Our current policy states that any stat/emergent femerol line must be removed in 24 hours and if placed under sterile conditions must be removed in 48 hours. We recently had a patient that is no longer a picc candidate, multiple failed central lines (IJ), PAC's, history of infected port and infected pacer x 2, new pacer placed a month ago. She is a frequent admission and we usely get away with a power glide with her. This time her stay is longer and she required dopamine. So they placed a femerol line in her. Everyone refuses to try another line to get this femerol line out. One of the surgeons, who is new, said he has updated literature to support that femerol lines are no increase for infection and can remain in as long as needed. Just curious if anyone has heard of this or know of this information??
On balance the availabe evidence doesn't actually show an increased risk of infection for femorally inserted central lines, despite that being the common wisdom.
Here is a good narrative on the full range of evidence: https://pulmccm.org/review-articles/femoral-lines-not-so-bad-after-all-f...
Although even if a facility holds the position that femoral sites should be used as infrequently and as short-term as possible, it still doesn't really work to set hard limits that don't take into account the overall picture. If the rule is that femoral access must be removed no matter what after a certain period of time, then that will directly result in a number of unecessary patient deaths, which sort of defeats the purpose of a policy intended to protect patients.
The medical team I work with acknowledge that femoral sites aren't necessarily at higher risk for infection, but they are still not preferred mainly due to activity and movement limitations. It's still not the preferred site, but in patients with difficult access and/or multiple devices requiring central access it's often necessary and on balance still safer for the patient than going without the treatments the patient requires.
I have noticed an increase in femoral site use of late. I still have a problem with using that site simply because of the obvious. It's a dark, moist, place and I believe the reason you don't see more infections is because femoral sites were never used frequently. Think Midlines. They say Midlines don't get infected as much as PICC's. Has anyone thought that Midlines were not as "common" as PICC's and never really dwelled for a long time. I think we will start seeing more and more infections related to Midline use and Femoral use the more we use them . I also noticed that PICC's were not mentioned. PICC lines have an average of 1.3 infections per 1000 catheter days. However, PICC lines are always lumped in with CVC's. If we believe that 1.3, we should be placing PICC's as the central line of choice, but we don't. I don't like what's happening in the VAT world but a shinning light?..Retirement in 3 years..lol
Femoral insertion sites have no recognized limit on their dwell time, so no maximum dwell time is known. There is the prevailing concern about infection but evidence is showing that infection is not associated with the insertion procedure itself and the rate of BSI during dwell time is the issue, just as it is with other CVADS. As mentioned movement, ambulation, etc is a serious concern. There are practice changes happening. For instance, it is becoming common for the actual insertion site to be in the mid-thigh and not the inguinal crease. This is being used in patients after all upper body sites have been destroyed with other CVADs and complications. Another issue is the actual length of the catheter being inserted. Most devices designed for insertion into the subclavian or IJ are simply not long enough to reach the IVC from a femoral or mid-thigh insertion site. Standards of practice call for a CVAD to be either in the SVC or IVC, above the level of the diaphragm with tip confirmation. To accomplish the correct tip location in the IVC, you will need to use a PICC or a tunneled cuffed catheter. There are several veins (eg, renal, hepatic) that are documented to be malpositioned sites for femoral insertions, so confirming tip location is very important. Shorter devices will end up in the common iliac vein, and this is a site of malposition in many medical articles on that issue. You may have challenges from physicians about tip conformation though since most were not taught the importance of this.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Femoral insertion sites have no recognized limit on their dwell time, so no maximum dwell time is known. There is the prevailing concern about infection but evidence is showing that infection is not associated with the insertion procedure itself and the rate of BSI during dwell time is the issue. As mentioned movement, ambulation, etc is a serious concern. There are practice changes happening. For instance, it is becoming common for the actual insertion site to be in the mid-thigh and not the actual inguinal crease. Another issue is the actual length of the catheter being inserted. Most devices designed for insertion into the subclavian or IJ are simply not long enough to reach the IVC from a femoral or mid-thigh insertion site. Standards of practice call for a CVAD to be either in the SVC or IVC, above the level of the diaphragm and confirmed by xray. To accomplish the correct tip location in the IVC, you will need to use a PICC or a tunneled cuffed catheter. There are several veins (eg, renal, hepatic) that are documented to be malpositioned sites for femoral insertions, so confirming tip location is very important. I think you may have challenges from physicians about this step though since most were not taught the importance of this.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Femoral sheaths are typically 6 or 8 inches in length, the distance between the femoral insertion site and the IVC is typically 4.5 inches in the average adult, putting the tip in the IVC which is the standard of care. Placing the tip above the level of the diaphragm is not the standard of care.
The mid-thigh is not an established site for central veinous or arterial access.
we will have to agree to disagree. there are plenty of studies showing IVC ABOVE diaphragm is the tip location when inserting from lower body. And mid-thigh is becoming an accepted site for insertion with many VA specialist leading this progress.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I think you're confusing upper and lower body insertion sites with the "above the diaphragm" recommendation. There are multiple organizations that recommend a central line not extend below the diaphragm, but this is with upper body insertion sites.
Percutaneous access of threadable veins in the mid-thigh is not anatomically plausible, I'd be curious to see documentation of this.
I am not confusing anything. From the lower body insertion sites, for a line to be considered a central venous catheter, the tip must be located in the IVC ABOVE the diaphragm. See INS Standard 33 VA Site Preparation and Device Placement and # 53 CVAD Malposition. Also take note of the numerous MEDICAL publications supporting these standards. There are numerous studies on mid-thigh insertion of lines for several reasons. First it gets insertion site out of inguinal crease and second it is needed for patients when all upper body sites have been totally exhausted. Matthew Ostroff, VA Team Manager from hopsital is NJ is doing a lot of these sites.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
It would be appreciated if you could point in the direction of the literature you're referring to. The only references to above the diaphragm placement are articles such as this; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4644031/ which refer to central catheters inserted in the upper body.
In disccussing "mid-thigh" central catheter insertion with a vascular surgeon, she's pretty perplexed what you might be referring to given that this would be a complex surgical procedure, again, sources would be appreciated.
As you know, literature searches requires a lot of time. These are the services for which I charge a fee. Please visit my website to learn more www.hadawayassociates.com.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I think Lynn is referring to tunnelling the catheter a bit away from the inguinal crease, not a complex procedure. Some advanced practice RNs are doing this tunnelling for PICCs on the arm when the entrance site location is less than ideal. I saw this demonstrated on cadevars at AVA 2016, Teleflex central venous access course.
Nancy Rose
actually, PICC devices are being placed mid thigh with excellent outcomes. Not tunneled, placed with standard MST.
Thanks JIll. US guided procedure inserted mid-thigh. A procedure done by VA specialist.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861