Clinical Procedures - Femoral Venous Catheter Insertion

Clinical Procedures - Femoral Venous Catheter Insertion 
Indications
• Inotrope therapy, parenteral nutrition (needs dedicated port), poor peripheral access, CVP measurement (trends useful rather than actual numbers).
Contraindications
• Fem-fem bypass surgery, inferior vena cava (IC) filter, infected site, thrombosed vein.
Risks
• Arterial puncture, infection, haematoma, thrombosis, air embolism, AV fistula, peritoneal puncture.
Procedure Tips
• Placing a sandbag underneath the patient's buttock may improve positioning (if a sandbag is not available, roll up a towel or wrap a 1L
bag of fluid in a sheet as an alternative)
• Do not force the guidewire. If there is resistance to insertion:
• Reduce the angle of the needle, attempt a shallower insertion
• Check you are still within the vein by aspirating with a syringe
• Rotate the needle: this moves the bevel away from any obstruction
• D Losing the guidewire can be disastrous always have one hand holding either the proximal or distal end of it
• Always consider the possibility of an inadvertent arterial puncture:
• Signs include pulsatile blood flow, high-pressure blood flow or blood bright red in colour (in the absence of hypotension or hypoxaemia)
• Do not dilate if in any doubt
• Consider sending blood for a blood gas to confirm venous placement
• The use of saline in the aspirating syringe may make flushing the needle easier but also makes it more difficult to differentiate between venous and arterial blood.
Documentation
• Time, date, indication, informed consent obtained
• Site and side of successful insertion
• Site, side, and complications of unsuccessful attempt (S)
• Aseptic technique: gloves, gown, hat, mask, sterile solution
• Local anaesthetic: type and amount infiltrated
• Technique used: e.g. landmark, ultrasound guidance
• Catheter used: e.g. triple lumen
• Length of catheter in situ (length at skin)
• Signature, printed name, and contact details.
Equipment
• Central line catheter pack.
• Containing: central line (16-20cm length, multilumen if required), introducer needle, 10mL syringe, guidewire, dilator, blade
• Large-dressing pack including a large sterile drape and gauze
• Normal saline
• Local anaesthetic for skin (1% lidocaine)
• Sterile preparation solution (2% chlorhexidine)
• Securing device or stitch
• Sterile gloves, sterile gown, surgical hat and mask
• Suitable dressing.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain written consent if possible
• Position the patient supine (1 pillow), abduct the leg slightly and place a spill sheet under the patient's leg
• Identify the femoral artery and mid-inguinal point:
• Midway between anterior superior iliac spine and pubic symphysis
• Identify the entry point: 1-2 cm below the mid-inguinal point and 1cm medial to femoral artery
• Wearing a surgical hat and mask, wash hands using a surgical scrub technique and put on the sterile gown and gloves
• Set up a trolley using an aseptic technique:
•Open the dressing pack onto the trolley creating a sterile field
• Open the central line catheter pack and place onto the sterile field
• Flush all lumens of the catheter with saline and clamps the end 
• Ensure the guidewire is ready for insertion
• Attach the introducer needle to a 10ml syrins
• Clean the area with sterile preparation solution arr piare a large drape over the area
• Inject local anaesthetic into the skin over the entry point
• Identify the femoral artery with your non-dominant hand
• Pierce the skin through the entry point with the introducer needle
• Direct the needle at a 30 45° angle to the skin and aim for the ipsilateral nipple, aspirating as you advance the needle
• On hitting the vein the syringe will fill with blood
• Keeping the needle still, carefully remove the syringe blood should ooze (and not pulsate) out through the hub of the needle
• Insert the guidewire part-way through the hub of the needle.
• Guidewires tend to be over 50cm in length; it is unnecessary to insert more than 20cm into the vein
• Remove the needle over the guidewire ensuring one hand is always holding either the proximal or distal end of the wire
• Thread the dilator over the wire, firmly pushing it through the skin:
• This may require a small stab incision in the skin with a blade
• Aim to get 2-3cm of dilator into the vein, not its full length
• Check the guidewire has not been kinked by ensuring it moves freely through the dilator
• Remove the dilator and apply pressure over the site with gauze to stop oozing
• Thread the catheter over the guidewire until it emerges through the end of the distal port (unclamp this lumen!):
• This may require withdrawing some of the inserted guidewire
• Holding the guidewire at its port exit site with one hand push the catheter through the skin with the other:
• Avoid handling the catheter, in particular its tip
• Remove the guidewire
• Blood should flow out of the end of the catheter
• Aspirate and flush all ports
• Fix catheter to skin using either a securing device or stitches
• Cover with transparent dressing.