Femoral CVC

1. Central Venous
Catheterization:
“From the ICU to the EC”
A REFRESHER COURSE
Pediatrics

2. Objectives
•By the end of this course the participant will be able to:
•Combine US guidance with the “landmark technique” when
performing femoral CVC
•Perform the steps for prepping and draping the femoral site
prior to CVC according to the TCH vascular insertion bundle
•Execute the proper sequence in the placement of US guided
femoral CVC according to a checklist
•Select an appropriate sized vascular catheter according to the
indication for placement and/or the patient’s size
•Incorporate, into clinical practice, the use of US guidance when
inserting central venous catheters as recommended by
governing/certifying bodies
Page 1
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

3. First things first…
Femoral Anatomy
Roger’s Textbook of Pediatric Intensive Care, 4th ed.
N
A
mpty space
ymphatics
Page 2
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

4. Roger’s Textbook of Pediatric Intensive Care, 4th ed.
Femoral Landmarks
Page 3
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

5. Indications
•Peripheral access unobtainable
•Medication/fluid administration
•Emergency resuscitation
•Monitoring of CVP and SvO2
•Parenteral nutrition
•Frequent blood sampling
•Hemodialysis/hemofiltration/apheresis
Page 4
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

6. Contraindications
•Coagulopathy
•Skin infection at site of needle puncture
•Trauma
•Distorted anatomy
•Thrombosis
Page 5
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

7. Complications Common to ALL Sites
•Infection
•Malposition
•Thrombosis
•Catheter fragment/
guidewire embolism
•Arterial puncture
•Cardiac dysrhythmias
•Arterial cannulation
‐IJ & Subclavian CVC
‐“high” femoral CVC
•Hemorrhage
•Air embolism
•Phlebitis
‐More so with IJ &
Subclavian CVC
Page 6
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

8. FEMORAL CVC Complications
•Bladder puncture
•Retroperitoneal hemorrhage
•Malposition
‐ Ascending lumbar veins
May cause complications…
•Uncooperative patient
•Lack of experience/supervision
Page 7
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

9. Choosing a Catheter
•Size?
•Length?
•Number of lumens?
•Patient
‐Weight/size
‐Size of vessel
‐Indications
Page 8
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

10. Choosing a Catheter Size/Length
“Standard Catheter Lengths Available for Pediatric Use”,
according to booklet attached to catheter tray…
…NOT HELPFUL
Page 9
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

11. ED CVL Insertion Bundle
Page 10
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

12. Sequence of Events
•INSERTION CHECKLIST (“Bundle”)
•PREPARATION
‐Inform/Consent parents if possible
‐Perform a “Time Out”
‐Position patient
‐Barrier precautions
•Proceduralist
•Patient
•Ultrasound
Page 11
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

13. ED CVL Insertion Bundle
Page 12
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

14. Sequence of Events
•PERFORM PROCEDURE
•APPLY STERILE DRESSING
‐See “CVC Dressing” video on moodle site
•CONFIRM PLACEMENT
‐Must use 2 methods for confirmation
•DOCUMENT
‐Especially if the line was emergent and bundle was unable to
be utilized
Page 13
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

15. ED CVL Insertion Bundle
Page 14
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

16. REFERENCES
•Rey et al. Mechanical complications during central venous cannulations
in pediatric patients. Intensive Care Med 2009; 35: 1438–1443.
•Froehlich et al. Ultrasound-guided central venous catheter placement
decreases complications and decreases placement attempts compared
with the landmark technique in patients in a pediatric Intensive care unit.
Crit Care Med 2009; 37(3): 1090-1096
•Miller et al. Decreasing PICU Catheter-Associated Bloodstream
Infections: NACHRI's Quality Transformation Efforts. Pediatrics 2010;
125: 206-213
•Wheeler et al. A Hospital-wide Quality-Improvement Collaborative to
Reduce Catheter-Associated Bloodstream Infections. Pediatrics 2011;
126(4): e995-e1007
Page 15
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

17. REFERENCES
•Kumar et al. Ultrasound guided vascular access: efficacy and safety.
Best Practice & Research Clinical Anaesthesiology 2009; 23: 299–311
•Srinivasan et al. Bedside ultrasound in pediatric critical care: A review.
Ped Crit Care Med 2011; 12(6): 667-674
•McGee et al. Preventing Complications of Central Venous
Catheterization. N Engl J Med 2003; 348(12): 1123-1133
•Moore et al. Point-of-Care Ultrasonography. N Engl J Med 2011; 364:
749-57.
•CDC for the Prevention of Intravascular Catheter-Related Infections,
2011. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
Page 16
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM

18. REFERENCES
•American College of Emergency Physicians: Emergency ultrasound
guidelines. Ann Emerg Med. 2009; 53: 550-570
•Costello et al. Minimizing Complications Associated with Percutaneous
Central Venous Catheter Placement in Children: Recent Advances.
Pediatr Crit Care Med. 2013; 14: 273-283
Page 17
Pediatrics
xxx00.#####.ppt 2/26/2014 6:39:21 PM