A sterilized individual to assist with opening packaging and handing sterile equipment in a manner that maintains the sterile field is generally helpful. Additionally, a separate individual to provide sedation/analgesia and monitor effects is ideal and safest for the patient. Lastly, a second, sterilized individual may be required to assist with ultrasonography depending on the comfort and/or experience of the proceduralist.

Provide informed consent to the patient by explaining the risks and benefits of the procedure, as well as, the alternatives to the procedure

Choose an appropriately sized central venous catheter for the patient.  This decision may be influenced by the clinical indication, patient size and/or vessel caliber.  Consider the following:

1. Catheter size in French (F) (e.g., 4F, 7F)
2. Catheter length (in centimeters)
3. Number of lumens required

Perform a procedural “timeout” to confirm that the correct procedure is being performed on the correct patient and on the correct side of the patient (i.e., right or left side)

Position the patient:

1. The patient can be placed in a reverse Trendelenburg position to engorge the femoral vein which could potentially increase the vessel’s caliber
2. The patient’s leg can be positioned in one of three ways: frog-leg position, external rotation at the hip with full leg extension, abduction of a fully extended leg with external rotation at the hip.

• Proceduralist washes hands with soap and water
• Proceduralist dons sterile personal protective equipment (PPE) (i.e., cap, facemask, sterile gown and gloves)
• Sterile prepping of the skin at the site of insertion with chlorhexidine gluconate or povidone-iodine solution
• Place a sterile drape over the patient ensuring coverage from head to toe
• If ultrasound-guidance is utilized, insert non-sterile ultrasound gel into the sterile probe cover and place the ultrasound probe into the cover. The sterile ultrasound gel will be used in the sterile field to assist with visualization
• Administer local anesthetic as an effort to minimize the use of systemic analgesia/sedation
• Flush all lumens of the central venous catheter with normal saline.

Employ the “landmark technique” to isolate the location of the femoral vein for puncture. There are several methods to do this, and some examples are to:

1. Use your index finger to locate the arterial pulsation along the inguinal ligament at the midpoint between the anterior superior iliac spine and the pubic symphysis.  Then move 1 cm to 2 cm inferior to this position as the needle puncture must be performed below the inguinal ligament. Next, move 1 cm to 2 cm medially as the vein lies medial to the artery.
2. Use your index and middle fingers to locate the distal and proximal pulsations of the femoral artery, respectively.  Just medial to your fingertips should be the general course of the femoral vein. Hence, you should puncture just medial to your index finger in a direction just medial to your middle finger.

At the desired location and using the slip tip syringe-introducer needle complex, puncture the skin at a 30 to 45-degree angle to the skin.

1. If utilizing ultrasound-guidance, information is provided on the relationship of vessels to each other as well as other surrounding structures. Additionally, vessel depth, caliber, and patency can also be assessed.   These findings should be integrated with landmark findings to assist in choosing an ideal puncture site, entry angle, and needle direction.

• Pull back on the plunger of the syringe while advancing the syringe-needle complex. Aspiration of blood into the syringe indicates entry into a vessel.  The color of blood aspirated does not help distinguish between arterial and venous blood.  If resistance is met, then retract the syringe-needle complex slowly as the needle may have gone through the vessel. If blood is still not aspirated, then pull back the syringe-needle complex, just short of coming out of the skin, and reconsider needle direction and angle.

1. When blood is easily aspirated, stabilize the hub of the needle and remove the syringe. A steady dripping of blood is to be expected. The presence of pulsatile blood flow should concern the practitioner for arterial puncture. Insert the guidewire into the needle hub and advance slowly. The guidewire should advance easily and only be inserted at a length that is 2 cm to 3 cm longer than the introducer needle. The proceduralist should never let go of the guidewire to avoid mishaps.
2. While maintaining guidewire position, slowly remove the needle.
3. Using the scalpel, incise the skin at the puncture site while also avoiding the guidewire.
4. Insert the dilator over the guidewire and advance slowly through the incised puncture site. In general, the entire length of the dilator does not need to be inserted. The dilator only needs to be advanced to a depth that allows it to pass through the skin and enter the vessel slightly.
5. Remove the dilator while maintaining guidewire position and then advance the central venous catheter over the guidewire.
6. Attempt to aspirate blood from each access port of the catheter to ensure patency and then place hubs on each access port.
7. Using the needle holder and silk sutures, suture the catheter in place.
8. Place the anti-microbial disc over the catheter insertion site and apply the dressing.
9. Confirm catheter placement via blood gas, x-ray, and/or pressure transduction.
10. Perform documentation of the procedure in the medical record.

Complications from central venous access can be classified into early and late complications. Again, some of these are not specific to the femoral site and can occur with insertion at other central venous access sites.[5][6][7][8]

Early

• Arterial puncture which could result in formation of a hematoma
• Hematoma formation could also result from routine placement
• Bladder puncture. At our institution, we catheterize or insert a foley catheter prior to placement of a femoral central line
• Hemorrhage
• Catheter fragment resulting in a guidewire embolism
• Cardiac dysrhythmias, particularly from high-lying central lines

 Late

• Central Line Associated Bloodstream Infection (CLABSI)
• Phlebitis
• Thrombosis
• Erosion/perforation

The following are not complications, per se, but can lead to complications:

• Uncooperative patient
• Lack of experience/supervision

CLABSIs are the most common complication of central venous catheter placement. CLABSIs are a source of significant morbidity and mortality, as well as, increased healthcare cost. A majority of the equipment, preparation, and technique described above have been incorporated into bundled practices and checklists that have been shown to reduce the incidence of CLABSIs. In adults, the femoral site is avoided due to evidence demonstrating a higher risk of bloodstream infection relative to other sites. However, this has not been demonstrated in children, and the femoral site is a preferred site in this population due to ease of access. Lastly, long-term central venous access, such as PICCs, have also been associated with a relatively lower risk of bloodstream infections.

Femoral vein cannulation is usually performed by the physician but the line is monitored by the nurse. In general, femoral vein cannulation is not preferred because the groin site is difficult to keep clean and patient ambulation is difficult. These lines should not be kept for more than 24 to 48 hours. Nurses should monitor the site for bleeding, infection and hematoma. The only benefit of a femoral line is that unlike a subclavian or IJ central line, the risk of a pneumothorax is non-existent.