Healthcare and Medicine Reference
In-Depth Information
Femoral vein
The femoral vein is the continuation of the popliteal vein and ends
medial to the artery at the inguinal ligament where it becomes the
external iliac vein. The femoral artery, vein and nerve lie within the
femoral triangle, arranged from lateral to medial: nerve, artery, vein
(Figure 11.2). The artery can easily be palpated on a subject, and the
vein lies 2 cm medial to the pulsation.
depends on a combination of factors, which are summarised in
Table 11.1.
Ultrasound
The use of ultrasound scanning (USS) has signifi cantly reduced
the complications from central venous access. Two-dimensional
ultrasound can be employed to identify the relevant veins and
accompanying artery and can be used throughout the proce-
dure to confi rm venous cannulation and fi nally at the end of the
procedure to confi rm catheter placement in the vein. USS may also
demonstrate thrombosis, stenosis and anatomical variants that
may preclude catheter insertion. Given the relatively low cost of
USS equipment and the straightforward training required to per-
form USS-guided central venous access it has become the standard
technique for elective line placement.
The step-by-step guide in this chapter covers insertion tech-
niques with and without ultrasound. It is important to learn
both, as the landmark technique is invaluable in emergency
situations.
Site selection
The anatomy of these areas is complex and the risk of
damaging nearby structures is signifi cant. The choice of site
Transverse
process
of atlas
Right posterior
auricular vein
Mastoid
process
Posterior
division of right
retromandibular vein
Right internal
jugular vein
Right external
jugular vein
Right anterior
jugular vein
External oblique
aponeurosis
Trapezius
Right transverse
cervical vein
Superficial ring
Ilioinguinal nerve
Sternocleidomastoid
Femoral artery
and vein in
femoral sheath
Spermatic cord
Femoral canal
Right subclavian vein
Right brachiocephalic vein
Figure 11.1 Anatomy of the great veins of the neck. (From Whitaker RH,
Borley NR. (2005) Instant Anatomy , 3rd edn. Blackwell Publishing, Oxford,
with permission.)
Figure 11.2 Anatomy of the femoral artery. (From Faiz O, Moffat D.
(2006) Anatomy at a Glance , 2nd edn. Blackwell Publishing, Oxford, with
permission.)
Table 11.1 Factors to consider when choosing a site for central venous access.
Site
Advantages
Potential for complications
Other factors
Internal jugular
Anatomy readily visible with ultrasound
Can be adapted to accommodate patient size
and position
Easily accessed surface of patient
Puncture of internal carotid or misplaced line
in the internal carotid
Pneumothorax is a recognised complication
Diffi cult to nurse long term
Dressings can be problematic due to
beard/stubble
Uncomfortable for patient
Subclavian
Lower risk of infection
Does not require movement of patient's head and
can be accessed during c-spine immobilisation
Useful in emergencies
Vein does not collapse fully in hypovolaemic states
Highest chance of pneumothorax
Puncture of tracheostomy or endotracheal
tube cuff
Cannot apply pressure to stop bleeding
Can be painful even with good skin anaesthesia
Less easy to visualise with USS
Easier to nurse
Comfortable for patient
Femoral
Safest vein to place large lines, for example for
veno-veno haemofi ltration because there are
fewer important structures nearby.
Puncture of femoral artery can usually be treated
with pressure
Femoral artery puncture leading to
retroperitoneal bleed
Femoral nerve damage
Diffi cult to nurse and keep clean
Highest likelihood of infection
Patient position is comfortable for
the patient
Easy to anaesthetise all tissues which
will be punctured, cut or dilated
 
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