What are some special considerations for placing a femoral central venous catheter?

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Elsevier ClinicalKey Clinical Overview

Screening and Prevention American Society of Anesthesiologists recommends avoiding insertion of central line at femoral site, if possible, due to increased risk of thrombosis Use of saline or heparin flush after catheter injection or infusion

Screening and Prevention For access procedures Whenever possible, correct risk factors such as hypovolemia Positioning Lower the head of the bed during central venous catheter placements in the neck or SC vein (Trendelenburg position) For femoral line placements, maintain neutral bed position or slightly head up (reverse Trendelenburg) so that the insertion site is below the level of the heart Avoid exposing the open end of the needle or catheter to the atmosphere, particularly during inspiration. Place a finger over the open end while manipulating the wire, for example. Ask awake patients who are breathing spontaneously to hold their breath during these maneuvers Apply an occlusive dressing after placement—antibiotic ointment can help "seal" the catheter site under the dressing For maintenance of central lines Connect all lines to a collapsible fluid source (eg, IV bag) that cannot entrain air Ensure all stopcocks are turned off when not in use Cap all lines after flushing when not connected to an IV fluid source Regularly inspect lines for loose connections, cracks, or broken seals Check all injecting syringes and remove any air before injection Maintain occlusive dressing over catheter site: air can be entrained through the catheter tract and not just the catheter itself. During dressing changes, maintain occlusive covering with gauze For central line removal Position the patient supine for central line removal Awake patients should be asked to hold their breath and perform a Valsalva maneuver as the catheter is being removed. If a patient is spontaneously breathing but cannot cooperate, remove the catheter during exhalation Cover the site immediately. Antibiotic ointment can help seal the site, followed by an occlusive dressing. Maintain an occlusive dressing for 24 hours Various authors recommend that the patient remain supine for 30 to 60 minutes after central venous catheter removal

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Kern, Morton J., Seto, Arnold H., Herrmann, Joerg (2022). In Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine (pp. 385). DOI: 10.1016/B978-0-323-72219-3.00022-0

Using the femoral arterial pulse as a landmark, the femoral vein sits approximately 1 cm medial to the femoral artery. If a combined arterial and venous access is needed, the entry skin area is infiltrated by lidocaine sufficient to cover both puncture sites. The venous puncture site is 0.5 to 1 cm medial and 0.5 to 1 cm caudal to the planned arterial entry site. Because venous pressure is low, a 10- or 20-mL syringe is attached to the Seldinger needle and gently aspirated during needle advancement. The operator inserts the needle through the skin at a 30- to 45-degree angle to the horizontal plane while palpating the femoral arterial pulse with light pressure so as to not occlude the vein. If arterial pulsations are felt at the tip of the needle, the needle is withdrawn and redirected at a slightly more medial angle. Ultrasound imaging guidance can improve successful cannulation and reduce accidental arterial puncture. Upon entry of the vein, venous (nonpulsatile) dark blood should flow easily into the syringe. If the vein has not been entered, the needle is withdrawn,flushed, and reintroduced in a slightly more lateral or medial direction. The remainder of the venous sheath placement is completed in the same fashion as described for the femoral arterial sheath insertion. A vein that has been entered mistakenly during a femoral artery puncture attempt should be used only if the needle tip did not puncture both walls of the artery and go into the vein behind it. Placing a sheath through the artery into the vein may create an arteriovenous (AV) fistula or cause uncontrolled bleeding from a large hole in the posterior wall of the femoral artery. After the procedure is completed, venous hemostasis can be achieved with light finger pressure applied over the vein as described for femoral artery sheath removal. Usually only 5 to 10 minutes of compression is needed to obtain adequate hemostasis.

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Elsevier ClinicalKey Clinical Overview

Screening and Prevention A full review of prevention of vascular catheter–associated infections is beyond the scope of this Clinical Overview. The following are considered "essential practices" with moderate to high quality of evidence to prevent CLABSI (central line–associated bloodstream infection) in health care facilities by the Society of Healthcare Epidemiology of America: Before insertion of vascular catheter Develop and provide easy access to an evidence-based list of indications for CVC placement (central venous catheter) Require education and competency assessment of health care practitioner involved in insertion, care, and maintenance of CVCs about CLABSI prevention Bathe ICU patients aged older than 2 months with a daily chlorhexidine preparation At insertion Use a checklist or other process to ensure adherence to infection prevention practices Perform hand hygiene before catheter insertion or manipulation In adults, nontunneled catheters inserted in the ICU should be placed preferentially in the subclavian vein rather than in the internal jugular or femoral vein, as long as there are no contraindications to subclavian vein placement (eg, risk of subclavian vein stenosis, operator skill) In children and infants, the risk of infection due to femoral catheterization is similar to that of other sites. Tunneled femoral catheters may reduce the risk of infection compared with nontunneled femoral catheters Use an all-inclusive catheter kit or cart Use ultrasonography guidance for catheter insertion Use maximum sterile barrier precautions Use at least 2% chlorhexidine gluconate solution to prepare the skin before insertion. May use 70% alcohol and tincture of iodine or an iodophor if there is a contraindication to chlorhexidine After insertion (maintenance) Ensure appropriate nurse to patient ratio and limit the use of float nurses in the ICU Use chlorhexidine-containing dressings for CVCs in patients older than 2 months