Overview
Definition:
Central venous catheter (CVC) insertion via the femoral vein is a medical procedure to place a catheter into the large veins of the groin, typically the common femoral vein, for accessing the central venous circulation
This provides a route for administering fluids, medications, nutritional support, and for hemodynamic monitoring.
Epidemiology:
Femoral vein catheterization is a common ICU and emergency procedure
rates vary by institution and patient population
While rates of complication are generally higher compared to subclavian or internal jugular approaches, its ease of access and lower pneumothorax risk make it a frequent choice, especially in emergent situations or when other sites are contraindicated.
Clinical Significance:
Femoral CVCs are crucial for critically ill patients requiring prolonged venous access for vasopressors, inotropes, chemotherapy, parenteral nutrition, and fluid resuscitation
Understanding proper technique, indications, and potential complications is vital for surgical residents preparing for DNB and NEET SS examinations, impacting patient outcomes and safety.
Indications
Common Indications:
Need for prolonged IV access for medications or fluids
Administration of hyperosmolar solutions (e.g., TPN, hypertonic saline)
Hemodynamic monitoring (e.g., central venous pressure)
Hemodialysis or plasmapheresis access
Rapid fluid resuscitation in trauma or shock
Patients with coagulopathy or anatomical challenges at other sites.
Emergent Indications:
Cardiopulmonary arrest
Severe hypovolemic shock
Contraindications to other sites (e.g., severe cervical spine injury, pneumothorax).
Contraindications:
Local infection at the insertion site
Lack of palpable landmark
Significant coagulopathy or bleeding diathesis (relative contraindication)
Thrombosis of the femoral vein
Ipsilateral limb paralysis or vascular insufficiency.
Preoperative Preparation
Patient Assessment:
Assess for bleeding risk (platelet count, INR, PTT)
Review previous vascular access attempts and anatomical variations
Identify allergies
Obtain informed consent.
Equipment Checklist:
Sterile gown, gloves, mask, and drapes
Antiseptic solution (e.g., chlorhexidine)
Local anesthetic (e.g., lidocaine 1-2%)
Syringe and needles for local anesthetic
Sterile saline
Ultrasound machine with sterile probe cover and gel
Central venous catheter kit (appropriate French size, length, and number of lumens)
Introducer needle
Guidewire
Dilator
Catheter
Suture material
Dressing materials (e.g., sterile gauze, transparent dressing)..
Patient Positioning:
Place the patient in a supine position
A slight Trendelenburg position may be beneficial to distend the femoral vein
Expose the groin area bilaterally
Prepare the skin with antiseptic solution using sterile technique.
Ultrasound Guidance:
Utilize ultrasound to identify the common femoral artery and vein
The common femoral vein is typically larger, anechoic, compressible, and located medial to the femoral artery
Mark the intended insertion site
Continuous ultrasound guidance improves success rates and reduces complications.
Procedure Steps
Landmark Identification:
Locate the inguinal ligament and the bifurcation of the common femoral artery
The common femoral vein lies medial and slightly posterior to the common femoral artery.
Local Anesthesia:
Infiltrate the skin and subcutaneous tissue with local anesthetic at the planned insertion site and along the anticipated path of the guidewire.
Vein Puncture:
With the ultrasound probe in place or using anatomical landmarks, insert the introducer needle at a 30-45 degree angle cephalad, aiming towards the ipsilateral iliac vein
Aspirate gently as the needle is advanced
a flash of venous blood indicates entry into the vein
If using ultrasound, visualize the needle tip entering the vein.
Guidewire Insertion:
Once venous access is confirmed, remove the syringe from the needle and advance the guidewire through the needle into the vein
Ensure smooth advancement without resistance
if resistance is met, withdraw and reposition
Secure the guidewire in place.
Catheter Insertion:
Remove the introducer needle, leaving the guidewire in situ
Advance the tissue dilator over the guidewire to create a tract
Remove the dilator
Thread the central venous catheter over the guidewire until the desired depth is reached, ensuring the appropriate number of lumens are positioned correctly in the superior vena cava or right atrium junction (audible "crunch" may be felt as it passes through the vein wall).
Guidewire Removal And Flushing:
Remove the guidewire
Immediately cap and flush each lumen of the catheter with sterile saline to confirm patency and prevent clotting
Aspirate blood from each lumen to check for proper venous placement and absence of arterial pulsatile flow.
Securement And Dressing:
Secure the catheter with a stat lock device or sutures
Apply a sterile occlusive dressing (e.g., transparent semipermeable membrane) over the insertion site
Document catheter size, insertion date, time, and location
Obtain a chest X-ray to confirm tip placement and rule out pneumothorax or pleural effusion.
Postoperative Care
Monitoring:
Monitor vital signs closely
Assess for signs of infection (redness, swelling, purulent discharge) at the insertion site
Monitor for signs of bleeding or hematoma formation.
Flushing And Locking:
Flush each lumen with saline before and after each use and lock with heparinized saline or appropriate preservative solution as per institutional protocol to prevent thrombosis.
Dressing Changes:
Change dressings using strict aseptic technique every 48-72 hours or if soiled or loose.
Removal Criteria:
Remove the catheter as soon as it is no longer clinically indicated
In adults, femoral CVCs are generally removed within 7 days if possible, due to increased risk of VTE and infection compared to other sites.
Complications
Early Complications:
Arterial puncture or laceration
Hematoma formation
Bleeding
Pneumothorax (less common with femoral approach but possible if needle goes too high)
Air embolism
Arrhythmias (if catheter tip is in right atrium)
Nerve injury
Thrombosis of the femoral vein
Catheter malposition.
Late Complications:
Catheter-related bloodstream infection (CRBSI)
Deep vein thrombosis (DVT) of the femoral vein
Superior vena cava syndrome (rare with femoral)
Catheter occlusion or fracture
Endocarditis (rare).
Prevention Strategies:
Meticulous sterile technique during insertion and dressing changes
Use of ultrasound for guidance
Proper patient selection and contraindication screening
Appropriate catheter material and lumen size
Adequate flushing and locking of lumens
Timely removal of the catheter
Patient education on signs of complications.
Key Points
Exam Focus:
Understand the anatomical landmarks of the femoral triangle for venous access
Differentiate femoral artery from vein using ultrasound characteristics (compressibility)
Know the complications specific to femoral vein catheterization, particularly DVT and infection
Recognize the importance of sterile technique and appropriate catheter care.
Clinical Pearls:
Always use ultrasound guidance for femoral vein access if available
it significantly reduces complications
A slight Trendelenburg position can help distend the vein
If arterial puncture occurs, do not remove the needle
apply firm pressure and consider other access routes
Consider the risks of DVT with prolonged femoral catheter use and opt for removal or alternative sites when possible.
Common Mistakes:
Failure to use sterile technique
Inadequate local anesthesia
Incorrect needle angle or depth leading to arterial puncture or malposition
Forgetting to remove the guidewire before flushing
Not flushing lumens adequately
Delayed catheter removal when no longer indicated
Not obtaining post-insertion imaging when indicated.