subject to copyright.
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 efciently 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 hemoltration
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 benets 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). Conrm 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
conrm 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, conrm venous
placement of the wire before use of the line. Also
conrm the nal position of the catheter tip, which
should lie in the inferior vena cava below the renal
veins and above the conuence 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.Conrmation 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.
9. Practice guidelines for central venous access: a report by the
American Society of Anesthesiologists Task Force on Central
Venous Access. Anesthesiology 2012;116:539-73.
106
Can J Rural Med 2013;18(3)
Fig. 9. Securing of the catheter.
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Patient safety has received increased attention in recent years, but mostly with a focus on the epidemiology of errors and adverse events, rather than on practices that reduce such events. This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety. SEARCH STRATEGY AND SELECTION CRITERIA: Patient safety practices were defined as those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions. Potential patient safety practices were identified based on preliminary surveys of the literature and expert consultation. This process resulted in the identification of 79 practices for review. The practices focused primarily on hospitalized patients, but some involved nursing home or ambulatory patients. Protocols specified the inclusion criteria for studies and the structure for evaluation of the evidence regarding each practice. Pertinent studies were identified using various bibliographic databases (e.g., MEDLINE, PsycINFO, ABI/INFORM, INSPEC), targeted searches of the Internet, and communication with relevant experts. Included literature consisted of controlled observational studies, clinical trials and systematic reviews found in the peer-reviewed medical literature, relevant non-health care literature and "gray literature." For most practices, the project team required that the primary outcome consist of a clinical endpoint (i.e., some measure of morbidity or mortality) or a surrogate outcome with a clear connection to patient morbidity or mortality. This criterion was relaxed for some practices drawn from the non-health care literature. The evidence supporting each practice was summarized using a prospectively determined format. The project team then used a predefined consensus technique to rank the practices according to the strength of evidence presented in practice summaries. A separate ranking was developed for research priorities. Practices with the strongest supporting evidence are generally clinical interventions that decrease the risks associated with hospitalization, critical care, or surgery. Many patient safety practices drawn primarily from nonmedical fields (e.g., use of simulators, bar coding, computerized physician order entry, crew resource management) deserve additional research to elucidate their value in the health care environment. The following 11 practices were rated most highly in terms of strength of the evidence supporting more widespread implementation. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk; Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality; Use of maximum sterile barriers while placing central intravenous catheters to prevent infections; Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections; Asking that patients recall and restate what they have been told during the informed consent process; Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia; Use of pressure relieving bedding materials to prevent pressure ulcers; Use of real-time ultrasound guidance during central line insertion to prevent complications; Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications; Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients; and Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections. An evidence-based approach can help identify practices that are likely to improve patient safety. Such practices target a diverse array of safety problems. Further research is needed to fill the substantial gaps in the evidentiary base, particularly with regard to the generalizability of patient safety practices heretofore tested only in limited settings and to promising practices drawn from industries outside of health care.
Article
Catheter-related bloodstream infections are an important cause of morbidity and mortality in hospitalized patients. Current guidelines recommend that femoral venous access should be avoided to reduce this complication (1A recommendation). However, the risk of catheter-related bloodstream infections from femoral as compared to subclavian and internal jugular venous catheterization has not been systematically reviewed. A systematic review of the literature to determine the risk of catheter-related bloodstream infections related to nontunneled central venous catheters inserted at the femoral site as compared to subclavian and internal jugular placement. MEDLINE, Embase, Cochrane Register of Controlled Trials, citation review of relevant primary and review articles, and an Internet search (Google). Randomized controlled trials and cohort studies that reported the frequency of catheter-related bloodstream infections (infections per 1,000 catheter days) in patients with nontunneled central venous catheters placed in the femoral site as compared to subclavian or internal jugular placement. Data were abstracted on study design, study size, study setting, patient population, number of catheters at each insertion site, number of catheter-related bloodstream infections, and the prevalence of deep venous thrombosis. Studies were subgrouped according to study design (cohort and randomized controlled trials). Meta-analytic techniques were used to summarize the data. Two randomized controlled trials (1006 catheters) and 8 cohort (16,370 catheters) studies met the inclusion criteria for this systematic review. Three thousand two hundred thirty catheters were placed in the subclavian vein, 10,958 in the internal jugular and 3,188 in the femoral vein for a total of 113,652 catheter days. The average catheter-related bloodstream infections density was 2.5 per 1,000 catheter days (range 0.6-7.2). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian/internal jugular sites in the two randomized controlled trials (i.e., no level 1A evidence). There was no significant difference in the risk of catheter-related bloodstream infections between the femoral and subclavian sites. The internal jugular site was associated with a significantly lower risk of catheter-related bloodstream infections compared to the femoral site (risk ratio 1.90; 95% confidence interval 1.21-2.97, p=.005, I²=35%). This difference was explained by two of the studies that were statistical outliers. When these two studies were removed from the analysis there was no significant difference in the risk of catheter-related bloodstream infections between the femoral and internal jugular sites (risk ratio 1.35; 95% confidence interval 0.84-2.19, p=0.2, I=0%). Meta-regression demonstrated a significant interaction between the risk of infection and the year of publication (p=.01), with the femoral site demonstrating a higher risk of infection in the earlier studies. There was no significant difference in the risk of catheter-related bloodstream infection between the subclavian and internal jugular sites. The risk of deep venous thrombosis was assessed in the two randomized controlled trials. A meta-analysis of this data demonstrates that there was no difference in the risk of deep venous thrombosis when the femoral site was compared to the subclavian and internal jugular sites combined. There was, however, significant heterogeneity between studies. Although earlier studies showed a lower risk of catheter-related bloodstream infections when the internal jugular was compared to the femoral site, recent studies show no difference in the rate of catheter-related bloodstream infections between the three sites.
Article
Femoral vein catheterization has advantages over subclavian vein catheterization during cardiac arrest in that there is minimal interference to ongoing CPR. In addition, risks of subclavian catheterization are not a factor in femoral vein catheterization. Few studies have compared the success rate for catheterization of one site with that of the other during cardiac arrest. We conducted a prospective study to compare the success and complication rates for femoral with those of subclavian vein catheterization. Ninety-four patients undergoing CPR had either femoral or subclavian vein catheters placed during the course of the arrest. Catheter placement was verified by injection of radiopaque contrast material. We found that the success rate for femoral catheterization was 77% compared with a success rate of 94% for subclavian vein catheterization (P less than .05). There were no instances of pneumothorax with subclavian vein catheterization. There was no apparent learning curve leading to an increased success rate during the course of the study. We conclude that femoral vein catheterization should not be used except in those instances where attempts at peripheral and central venous cannulation are unsuccessful.
Article
To provide current information related to central venous catheterization. Review of literature relevant to central venous catheterization and its indications, insertion techniques, and prevention of complications. Central venous catheterization can be lifesaving but is associated with complication rates of approximately 15%. Operator experience, familiarity with the advantages and disadvantages of the various catheterization sites, and strict attention to detail during insertion help in reducing mechanical complications associated with catheterization. Strict aseptic technique and proper catheter maintenance decrease the frequency of catheter-related infections. Appropriate catheter and site selection, sufficient operator experience, careful technique, and proper catheter maintenance with removal as soon as possible are associated with optimal outcome.
Article
A femoral venous catheter may be necessary when peripheral access to the circulatory system is compromised and no other sites for placing a central catheter are available. This video demonstrates the insertion of a femoral venous catheter and explains the indications and potential complications.
Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access
Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 2012;116:539-73.