Selective Femoral CVCs: Fighting DOGMA in ICU

[bulgethetwine]

I've had it. Yet AGAIN another condescending ICU attending denigrates our care for putting in a STERILE femoral line in someone who had contraindications to a IJ/SC line. Time to re-educate some colleagues:

1. Local infection at a catheter site is indeed a risk FACTOR for a serious infection. Ergo, all things being equal, I prefer a SC or IJ over the femoral. For those who are wondering, the relative risk is 7x greater for a femoral line vs. SC, and nearly double the risk for IJ vs. SC. (Lorente, 2004). Let me clarify: These are the relative rates of local site infection - a RISK FACTOR for the serious catheter-related blood stream infection we're seeking to avoid -- per 1000 catheter days.

2. The actual rates of catheter-related blood stream infection -- the *REAL* problem we're trying to avoid is not significantly different between any of the 3 sites!

3. So, if a patient has contra-indications for an IJ/SC -- for example, multiple bilateral previous lines, bilateral clots seen on u/s, inability to thread catheter, AV fistula in one side and any of these problems on the other, then it makes sense that the actual line that should be preferred in such a patient might actually be a STERILE FEMORAL LINE.


It's time for a movement to reverse this completely disproportionate (and thus irrational) aversion to femoral lines in the ICU. Is it the preferred site? NO! But is it the right site in some patients since the actual incidence of catheter-related blood stream infection is not higher? YES.

Too many folks following DOGMA based on rates of RISK FACTORS for catheter-related blood infections.

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[HarryRosenMD]

Well said.

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[proman]

An argument against the femoral site is increase thrombotic complications as well. Like you said, it should not be the prefered site, but it isn't the end of the world either.

 

[southerndoc]

An argument against the femoral site is increase thrombotic complications as well. Like you said, it should not be the prefered site, but it isn't the end of the world either.

Is the risk of thrombosis greater with a femoral line than an IJ, or is it the same?

 

[proman]

I haven't seen a study of IJ vs femoral. The OR is 14.4 for femoral vs subclavian. See PMID: 18676389
A critical review of thromboembolic complications associated with central venous catheters.
Can J Anaesth. 2008 Aug;55(8):532-41.

 

[southerndoc]

I miss doing US-guided IJ's. So simple to do, but unfortunately it's a hassle to get the ultrasound from the IV team where I practice. So subclavians it is, and thankfully, I haven't dropped a lung in six months of attendinghood (average 4-5 lines/month).

 

[surg]

While they should not be directed at you since it sounds like you actually think about where to put the line before putting it in the groin AND take sterile precautions, I think the looks are directed at some of your colleagues particularly in the less procedural specialties (gen med for instance) who do a femoral 1st because they are too uncomfortable with IJ's and SC's to even try it. Their stress over dropping a lung is so high that they won't even try when there are no contraindications. Sometimes, they even make up one. Then you find them bed-bound and septic later because someone told them they can't get up with a femoral line and no one ever changed the dressing. Also, unfortunately, far too many lines get put in without sterile precautions (I give the ED a pass in general as many of those are too pressing to gown up, so I just replace theirs routinely, but not much excuse in the OR and ICU setting in >95% of lines, and I have seen any number of times where people just put on gloves and go at it. )

 

[southerndoc]

Also, unfortunately, far too many lines get put in without sterile precautions (I give the ED a pass in general as many of those are too pressing to gown up, so I just replace theirs routinely, but not much excuse in the OR and ICU setting in >95% of lines, and I have seen any number of times where people just put on gloves and go at it. )

Where I work, one would have to purposefully not want to gown up to put in a line. The kit contains a sterile gown, hair net, mask/face shield, and a full body drape.

The only time I put one in without sterile technique is if the patient is in extreme condition (like cardiac arrest or a BP in the 50's and about to arrest). Even then I still use sterile gloves and throw on some betadine. The line must be replaced though. We have 24/7 pulmonary/critical care coverage in my ED, so it's easy to get lines placed by them.

 

[proman]

I'm sure you meant chloroprep. Betadine has no role in central line placement.

 

[southerndoc]

I'm sure you meant chloroprep. Betadine has no role in central line placement.

Yea, sorry. The chloroprep is in our kits.

 

[jetproppilot]

Dude, gimme a break.

Placing a central line is a big deal in my book, even though I do a million of them.....OK....not a million......probably 20 a month between the OR and the ICU.

Your argument for femoral lines holds no value.....any increased risk of infection in the patient population you are probably referring to....the immunosuppressed patients in the ICU...means if you won't/can't place an IJ/subclavian, then call the PIC line nurse before putting in a femoral line.

INFECTION KILLS.

A central line in the groin in a sick patient aint the best, nor even an equivalent option.

 

[souljah1]

Dude, gimme a break.

Placing a central line is a big deal in my book, even though I do a million of them.....OK....not a million......probably 20 a month between the OR and the ICU.

Your argument for femoral lines holds no value.....any increased risk of infection in the patient population you are probably referring to....the immunosuppressed patients in the ICU...means if you won't/can't place an IJ/subclavian, then call the PIC line nurse before putting in a femoral line.

INFECTION KILLS.

A central line in the groin in a sick patient aint the best, nor even an equivalent option.

A PICC is not a resuscitation line. I agree that an ultrasound guided IJ or a subclavian should be the first/second approach in a critically ill patient. If you can't get a stick and the patient is in need of central access for volume resuscitation, then you should place a femoral. A PICC would be great, if you have two large bores in addition...

 

[proman]

I've noticed a pattern recently in multiple forums across specialty lines that people are only willing to do ultrasound guided IJs. Are you guys still learning how to do an IJ on landmarks? I know some attendings will flail about how US is standard of care etc etc but that is not established. If you are ever in the position of needing to place an emergency line, I hope you know how to do a landmark guided IJ. BTW, as an anesthesiology resident I place about half of my IJs based on landmarks, and feel comfortable to do so in urgent patients. In fact, there was one patient recently in the heart room where I could visualize the IJ but just could not cannulate it with any needle. I put the probe down, used landmarks and 1 minute later the introducer was in. We need to know how to do this line.

 

[southerndoc]

I've noticed a pattern recently in multiple forums across specialty lines that people are only willing to do ultrasound guided IJs. Are you guys still learning how to do an IJ on landmarks? I know some attendings will flail about how US is standard of care etc etc but that is not established. If you are ever in the position of needing to place an emergency line, I hope you know how to do a landmark guided IJ. BTW, as an anesthesiology resident I place about half of my IJs based on landmarks, and feel comfortable to do so in urgent patients. In fact, there was one patient recently in the heart room where I could visualize the IJ but just could not cannulate it with any needle. I put the probe down, used landmarks and 1 minute later the introducer was in. We need to know how to do this line.

During residency, I put 1 IJ in that was not ultrasound guided. Our ultrasound director required you use the ultrasound and actually record the needle entering the vein. Part of it was for his perception of safety, but a lot of it was for billing purposes. Physicians can charge an additional $30 for an ultrasound guided central line. My reimbursement is higher for my group, but I don't get the full amount.

 

[bulgethetwine]

Dude, gimme a break.

Placing a central line is a big deal in my book, even though I do a million of them.....OK....not a million......probably 20 a month between the OR and the ICU.

Your argument for femoral lines holds no value.....any increased risk of infection in the patient population you are probably referring to....the immunosuppressed patients in the ICU...means if you won't/can't place an IJ/subclavian, then call the PIC line nurse before putting in a femoral line.

INFECTION KILLS.

A central line in the groin in a sick patient aint the best, nor even an equivalent option.

Agree it ain't the best, but the data says the risk is overblown. And a PICC isn't a resuscitation line, nor do I have the luxury to call a PIC nurse when a patient is crashing.

Sorry Jet, I've come to understand your bombastic responses as almost always entertaining, mostly on-point, and sometimes educational, but I disagree here. Might be different in the OR where you've always got time to try another trick, or another approach, or something that isn't time-dependent. Often times in my world, I don't have that luxury.

 

[Dimoak]

Your argument for femoral lines holds no value.....any increased risk of infection in the patient population you are probably referring to....the immunosuppressed patients in the ICU...means if you won't/can't place an IJ/subclavian, then call the PIC line nurse before putting in a femoral line.

INFECTION KILLS.

A central line in the groin in a sick patient aint the best, nor even an equivalent option.

I'm not sure if I'm understanding what you're advocating here. Are you saying that for central line access, if you can't get an IJ or subclavian line, to try and get a PICC prior to placing a femoral line? I agree that hospital acquired infections are absolutely brutal, but if you have a crashing patient, how are peripheral lines a viable option? Were you referring to a non-coding scenario?

Some studies I've read about had some interesting summaries. For 1000 catheter days, one had an incidence of 20 H-A infections with femoral vs. subclavian. Another 1000 catheter day study had a P>0.4 infection incidence between femoral and IJ, even though the current mantra includes femoral lines being considerably likelier to get infected than IJs.

 

[leviathan]

Might be different in the OR where you've always got time to try another trick, or another approach, or something that isn't time-dependent. Often times in my world, I don't have that luxury.

Sometimes when your patient is crashing and you can't get an IJ/SC, in the words of jet, you gotta STEP UP TO THE MIC WITH MICATIN.

 

[bulgethetwine]

Sometimes when your patient is crashing and you can't get an IJ/SC, in the words of jet, you gotta STEP UP TO THE MIC WITH MICATIN.

Haha. I've always liked Jet's patented phrases, too
But I don't think when your patient is crashing, you call el-Nurso to come put in a PICC for your crashing patient while your hands are shaking.

Besides, I have a philosophy that, for me at least, trumps anything that's shouted out loud, or posted on some internet billboard in BIG BOLD CAPS:


Well done is better than well said.

 

[carrigallen]

Your argument for femoral lines holds no value.....in the ICU...means if you won't/can't place an IJ/subclavian, then call the PIC line nurse before putting in a femoral line.

Septic patient?
Vitals crashing?
CALL THE PICC NURSE STAT!