critical care medicine
How To Do Femoral Vein Cannulation
Step by Step Description of Procedure
Do a preliminary inspection (nonsterile) to identify the symphysis pubis, anterior superior iliac crest, femoral pulse, and umbilicus. Attach the cardiac monitor to the patient and turn it on. Excess hair may be clipped but not shaved from the site. Shaving increases the risk of infection. Place sterile equipment on sterilely covered equipment trays. Dress in sterile garb and use barrier protection. Draw the local anesthetic into a syringe. Optional: Attach a finder needle to a 5-mL syringe with 1 to 2 mL of sterile saline in it. Attach the introducer needle to a 5-mL syringe with 1 to 2 mL of sterile saline in it. Align the bevel of the needle with the volume markings on the syringe. Pre-flush all lines of the CVC with 3 to 5 mL of sterile saline and then close the ports with caps or syringes. When flushing a central line, use a 10-mL syringe (or one of equal or greater volume) and do not push too hard to avoid rupturing the line. Swab a broad area of skin with antiseptic solution, from the anterior superior iliac spine to the midline and extending down 15 cm below the inguinal ligament. Allow the antiseptic solution to dry for at least 1 minute. Place sterile towels around the site. Place large sterile drapes (eg, a full-body drape) to establish a large sterile field. Gently palpate the femoral arterial pulse using 2 or 3 fingers. Palpate gently so as not to compress the adjacent femoral vein (a compressed venous lumen is difficult to access). The needle insertion path:Insert procedural needles (local anesthetic, finder, and introducer needles) 2 to 4 cm inferior to the inguinal ligament, 1 cm medial to the femoral artery, at a 45 to 60° angle into the skin, and aim toward the umbilicus. Maintain femoral artery palpation during needle insertions and keep the needle medial to the artery to avoid impaling the artery. Place a wheal of anesthetic at the needle entry site and then inject anesthetic into the skin and soft tissues along the anticipated needle insertion path. Maintain gentle negative pressure on the syringe plunger as you advance to identify intravascular placement and prevent an intravascular injection. stop advancing, hold the syringe in place, and now regard this needle as a finder needle. Proceed to Assess the blood return below. Insert the introducer needle (or, optionally, finder needle), with the bevel facing up, along the needle insertion path. Maintain gentle negative pressure on the syringe plunger as you advance the needle. Stop advancing when a flash of blood appears in the barrel of the syringe (you may feel the needle pop through the wall as it enters the lumen). Hold the syringe motionless in this spot. Even a slight movement may displace the needle tip from the vein. If no flash of blood appears in the barrel after 2 to 4 cm of insertion,withdraw the needle slowly. If the needle had initially passed completely through the vein, a flash may now appear as you withdraw the needle tip back into the lumen. If a flash still does not appear, withdraw the needle almost to the skin surface, change direction, and try again to advance the needle into the vein.Do not change direction of the needle while it is fully inserted. Continue to hold the syringe motionless. Securely grasp the needle hub and also hold it motionless. Remove the syringe from the needle hub and briefly let blood flow out to confirm that the blood is venous (ie, dark red and flowing but not pulsatile). Then immediately cover the hub with your thumb to stop the blood flow and prevent air embolism. However, if the blood is bright red and pulsatile (arterial),terminate the procedure. Remove the needle and use 4 × 4 gauze squares for 10 minutes to hold external pressure on the area and to help prevent bleeding and hematoma. If up to this point you have been inserting a finder needle (or an anesthetic needle that found the vein), now you will use this needle to guide insertion of the introducer needle. Hold the introducer syringe with the needle bevel facing up. Use one of two insertion methods: Either remove the finder needle and immediately insert the introducer needle along the same path, or keep the finder needle in place and insert the introducer needle underneath and roughly parallel to it (at a slightly shallower angle to the skin). Stop advancing the introducer needle and hold it motionless when a flash of blood appears in the barrel of the syringe. If the finder needle has not been removed, remove it now. Assess blood flow from the introducer needle as described in Assess the blood return above. Continue to hold the introducer needle motionless. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. Advance the guidewire through the needle and into the vein. Do not force the wire; it should slide smoothly. Advance the wire 20 to 30 cm. If you feel any resistance as you advance the guidewire,stop advancing it. Try to gently withdraw the wire slightly, rotate it slightly, and then readvance it, or try to gently withdraw the wire entirely, reestablish the needle tip within the vein (confirmed by venous blood return), and then reinsert the wire. However, if you feel any resistance as you withdraw the wire,terminate the procedure and withdraw the needle and guidewire together as a unit (to prevent the needle tip from shearing through the guidewire within the patient). Then use 4 × 4 gauze squares for 10 minutes to hold external pressure on the area and to help prevent bleeding and hematoma. Once the guidewire has been inserted, continue to hold it securely in place with one hand and maintain control of it throughout the remainder of the procedure. First, securely hold the guidewire distal to the needle and pull the needle from the skin. Then, securely hold the guidewire at the skin surface and slide the needle down the remaining length of the guidewire to remove the needle. Extend the skin insertion site: Using the scalpel, make a small stab incision (about 4 mm) into the skin insertion site, avoiding contact with the guidewire, to enlarge the site and allow it to accommodate the larger diameters of the tissue dilator and the catheter. Advance the tissue dilator over the guidewire: First, grasp the guidewire at the skin and slide the dilator down the length of the wire to the skin. Then grasp the wire just distal to the dilator, hold the dilator near the skin surface, and use a corkscrew motion as needed to stepwise insert the entire length of the dilator. Maintain your grasp on the guidewire at all times during the insertion. Remove the dilator: First, securely hold the guidewire distal to the dilator and pull the dilator from the skin. When the guidewire is visible at the skin surface, completely remove the dilator by sliding it down the remaining length of the guidewire. Advance the catheter over the guidewire to the skin surface: Hold the guidewire fixed at the skin surface, thread the catheter tip over the distal end of the guidewire, and slide the catheter down to the skin surface. The distal end of the guidewire should now be protruding from the port hub. If the distal end of the guidewire is not protruding from the port hub,inch the guidewire outward from the skin surface while holding the catheter tip close to the surface until the guidewire protrudes. Continue to advance the catheter into the vein: Grasp and control the guidewire where it protrudes from the hub. Hold the catheter near its tip and insert the tip through the skin. Then, in increments of several centimeters and using a corkscrew motion as necessary, stepwise advance the entire length of the femoral catheter. Maintain your grasp on both the guidewire and the catheter. Remove the guidewire: Withdraw the guidewire while holding the catheter securely in place at the skin surface. Flush each catheter port with saline: First, draw any air from the line and confirm venous blood flow into the hub. Then, using a 10-mL syringe (or one of equal or greater diameter) and nonexcessive force, push 20 mL of saline into the line to clear it. If the patient is awake or minimally sedated, use 1%lidocaineto numb the skin at the planned suture locations. Place achlorhexidine-impregnated disk on the skin at the catheter insertion point. Suture the skin to the mounting clip on the catheter. To prevent pulling on the insertion site, suture the catheter at a second site so that a curved or looped segment of catheter lies between the two sites. Apply a sterile occlusive dressing. Transparent membrane dressings are commonly used. 