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Introduction with a case
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A 75-year-old man presents in transfer to the ICU for management of bradycardia and hyperkalemia. His history is notable for hypertension with chronic use of an ACE-inhibitor. He developed gastroenteritis due to endemic Norovirus some days prior. Today he presented to the outside hospital with hypotension and bradycardia, with a potassium of 8 mg/dL and a Creatinine of 3 mg/dL.
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When he arrives in the ICU he is noted to be hypotensive to 75/40 with a heart rate of 45 b/m. He is restless and slightly confused. He is oxygenating adequately on room air. His only functioning access is a 22-Gauge peripheral IV in his left hand. What is the best approach to obtaining IV access in this patient?
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How I used to manage this
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My approach used to start with placing an internal jugular central line. This may be challenging in a confused patient with difficulty lying still, but can generally be accomplished (perhaps with an assistant gently holding the patient’s head still). Following this procedure, I might have attempted a radial arterial catheterization to monitor blood pressure. If this failed, then I would place a femoral arterial catheter. All told, this process could easily take 40 minutes or longer, during which time my attention would be diverted primarily to various procedures.
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How I might manage this currently
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Currently I begin by placing two catheters in the femoral artery and vein, immediately next to each other. This may be done using a single sterile field. The central venous catheter is placed first because it is generally more important. In highly acute situations, a nurse may attach extension tubing to the central line and start using it immediately (prior to inserting the arterial catheter). This will compromise the sterility of a portion of the sterile field, which can then be covered with a sterile towel.
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These lines are placed with the intention that they will be “dirty” lines which must be removed within ~24 hours. They are placed using sterile gloves, a mask, and a sterile sheet but without full sterility. For example, this will typically occur during a resuscitation with many people at the bedside, and not everyone may be wearing a mask. The sterile sheet will generally not cover the patient's entire body (typically the upper body and head are left exposed to allow monitoring of the patient’s ventilation and mental status).
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Advantages of emergent femoral arteriovenous access
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Speed This is probably the fastest way for a single operator to achieve central venous and arterial cannulation. Radial arterial catheters may be hard to place in shocky elderly patients, so the femoral arterial line provides a speed advantage compared to the radial site. Preparing only a single site further reduces the time required.
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Patients with difficulty lying still Many crashing patients are delirious and will be unable to hold still. Although patients may certainly move their legs, the femoral site overall seems to be more stable than most other sites for patients who are wiggling around a bit.
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Respiratory Monitoring Placing a central line in the jugular or subclavian position typically requires covering the patient’s face. For crashing patients who are not intubated, it may be safer to leave their face and chest exposed to facilitate monitoring of the respiratory and mental status. If the patient should start vomiting or obstructing their airway, this will be noticed and acted upon immediately.
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Definitive Access Intraosseous access is faster than placing a central line, and may be needed while awaiting central access. However, a patient in this situation will require multiple IV medications and lab tests so an intraosseous line will not entirely solve the IV access problem.
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Save the jugular, subclavian, and radial vessels for later Some patients may respond to treatment rapidly, and may not require ongoing arterial and/or central venous access. If ongoing access is needed, then “clean” lines must to be placed later, when more time is available to achieve full sterility. One advantage of placing the dirty lines in the femoral position is that this leaves the remainder of the vasculature untouched so that the clean lines can be placed wherever is desired.
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Absolute avoidance of a pneumothorax Iatrogenic pneumothorax is never a good thing, but there are some patients in whom a pneumothorax would be particularly dangerous (e.g., a patient with severe diabetic ketoacidosis who is struggling to compensate for their acidosis from a respiratory standpoint). An experienced operator can usually place an ultrasound-guided internal jugular catheter with a near-zero pneumothorax rate, but if the patient is unable to lie still then nothing can be guaranteed. Thus, for a crashing agitated patient who would be unable to tolerate a pneumothorax, femoral access may be a rational choice.
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It’s OK to be dirty, as long as you come clean about it
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During the resuscitation of a patient who is very unstable, it is difficult to achieve complete sterility (e.g. caps and hats for the entire team, full body draping, etc.). Thus, most central lines placed in this situation may not be 100% sterile. If a line is placed in this situation with <100% sterility and is incorrectly designated as a “clean” line then it may remain in place, causing a line infection.
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Alternatively, if a line is emergently placed without full sterility but it is accurately designated as a “dirty” line, then this is not a problem. The line will be removed before a line infection could occur. Linguistically it sounds wrong to put in a “dirty” line, but this is actually a rational approach to central access in a crashing patient.
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Beware of the intubation trap for hemodynamic crashes
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When approaching an unstable patient, one consideration is always whether the airway should be secured. As discussed earlier, if there is concern that the patient is going to lose their airway, it may be reasonable to err on the side of intubation. A previous post discussed rapid sequence intubation and procedurization as an approach to a patient with respiratory failure.
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However, for patients with a primary cardiac problem and severe hypotension, immediate intubation is extremely dangerous and may precipitate cardiac arrest. This patient’s problem is not respiratory failure. Intubation will not solve their problem, but will actually make it worse (adding sedation and positive-pressure ventilation are likely to worsen the patient's hemodynamics). When facing a crashing patient with a primary hemodynamic problem, there may be a tendency to start by securing the airway (“start with the ABCs”), but it is often best to avoid intubation if possible.
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To ultrasound or not to ultrasound?
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The debate about whether or not to use ultrasonography for central lines is getting a bit stale at this point. My preference is to use ultrasonography for double femoral cannulation if possible. Setting up the ultrasound machine takes a little time up-front, but this may improve the speed and accuracy of both procedures.
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Approach in morbid obesity
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Although femoral access is generally straightforward, it can be challenging in the morbidly obese. Certainly, the site of vascular access will vary between different patients and this must be determined on a patient-by-patient basis. When in doubt, examining the vessels with ultrasonography before starting the procedure takes a few seconds, and can provide a good concept of how difficult the procedure will be. If a femoral approach is chosen in a patient with morbid obesity, it may be extremely helpful to retract the pannus (using tape or an assistant) in order to open up the inguinal crease.
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- For a crashing patient who needs immediate arterial and venous access, one approach is to place adjacent catheters into a femoral artery and vein.
- With the exception of severe obesity, this is generally fast and technically straightforward (especially with the use of ultrasonography).
- It may be difficult to place a completely sterile central line in the middle of a resuscitation. In an emergency it is reasonable to intentionally place “dirty” lines with a plan of removing these within ~24 hours. Placing “dirty” lines in the femoral position leaves the remainder of the vasculature available for placing a sterile line when time allows.
Image credits
Femoral artery and vein: http://upload.wikimedia.org/wikipedia/en/3/34/Femoral_triangle.gif
It's a trap: http://knowyourmeme.com/memes/its-a-trap
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I would like to add that hyperkalemia is also a relative contraindication for the placement of a central line in the subclavian or in the jugular vein as the central line can cause arrhythmias in case it goes near or in the right atrium.
Absolutely agree. Excellent point. IO is also a good way to get access in a patient prior to emergent inter-hospital transfer. Placing a central line prior to transfer may delay the transfer process considerably and expose patients to risks such as pneumothorax en route (have seen this unfortunately). Alternatively, multiple IOs may establish reliable access immediately and without need to confirm placement with an Xray.
I totally agree. I would like to add that we should not hesitate to put more than one intra-osseous if the need arises. We can easily get 4 IV access in seconds if we use all sites. Humeral site should be preferred over tibial site since it provides faster infusion rate.
very cool, Josh
thank you
personally, i prefer the fem’s for access. as i tell the nurses, its hard even for me to drop a lung or hit the carotid when i go femoral.
tom
Hi
Can anyone recommend a particular arterial line for femoral artery insertion?
I tried recently with a standard Vygon ‘radial’ kit and the catheter wouldn’t feed over the guidwire. Are there femoral kits where the wire is a bit stiffer/longer?
Interested if you’ve found any particularly good/user friendly.
This is for a “crashing” patient but what about the “crashed” patient during a code when access is lost. We’ve all seen fem-lines being attempted and end up being slightly disruptive to the reset of the code and take time to get. Would it not be easier and safer to secure 1 or 2 humoral IOs to push meds through until ROSC, then post-code place a central line (+/- dirty line), where you can use an ultrasound and get it with a single stick? Just seems way more efficient.
How common is femoral artery thrombosis after catheterization in such scenario, is that a concern
excellent resource
The end of the pressure tubing is no longer sterile. Why is it connected to the CVP or arterial line, without using a 6 inch sterile extension set.
I was taught this 30 years ago, but nobody does this!!!!!!
Why not. Most of the patients become febrile.
This should be a red flag. But I’m scrutinized when I point this out.
Please comment