In today’s resource, please carefully review Hemodynamic access for the crashing patient: The dirty double. This outstanding post details how to very rapidly obtain Femoral Arterial and Femoral Venous Access in an emergency.
March 1, 2015 by Dr. Josh Farkas‘ blog, Pulmcrit.
Be sure and explore Dr. Farkas’ outstanding Internet Book of Critical Care (IBCC) [Link is to the IBCC Table of Contents].
All that follows is from the above resource, Hemodynamic access for the crashing patient: The dirty double.
- For a crashing patient who needs immediate arterial and venous access, one approach is to place adjacent catheters into a femoral artery and vein.
- With the exception of severe obesity, this is generally fast and technically straightforward (especially with the use of ultrasonography).
- It may be difficult to place a completely sterile central line in the middle of a resuscitation. In an emergency it is reasonable to intentionally place “dirty” lines with a plan of removing these within ~24 hours. Placing “dirty” lines in the femoral position leaves the remainder of the vasculature available for placing a sterile line when time allows.
Introduction with a case
A 75-year-old man presents in transfer to the ICU for management of bradycardia and hyperkalemia. His history is notable for hypertension with chronic use of an ACE-inhibitor. He developed gastroenteritis due to endemic Norovirus some days prior. Today he presented to the outside hospital with hypotension and bradycardia, with a potassium of 8 mg/dL and a Creatinine of 3 mg/dL.When he arrives in the ICU he is noted to be hypotensive to 75/40 with a heart rate of 45 b/m. He is restless and slightly confused. He is oxygenating adequately on room air. His only functioning access is a 22-Gauge peripheral IV in his left hand. What is the best approach to obtaining IV access in this patient?
In the past, Dr. Farkas states that he might have inserted a subclavian venous catheter and a radial artery catheter. These are time consuming and divert the physician’s attention from other needed aspects of the patient’s care. Dr. Farkas states:
How I might manage this currently
Currently I begin by placing two catheters in the femoral artery and vein, immediately next to each other. This may be done using a single sterile field. The central venous catheter is placed first because it is generally more important. In highly acute situations, a nurse may attach extension tubing to the central line and start using it immediately (prior to inserting the arterial catheter). This will compromise the sterility of a portion of the sterile field, which can then be covered with a sterile towel.These lines are placed with the intention that they will be “dirty” lines which must be removed within ~24 hours. They are placed using sterile gloves, a mask, and a sterile sheet but without full sterility. For example, this will typically occur during a resuscitation with many people at the bedside, and not everyone may be wearing a mask. The sterile sheet will generally not cover the patient’s entire body (typically the upper body and head are left exposed to allow monitoring of the patient’s ventilation and mental status).Advantages of emergent femoral arteriovenous access
Speed This is probably the fastest way for a single operator to achieve central venous and arterial cannulation. Radial arterial catheters may be hard to place in shocky elderly patients, so the femoral arterial line provides a speed advantage compared to the radial site. Preparing only a single site further reduces the time required.
[Best for] Patients with difficulty lying still
[Allows For Continous Visual] Respiratory Monitoring
Definitive Access Intraosseous access is faster than placing a central line, and may be needed while awaiting central access. However, a patient in this situation will require multiple IV medications and lab tests so an intraosseous line will not entirely solve the IV access problem.
It’s OK to be dirty [meaning not completely sterile in the interest of speed in an emergency], as long as you come clean about it
[Therefore], if a line is emergently placed without full sterility but it is accurately designated as a “dirty” line, then this is not a problem. The line will be removed before a line infection could occur. Linguistically it sounds wrong to put in a “dirty” line, but this is actually a rational approach to central access in a crashing patient.
Beware of the intubation trap for hemodynamic crashes
When approaching an unstable patient, one consideration is always whether the airway should be secured. As discussed earlier, if there is concern that the patient is going to lose their airway, it may be reasonable to err on the side of intubation. A previous post discussed rapid sequence intubation and procedurization as an approach to a patient with respiratory failure.However, for patients with a primary cardiac problem and severe hypotension, immediate intubation is extremely dangerous and may precipitate cardiac arrest. This patient’s problem is not respiratory failure. Intubation will not solve their problem, but will actually make it worse (adding sedation and positive-pressure ventilation are likely to worsen the patient’s hemodynamics). When facing a crashing patient with a primary hemodynamic problem, there may be a tendency to start by securing the airway (“start with the ABCs”), but it is often best to avoid intubation if possible.To ultrasound or not to ultrasound? [Use the ultrasound as it will save time]The debate about whether or not to use ultrasonography for central lines is getting a bit stale at this point. My preference is to use ultrasonography for double femoral cannulation if possible. Setting up the ultrasound machine takes a little time up-front, but this may improve the speed and accuracy of both procedures.Approach in morbid obesity
Although femoral access is generally straightforward, it can be challenging in the morbidly obese. Certainly, the site of vascular access will vary between different patients and this must be determined on a patient-by-patient basis. When in doubt, examining the vessels with ultrasonography before starting the procedure takes a few seconds, and can provide a good concept of how difficult the procedure will be. If a femoral approach is chosen in a patient with morbid obesity, it may be extremely helpful to retract the pannus (using tape or an assistant) in order to open up the inguinal crease.
