Femoral Arterial Line Placement
Femoral Arterial Line Placement
The Placement of a Femoral Arterial Line.
Arterial access is often necessary for hemodynamic monitoring or repeated arterial blood sampling for patients in acute care settings. While the radial artery is generally the preferred site, the femoral artery is much larger and easier to palpate, and is easier to cannulate in clinical situations when hemodynamics are unsteady, such as in patients with hypotension or shock.
The femoral artery also provides a more accurate measure of central arterial pressure.
Arterial palpation is often indicated for continuous hemodynamic monitoring for critically ill patients, direct blood pressure measurement when noninvasive techniques are not available, assessment of arterial blood gases, frequent blood sampling, or due to lack of access to more peripheral arteries, such as the radial or dorsalis pedis artery.
The placement of arterial cannula through the femoral artery should be avoided in patients with infection at the site or severe atherosclerosis. Previous femoral artery graph is also a contraindication.
The following equipment is required for femoral arterial cannulation.
Antiseptic solution; sterile gloves and drapes; local anesthetic, for awake patients; a femoral artery cannulation kit, or any cannulation kit with a 10-centimeter introducer needle; a 5-milliliter syringe; a 20-centimeter single-lumen catheter; as well as a guide wire, suture, and sterile gauze; a transparent dressing, such as a Tegaderm, and ultrasonography, which may be beneficial in situations when palpation of the femoral pulsation is difficult, such as in obese patients.
If possible, informed consent should be obtained prior to performing this procedure. The patient should be positioned supine with no flexion at the waist. Prior to the sterile preparation, it is prudent to locate and mark the location of the femoral artery by palpation. Using the non-dominant hand, the artery can be palpated approximately 4 to 5 centimeters lateral of midline, in line with the pubic symphysis and approximately 5 centimeters distal to the ilioinguinal ligament.
Adjacent anatomical structures include the femoral vein medially and the femoral nerve laterally. If performed in an awake patient, the puncture site can be cleaned with alcohol and then anesthetized with a 1% lidocaine infiltration. The site should be cleaned with chlorhexidine or other antiseptic solution, and draped. Many femoral arterial cannulation kits are commercially available to allow femoral artery puncture, using either an introducer needle alone or a catheter over needle.
Only the introducer needle technique will be discussed in this video. Using the non-dominant hand to locate the femoral artery, the tip of the introducer needle attached to a 5-milliliter syringe enters the skin at approximately a 45-degree angle. With constant, gentle aspiration of the syringe, the introducer needle is slowly advanced towards the point of maximal pulsation.
If blood is not visualized on the first attempt, care should be taken to only enter and exit the skin in straight lines. As the needle tip enters the arterial lumen, a flash of blood into the syringe will be visualized. Following the removal of the syringe, if pulsatile blood continues to flow through the needle, a soft-tipped guide wire can be advanced through the needle into the lumen of the artery.
The needle is then removed, and a long femoral cannula is then advanced over the guide wire into the femoral artery. Unlike the placement of a central venous catheter, the arterial puncture site should never be incised nor dilated prior to advancing the femoral cannula over the guide wire. The hub of the catheter is then connected to the arterial transduction tubing immediately after removal of the guide wire.
Segment:7 Post-Placement Care.
In most cases, the arterial cannula should be secured by suturing it to the skin using a 3-0 monofilament-- and judicious local anesthetic infiltration, if the patient is awake. The hub of the catheter can then be protected with a transparent dressing, such as a Tegaderm. Blood should be withdrawn to remove bubbles trapped within the pressure transducer system, and the tubing should be flushed with pressurized saline or diluted heparin solution, depending on the clinical situation.
Common complications associated with the placement of a femoral artery cannula include failure to cannulate, venous cannulation, hematoma, discomfort, femoral nerve damage, air embolism, abdominal viscera injury, faulty equipment, thrombosis, and infection.
Difficulty locating the femoral artery.
The femoral pulse can be difficult to palpate in obese or edematous patients, or those with profound hypotension. In these situations, and ultrasound probe can help identify the femoral vein, artery, and nerve. This technique can be done in a non-sterile fashion to verify caliber and precise location of the artery prior to beginning the arterial placement procedure.
Alternatively, the ultrasound probe can be placed in a sterile sheath and used for real-time needle visualization and entry into the artery. Arterial cannulation can be performed either with a transverse view or longitudinal ultrasound view of the artery. But care should be taken to always visualize the tip of the needle.
Once the femoral artery is entered, the ultrasound probe can be safely put aside. Excessive bleeding following placement. To minimize bleeding, avoid arterial cannulation in patients with coagulopathy, if possible. Continuous direct pressure over hematoma may help to stop the bleeding. Line infection. Every effort should be made to ensure the placement of the femoral arterial cannula is performed under sterile conditions with maximal barrier precautions.
However, the groin is not an ideal location for a long-term arterial line, and the femoral cannula should be removed or replaced with a radial arterial cannula at the soonest convenience. If a line infection is identified, the cannula should be removed and cultured, and appropriate antibiotics initiated.
Successful placement of a femoral arterial cannula requires meticulous preparation of the patient and the equipment, knowledge of the anatomy, and manual dexterity.
Although femoral artery palpation can be readily performed using palpation alone in most cases, with or without a guide wire, the use of ultrasonography may be beneficial if palpation proves difficult.