Real-Time Ultrasound–Guided Femoral Vein Catheterization During Cardiopulmonary Resuscitation,☆☆,

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Abstract

Study objective: To compare the use of real-time–ultrasound guidance with the standard landmark-oriented approach for obtaining femoral vein catheterization in patients requiring intravenous access during CPR. Methods: Prospective, randomized, paired subject-controlled clinical trial in the setting of an urban teaching county hospital emergency department. The study comprised a convenience sample of 20 patients presenting with apnea and pulselessness in the ED. Each patient received bilateral femoral lines, one by ultrasound guidance and one by the landmark approach (control). Randomization determined which technique and which side would be attempted first. The following parameters were recorded: time to initial flash of blood, time to completion of catheterization, number of needle passes, and rate of arterial catheterization. CPR and Advanced Cardiac Life Support protocols were continued during both procedures. Results: Real-time ultrasound-guided catheterization had a higher success rate (90% versus 65%, P=.058), a lower number of needle passes (2.3±3 versus 5.0±5, P=.0057), and a lower rate of arterial catheterization (0% versus 20%, P=.025) than the standard landmark-oriented approach. Ultrasound was also slightly faster in time to blood flash and in time to catheterization. An incidental finding of interest was that real-time ultrasound demonstrated the presence of femoral vein pulsations during CPR. Conclusion: Real-time ultrasound-guided femoral vein catheterization was faster and produced a lower rate of inadvertent arterial catheterization and a higher rate of success during CPR than the standard landmark-oriented approach. Also, ultrasound demonstrated that palpable femoral pulsation during CPR is venous rather than arterial. [Hilty WM, Hudson PA, Levitt MA, Hall JB: Real-time ultrasound–guided femoral vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med March 1997;29:331-337.]

Section snippets

INTRODUCTION

Central IV access is a relatively common procedure in the emergency department. Emergency physicians rely on their skill to establish a central line as a lifesaving procedure for delivery of critical care medications, for volume resuscitation with saline or blood products, and for central cardiac monitoring and pacing. The success rate, the time to completion, and the rate of complications are all important aspects of this procedure.

Ultrasound-guided IV catheterization in the ED is an emerging

MATERIALS AND METHODS

We used a convenience sample comprising serial patients who presented in cardiopulmonary arrest to the ED at Highland General Hospital when either of two investigators (WH or PH) was present. CPR and resuscitative efforts following the Advanced Cardiac Life Support protocol were directed by an attending physician or other senior emergency medicine resident to allow the study investigators to focus on the establishment of femoral venous access. This study was approved by the Highland General

RESULTS

Twenty patients completed the study protocol. No patients had femoral scars from previous surgery or use of injection drugs. None of the study patients survived to hospital discharge. The mean age of study patients was 64±15 years (range, 30 to 82 years). Thirteen were men and seven women. Average weight was 76.3 kg (range, 50 to 160 kg). Average height was 170.9 cm.

The Table summarizes the results of the 20 ultrasound-guided and 20 landmark-oriented catheterizations. Of the seven failures by

DISCUSSION

Femoral vein catheterization in the ED is a useful technique for the administration of fluid, blood products, and medications and for limited central venous monitoring.8 Its application has been studied in trauma,7, 9, 10, 11, 12 in critically ill patients,13 in comparison with saphenous vein cutdown11, in subclavicular and internal jugular vein catheterizations9, and in CPR.12, 14 Many studies have touted its usefulness and accessibility. The scope of reported complications with femoral line

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    From the Department of Emergency Medicine, Highland General Hospital, Oakland, California*; and the Division of Emergency Medicine, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri.

    ☆☆

    Reprint no.47/1/79382

    Address for reprints: William M Hilty, MD Highland General Hospital Department of Emergency Medicine 1411 East 31st Street Oakland, California 94602 510-437-4564 Fax 510-437-8322 E-mail [email protected]

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