Use of “low approach” femoral central venous cannulation during COVID-19 pandemic

ABSTRACT

Introduction: Many times critically ill patients who are either suspected cases of COVID-19 or COVID-19 positive coming to intensive care units require central venous access. Wearing personal protective equipment (PPE) for placing a central venous catheter can make the procedure challenging because of poor visibility. Insertion of the central venous catheter becomes even more difficult when the patient is in respiratory distress and is unable to lie flat on the bed. In COVID-19 positive or suspected patients where it is difficult to cannulate internal jugular vein (IJV) or subclavian vein due to anatomical or medical reasons, we suggest ultrasound-guided “low approach” femoral central venous access as an alternative.2 We report a case of acute pulmonary edema secondary to rheumatic heart disease which was managed successfully with ultrasoundguided low approach femoral central venous access. Materials and methods: A 37-year-old woman with a history of rheumatic heart disease presented in intensive care with acute pulmonary edema. The nasopharyngeal swab was taken for reverse-transcriptionpolymerase- chain-reaction (RT-PCR) assay to rule out COVID-19. The patient was managed in a line of acute pulmonary edema with an upright position, oxygen support, noninvasive ventilation (NIV), furosemide, and morphine. This patient required urgent central venous access for starting vasopressor and further management. As the patient was unable to lie flat on the bed and multiple attempts for vascular access were already tried in the emergency department, we planned for low approach femoral access. We used ultrasound with a linear probe to scan the femoral vessel at the level of the groin. By keeping the femoral vein in the center of the screen, a needle was inserted from the middle of the linear probe at an angle of 30 to 45°. The position of the guidewire inside the femoral vein was confirmed with ultrasound by using a long axis view before threading the catheter over it. The cannulation was successful in the first attempt. Discussions In this case, we successfully inserted an ultrasound-guided femoral central line 5 cm below the inguinal ligament in a view to further reduce catheter induced infection rate. It has been suggested that the risk of infection will be very much reduced if we use full barrier precaution, ultrasound guidance, low approach, tunneling, and medicated catheter. Another advantage of low approach femoral access is that a person doing this procedure is away from the respiratory passage of the patient it may reduce chances of airborne infection during the COVID-19 pandemic. Placing the catheter in the femoral vessel will not interfere with the respiratory care (helmet-based NIV). Proning patients during mechanical ventilation and dressing of the line is also not a problem with low approach femoral venous access. Femoral access should be avoided in patients with peripheral venous and arterial disease and renal transplant. Conclusion: In this case, we have highlighted that modification of femoral venous access helps to achieve the central access quite fast and also increases the safety of both patient and operator. We suggest that in present times of COVID-19 pandemic, ultrasound-guided low approach femoral central venous access may be used in emergencies and also where other options of central venous cannulation are not suitable.