Clinical scenario

You are in the emergency department attending to a 68 year old man who was found in his car that had left the road and hit a tree. On arrival his GCS was 6 and he had two fractured clavicles and an open fracture of the left humerus. His BP is 90/50 and his pulse is 110 and after stabilisation you call an anaesthetist to intubate him, with cervical collar in situ. While he is doing this, you find multiple medications for heart failure in his pockets and the radiographer brings you a large packet of his old films including several showing pulmonary oedema over the past few days. There is nothing acute on his ECG and only cerebral oedema is seen on the head computed tomography. You can see that his fluid balance will be very difficult to manage over the next few days. You elect to insert a femoral central line but wonder if there will be any additional risks to placing this into the femoral vein rather than the currently inaccessible cervical region.

Three part question

In [patients requiring central venous pressure monitoring] does the insertion of [a femoral central line as compared with an internal jugular or subclavian line] increase [the rate of thrombotic complications]?

Search strategy

Medline 1966-07/04 using the OVID interface. [(exp femoral vein OR femoral vein.mp) AND (exp catheterisation, central venous OR exp Catheterisation OR catheterisation.mp) AND (exp thrombosis OR thrombosis.mp OR exp venous thrombosis)] AND maximally sensitive RCT filter.

Search outcome

Altogether 90 papers were found of which seven were relevant. A further paper was found by cross referencing. These papers are shown in table 5.

Comment(s)

All studies found evidence of thrombosis after femoral central line insertion. Rates ranged from a 2% rate of DVTs seen clinically by Timsit et al in a study that did not specifically look for evidence of a DVT, to 21% detection of thrombus by USS by Merrer et al, a 34% rate of thrombus detection on phlebography by Durbec et al. Of note Joynt et al found an 8% rate of iliofemoral DVTs, but two DVTs were also seen in contralateral, uncannulated legs. All studies detect high rates of lower limb thromboses and therefore extreme caution should be used when deciding to insert a femoral central line. If a femoral line is deemed necessary attention should be paid to gaining access elsewhere at the earliest possible opportunity.

CLINICAL BOTTOM LINE

Central lines inserted into the femoral vein have an unacceptably high rate of thrombotic complications and efforts to minimise the use of this route of access should be taken.