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Central Vein Cannulation
is often recommended during cardiopulmonary
resuscitation. Both the American and European
Resuscitation Society agree that it presents
a fast, reliable, and with some drugs
like Cathecol-amines, it could be even
safer than peripheral veins. In their
guidelines, the recommended routes are
the internal jugular or subclavian veins.
However these routes are close to the
chest, which interferes with the on going
chest compression and intubation. These
are often interrupted to allow for a steady
venous cannulation procedure.
We have often found the
femoral approach to be very rewarding
for several reasons. It is as easy as
the jugular or subclavian routes, but
without some of the risks and complications,
like pneumothorax. Pneumothorax during
cardiopulmonary arrest is difficult to
diagnose and if unnoticed can lead to
death of the victim despite an otherwise
adequate resuscitation. I am not aware
of any studies into the frequency of this
complication not only in survivors of
CPR, but also in those who succumb. Unwanted
arterial puncture is probably as common
in the femoral route as the other two
sites, but vessel compression is easier
and the consequences of hematoma in the
groin are less serious than in the neck.
In fact, if the femoral artery is punctured,
we often leave an arterial line for accurate
and continuous blood pressure and gas
monitoring. The same cannot be applied
to puncture of the subclavian or carotid
artery.
Clearly, one must pay
more attention to cleaning and disinfection
of the groin. Although infection is said
to be more common after femoral cannulation,
but to my knowledge, there are no properly
controlled studies to support this view.
Seneff suggests that the incidence of
infection is similar(1). Likewise there
are no studies to look at the bio-availability
of drugs given through femoral, versus
subclavian or jugular routes.
One may argue that chest
compression during CPR may improve the
distribution of drugs given through the
superior as opposed to inferior Vena Cava.
However, this is not known. Likewise,
it is also not known if abdominal "counter
compression" improves the distribution
of drugs given by the femoral route.
Finally, measurement
of central venous pressure (CVP) in the
resuscitated patient is one of the aims
of central venous cannulation. Certainly
there should be no difference between
the various routes provided the catheter
tip is situated in the right atrium. However,
is there a difference between measurements
of CVP in the inferior or superior vena
cava? A study by Kwok et al suggested
no difference(2) and we are contemplating
a similar study in elective patients.
In conclusion, in the setting of Cardiopulmonary
Resuscitation, there are some advantages
using the femoral vein for central venous
cannulation. Mainly due to less interference
with intubation and chest compression
and with respect to some complications.
I feel that personnel involved in advanced
resuscitation should be aware of these
advantages and possibly trained in the
basic technique of femoral route. It may
be early to suggest including the femoral
cannulation in any guidelines, but I welcome
the comments of colleagues, especially
if studies should be instigated to evaluate
the advantages of the femoral route compared
to the established routes of jugular and
or subclavian veins.
References:
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