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Femoral venous catheterization during cardiopulmonary resuscitation: A critical appraisal
The Jourflal of Emergency M&me,
Vol. 1, pp. 387-391, 1984
Printed I” the USA
CopyrIght 0 1984 Pergamon Press Ltd
??
FEMORAL VENOUS CATHETERIZATION DURING CARDIOPULMONARY RESUSCITATION: A CRITICAL APPRAISAL Michael S. Jastremski, MD,* Heddy Dale Matthias, M&t and Patricia A. Randell, MD+ *Associate Professor, Critical Care and Emergency Medicine, tAssistant Professor, Critical Care and Emergency Medicine, and *Associate Professor, Radiology, State University of New York Upstate Medical Center, Syracuse, New York Reprint address: Michael S. Jastremski, MD, SUNY-Upstate Medical Center, 750 East Adams Street, Syracuse, NY 13210
0 Abstract-The placement of femoral venous catheters inserted during unsuccessful resuscitation attempts was studied by postmortem angiograms through the catheters. In 31% of the catheterixations the final position of the catheter was not in the femoral vein. We conclude that femoral venous catheterization by inexperienced operators is an unreliable technique during cardiopulmonary resuscitation. 0 Keywords-cardiopulmonary femoral venous catheterization
resuscitation;
Introduction A venous lifeline is essential for drug administration during advanced cardiac life support (ACLS). The peripheral route is advocated by the American Heart Association (AHA) for a number of reasons: It is easy to master, has a low complication rate, and does not interfere with the uninterrupted continuation of basic life support.’ There are a number of clinical settings when peripheral cannulation is impossible or not preferred, eg, inadequate or absent peripheral veins, administration of potentially caustic agents (dopamine, epinephrine, norepinephrine), or when central
catheterization and access might prove lifesaving (transvenous cardiac pacing). A recent study has also raised serious questions about the effectiveness of peripherally administered drugs during cardiac arrest because of the low flow and venous stasis associated with chest compression.* Thus, central venous cannulation will often be necessary during cardiac arrest. The femoral vein has been suggested as a reasonable first choice for central venous access during ACLS because chest compression can continue uninterrupted, and acute, life-threatening complications are less likely than with subclavian or internal jugular punctures.’ To assess the efficacy of femoral venous cannulation during ACLS we studied the success rate of percutaneous femoral venous catheterization (PFVC) during unsuccessful resuscitations in the emergency department.
Methods The femoral catheterizations were performed by medical residents, surgical residents, or emergency department attending physicians using standard anatomic land-
RECEIVED:5 July 1983; ACCEPTED: 16 February 387
1984
0736-4679/84 $3.00 + .OO
388
Michael S. Jastremski, Heddy Dale Matthias, Patricia A. Randell
marks and a through-the-needle (catheter or guidewire) technique.’ Only the attending physicians were ACLS certified by the AHA. Sixteen patients who had PFVC during ACLS and then expired were studied. Postmortem angiograms were obtained by injecting 10 mL of diatrizoate meglumine and diatrizoate sodium through the femoral cannula as a simultaneous abdominal radiograph was obtained.
Results In 16 femoral venous catheterization attempts studied, 5 catheters were in the femoral artery, 1 was in the soft tissue, and 11 were in the femoral vein or inferior vena cava (Figures l-3). The soft-tissue placement and two of the five arterial catheterizations were not recognized during the resuscitation. When the radiologist analyzed this first group of patients and advised us of the 3 1% failure rate, the study was terminated. Unsuccessful catheterizations were observed in all operator groups (medical residents, surgical residents, attending physicians). There was no significant difference in failure rate among groups or between ACLS-certified and noncertified operators.
Discussion The success rate for elective femoral venous catheterization is high.3v4The low flow state and poor oxygenation present during cardiopulmonary resuscitation (CPR) may compromise localization of the femoral arterial pulse and make femoral venous catheterization during CPR more difficult than under elective conditions. However, Getzen has reported a 95% success rate for femoral venous catheterization in 796 young males with hypovolemic shock, 90% of whom had no palpable femoral pu1se.5 He does not specifically report the success rate
in the smaller subset of those patients who were receiving chest compression. The most likely factor that explains the high failure rate in our patients is operator inexperience in the technique of femoral venous catheterization. The prevailing bias in our institution is that the femoral route should not be used for routine central vascular access, and, therefore, the house staff and attendings in our institution almost never perform elective femoral venous catheterization. Although the attending physicians in our emergency department are ACLS-certified and familiar with the theoretical aspects of femoral venous catheterization, they do not use the procedure and thus are not practiced in it. Perhaps if we had extended our study to a much larger number of patients, the staff would have had adequate exposure to the technique to achieve a higher success rate. However, we felt that this would not be in the best interest of the patients and, therefore, terminated the study and returned to subclavian catheterization, a technique of vascular catheterization that is well known to our house staff. Although we have not studied subclavian attempts during CPR specifically, in a previous study of Swan-Ganz catheterization by the residents of our institution, there were no unsuccessful subclavian catherizations in 135 attempts.6 This study demonstrates that femoral venous catheterization may be an unreliable technique during CPR, especially if performed by inexperienced operators. Although the AI-IA states on page XII-2 of its Textbook of Advanced Cardiac Life Support’ that “During cardiopulmonary resuscitation, cannulation of peripheral or femoral veins should be the choice of first site since cardiopulmonary resuscitation (CPR) may have to be interrupted if either jugular or subclavian veins are chosen”; we suggest that this recommendation be reevaluated. Central venous access during CPR can be most expeditiously obtained if the operator uses the technique with which he or she has had the most experience.
Femoral Venous Catheterization
389
FigrIre 1. Supine abdominal radiograph of a 73-year-old woman after placement of a left fenioral ous line during the course of CPR. The lo-mL injection of contrast material demonstrates norvenm venous structures with flow back toward the lnferlor vena cava.
390
Michael S. Jastremski, Heddy Dale Matthias, Patricia A. Randell
Figuore2. Supine abdominal radiograph of a 5%year-old man after placement of a left femoral venous line during CPR. However, a lo-mL injection of contrast material demonstrates arterial stnJctures flow away from the end of the catheter. Reflux back to the abdominal aorta demonstrates/severe aoti ic iliac obstruction. There is good filling of the internal iliac artery and its gluteai braInches.
Femoral Venous Catheterization
391
Figure 3. Supine abdominal radiograph of a 60-year-old man after the placement of a left femoral venous line during CPR. A lo-mL Injection of contrast material demonstrates extravasatlon into the soft tissues. No vascular structures are outlined.
REFERENCES 1. Kaye W: Intravenous techniques, in McIntyre KM, Lewis AJ (eds): Textbook of Advanced Cardiac Life Support. Dallas, American Heart Association 1981, pp XII-l-X11-12. 2. Kuhn GJ, White BC, Stetnam RE, et al: Peripheral vs central circulation times during CPR: A pilot study. Ann Emerg Med 1981; 10:417-419. 3. Duffy BJ: The clinical use of polyethylene tubing for intravenous therapy. Ann Surg 1949; 130:929936.
4. Moncrief JA: Femoral catheters. Ann Surg 1958; 147:166-172.
5. Getzen LC, Pollak EW: Short-term femoral vein catheterization. Am J Surg 1979; 138:875878. 6. Jastremski MS, Wagner IJ, McAnulty J: SwanGanz catheterization by residents. Crit Care Med 1981; 9(3):143.
Vol. 1, pp. 387-391, 1984
Printed I” the USA
CopyrIght 0 1984 Pergamon Press Ltd
??
FEMORAL VENOUS CATHETERIZATION DURING CARDIOPULMONARY RESUSCITATION: A CRITICAL APPRAISAL Michael S. Jastremski, MD,* Heddy Dale Matthias, M&t and Patricia A. Randell, MD+ *Associate Professor, Critical Care and Emergency Medicine, tAssistant Professor, Critical Care and Emergency Medicine, and *Associate Professor, Radiology, State University of New York Upstate Medical Center, Syracuse, New York Reprint address: Michael S. Jastremski, MD, SUNY-Upstate Medical Center, 750 East Adams Street, Syracuse, NY 13210
0 Abstract-The placement of femoral venous catheters inserted during unsuccessful resuscitation attempts was studied by postmortem angiograms through the catheters. In 31% of the catheterixations the final position of the catheter was not in the femoral vein. We conclude that femoral venous catheterization by inexperienced operators is an unreliable technique during cardiopulmonary resuscitation. 0 Keywords-cardiopulmonary femoral venous catheterization
resuscitation;
Introduction A venous lifeline is essential for drug administration during advanced cardiac life support (ACLS). The peripheral route is advocated by the American Heart Association (AHA) for a number of reasons: It is easy to master, has a low complication rate, and does not interfere with the uninterrupted continuation of basic life support.’ There are a number of clinical settings when peripheral cannulation is impossible or not preferred, eg, inadequate or absent peripheral veins, administration of potentially caustic agents (dopamine, epinephrine, norepinephrine), or when central
catheterization and access might prove lifesaving (transvenous cardiac pacing). A recent study has also raised serious questions about the effectiveness of peripherally administered drugs during cardiac arrest because of the low flow and venous stasis associated with chest compression.* Thus, central venous cannulation will often be necessary during cardiac arrest. The femoral vein has been suggested as a reasonable first choice for central venous access during ACLS because chest compression can continue uninterrupted, and acute, life-threatening complications are less likely than with subclavian or internal jugular punctures.’ To assess the efficacy of femoral venous cannulation during ACLS we studied the success rate of percutaneous femoral venous catheterization (PFVC) during unsuccessful resuscitations in the emergency department.
Methods The femoral catheterizations were performed by medical residents, surgical residents, or emergency department attending physicians using standard anatomic land-
RECEIVED:5 July 1983; ACCEPTED: 16 February 387
1984
0736-4679/84 $3.00 + .OO
388
Michael S. Jastremski, Heddy Dale Matthias, Patricia A. Randell
marks and a through-the-needle (catheter or guidewire) technique.’ Only the attending physicians were ACLS certified by the AHA. Sixteen patients who had PFVC during ACLS and then expired were studied. Postmortem angiograms were obtained by injecting 10 mL of diatrizoate meglumine and diatrizoate sodium through the femoral cannula as a simultaneous abdominal radiograph was obtained.
Results In 16 femoral venous catheterization attempts studied, 5 catheters were in the femoral artery, 1 was in the soft tissue, and 11 were in the femoral vein or inferior vena cava (Figures l-3). The soft-tissue placement and two of the five arterial catheterizations were not recognized during the resuscitation. When the radiologist analyzed this first group of patients and advised us of the 3 1% failure rate, the study was terminated. Unsuccessful catheterizations were observed in all operator groups (medical residents, surgical residents, attending physicians). There was no significant difference in failure rate among groups or between ACLS-certified and noncertified operators.
Discussion The success rate for elective femoral venous catheterization is high.3v4The low flow state and poor oxygenation present during cardiopulmonary resuscitation (CPR) may compromise localization of the femoral arterial pulse and make femoral venous catheterization during CPR more difficult than under elective conditions. However, Getzen has reported a 95% success rate for femoral venous catheterization in 796 young males with hypovolemic shock, 90% of whom had no palpable femoral pu1se.5 He does not specifically report the success rate
in the smaller subset of those patients who were receiving chest compression. The most likely factor that explains the high failure rate in our patients is operator inexperience in the technique of femoral venous catheterization. The prevailing bias in our institution is that the femoral route should not be used for routine central vascular access, and, therefore, the house staff and attendings in our institution almost never perform elective femoral venous catheterization. Although the attending physicians in our emergency department are ACLS-certified and familiar with the theoretical aspects of femoral venous catheterization, they do not use the procedure and thus are not practiced in it. Perhaps if we had extended our study to a much larger number of patients, the staff would have had adequate exposure to the technique to achieve a higher success rate. However, we felt that this would not be in the best interest of the patients and, therefore, terminated the study and returned to subclavian catheterization, a technique of vascular catheterization that is well known to our house staff. Although we have not studied subclavian attempts during CPR specifically, in a previous study of Swan-Ganz catheterization by the residents of our institution, there were no unsuccessful subclavian catherizations in 135 attempts.6 This study demonstrates that femoral venous catheterization may be an unreliable technique during CPR, especially if performed by inexperienced operators. Although the AI-IA states on page XII-2 of its Textbook of Advanced Cardiac Life Support’ that “During cardiopulmonary resuscitation, cannulation of peripheral or femoral veins should be the choice of first site since cardiopulmonary resuscitation (CPR) may have to be interrupted if either jugular or subclavian veins are chosen”; we suggest that this recommendation be reevaluated. Central venous access during CPR can be most expeditiously obtained if the operator uses the technique with which he or she has had the most experience.
Femoral Venous Catheterization
389
FigrIre 1. Supine abdominal radiograph of a 73-year-old woman after placement of a left fenioral ous line during the course of CPR. The lo-mL injection of contrast material demonstrates norvenm venous structures with flow back toward the lnferlor vena cava.
390
Michael S. Jastremski, Heddy Dale Matthias, Patricia A. Randell
Figuore2. Supine abdominal radiograph of a 5%year-old man after placement of a left femoral venous line during CPR. However, a lo-mL injection of contrast material demonstrates arterial stnJctures flow away from the end of the catheter. Reflux back to the abdominal aorta demonstrates/severe aoti ic iliac obstruction. There is good filling of the internal iliac artery and its gluteai braInches.
Femoral Venous Catheterization
391
Figure 3. Supine abdominal radiograph of a 60-year-old man after the placement of a left femoral venous line during CPR. A lo-mL Injection of contrast material demonstrates extravasatlon into the soft tissues. No vascular structures are outlined.
REFERENCES 1. Kaye W: Intravenous techniques, in McIntyre KM, Lewis AJ (eds): Textbook of Advanced Cardiac Life Support. Dallas, American Heart Association 1981, pp XII-l-X11-12. 2. Kuhn GJ, White BC, Stetnam RE, et al: Peripheral vs central circulation times during CPR: A pilot study. Ann Emerg Med 1981; 10:417-419. 3. Duffy BJ: The clinical use of polyethylene tubing for intravenous therapy. Ann Surg 1949; 130:929936.
4. Moncrief JA: Femoral catheters. Ann Surg 1958; 147:166-172.
5. Getzen LC, Pollak EW: Short-term femoral vein catheterization. Am J Surg 1979; 138:875878. 6. Jastremski MS, Wagner IJ, McAnulty J: SwanGanz catheterization by residents. Crit Care Med 1981; 9(3):143.