Ultrasound-Guided Cannulation of the Femoral Vein

Chlorhexidine swab is used to prep the skin in the right groin area. We use a wide prep to prepare for a right central venous catheter insertion. After the prep dries, we will place a wide sterile barrier. The sterile drape should cover the entire lower half of the body including the bed between the patient and the operator. We're now using a sterile sheath to grasp the ultrasound probe that has had a non-sterile ultrasound gel applied to the top. You grasp the ultrasound probe and then carefully pull the sterile sheath over the probe so that you can have a sterile probe to do real time ultrasound.

Now we're going to prepare the catheter. We're applying needleless caps on to the blue port and the white port of the catheter and we're going to use sterile saline to flush each of the ports. Here we're flushing the white and the blue port of the catheter that have the caps in place. And with the brown port which is the distal port the wire will be coming out of that port so we do not have a cap in place but after we flush that port we'll have to clip the line before removing the sterile saline syringe.

Now with the 1 percent lidocaine we're applying a sterile label so that all the syringes can have sterile identification. Sterile ultrasound gel is then used on the skin and now we're looking at the right femoral artery and the femoral vein in transverse orientation. The femoral artery is on the top left-hand side. With compression you can see that the right femoral vein compresses but that the right femoral artery which is more superficial and to the left does not compress. We're using 1 percent lidocaine for local anesthesia of the skin and the underlying soft tissue.

Now we're introducing a introducer needle at about a 45 degree angle inserted the same depth away from the probe as the vein is deep to the probe. We are inserting so that we gradually can see the needle advance into the vein and now we have return of venous blood. We're going to grasp the hub of the needle and withdraw the syringe to confirm that it is nonpulsatile blood. Now we're going to insert the sterile wire through the sheath and through the needle. We are going to rotate the probe into the longitudinal orientation and we can see that the wire is threading into the vein as the wire is advanced through the needle.

In the femoral location the wire can be advanced even as deep as 30 centimeters. Now the sheath is removed and the wire is left in place. The needle is now withdrawn and leaving the wire in place you can still see that the wire is in the vein on the ultrasound image. And now the probe can be dropped and sterile gauze can be used to identify the insertion site clearly, and then a scalpel could be used to nick the skin over the wire. Now a dilator is inserted over the wire and the wire is grasped on the opposite side of the dilator. The dilator is advanced with a twisting motion to dilate a tract through the subcutaneous tissue and into the femoral vein.

Now the dilator is withdrawn leaving the wire in place. The wire is then threaded back through the central venous catheter until you can grasp the wire on the opposite end of the brown or distal port of the catheter. Now the wire is grasped on the distal end of the catheter and then the catheter is advanced all the way to the end of the catheter. And now the wire is withdrawn back into its sterile sheath and completely withdrawn out of the body. Once the wire is completely withdrawn the brown port is clipped.

Now we're introducing the last needleless cap onto the brown port and then it will be unclipped and then you will withdraw the blood into the syringe and then the whole line is flushed, care being taken not to inject any air into the port. Now the white and the blue ports of the central venous catheter are flushed with sterile saline. Now some local anesthesia is used to numb up the skin adjacent to the central venous catheter, a bio-patch is applied at the insertion site with the blue side angled towards the ceiling. This is a patch that's impregnated with chlorhexidine to minimize the risk of catheter related bloodstream infections.

And now suture is used to secure the catheter in place in two locations. After this is secured, a sterile occlusive dressing will be applied over the central line to complete the procedure. Here an instrument tie is being used to secure the central line using suture which is done in two locations.