Correspondence

Femoral Venous Catheterization

N Engl J Med 2008; 359:1294-1295September 18, 2008

Article

To the Editor:

In their article and video on the placement of a femoral venous catheter, Tsui et al. (June 26 issue)1 describe several procedural complications. One rare but potentially lethal complication is not mentioned, however. A guide wire and venous catheter, introduced through the left femoral vein and advanced into the left common iliac vein, may subsequently be advanced into the left ascending lumbar vein instead of the inferior vena cava. When unrecognized, this complication has been associated with a reported rate of death of 50%.2 This malpositioning can be seen on a plain anteroposterior abdominal radiograph as left lateral deviation of the venous catheter (seen as a “hump”) or as a position left of midline (Figure 1Figure 1Anteroposterior Abdominal Radiograph Showing Incorrect Placement of Femoral Venous Catheter.). Most reports concern infants and children, but the complication may also occur in adolescents and adults. My colleagues and I recently witnessed this type of malpositioning in a 16-year-old girl after rapid cannulation of the left femoral vein with a 7-French, 30-cm, double-lumen catheter (Figure 1). We believe that an abdominal plain film should be considered after left femoral vein cannulation.

Marcel J. Albers, M.D., Ph.D.
University Medical Center Groningen, 9700 RB Groningen, the Netherlands
m.albers@bkk.umcg.nl

2 References

1. 1

   Tsui JY, Collins AB, White DW, Lai J, Tabas JA. Placement of a femoral venous catheter. N Engl J Med 2008;358:e30 (Web only). (Available at http://www.nejm.org.)
   

2. 2

   Carrion E, Hertzog JH, Gunter AW, Lu T, Ruff C, Hauser GJ. Misplacement of a femoral venous catheter into the ascending lumbar vein: repositioning using ultrasonographic guidance. Intensive Care Med 2001;27:240-242
   CrossRef | Web of Science | Medline

To the Editor:

In their video about placement of a femoral venous catheter, Tsui et al. state that “additional lidocaine with epinephrine or bupivacaine” is needed to ensure adequate field-block anesthesia of the femoral region, but they fail to specify the appropriate concentration and total amount of local anesthetic. In most cases, a total of 5 ml of plain 1% lidocaine is sufficient to anesthetize the skin for placement of the femoral venous catheter and for the two or three retention sutures. In addition, I disagree with the authors' suggestion that bupivacaine be used for the field block. Because the close proximity of the large femoral vessels to the surface of the skin, there is a risk of accidental intravascular injection, and bupivacaine is the most cardiotoxic of the local anesthetics.1 Furthermore, basing the selection of this agent on the fact that it is longer lasting than other anesthetics is of dubious value for a procedure that in most cases requires less than 30 minutes.

Andrea Torri, M.D.
Massachusetts General Hospital, Boston, MA 02114

1 References

1. 1

   Weinberg GL. Current concepts in resuscitation of patients with local anesthetic cardiac toxicity. Reg Anesth Pain Med 2002;27:568-575
   Web of Science | Medline

Author/Editor Response

We appreciate the description by Albers of the misdirection of a left femoral venous catheter into the left ascending lumbar vein. Although a description of all the possible procedural complications was outside the scope of this video and article, it is important to recognize the possibility of even infrequent problems. Because this complication has been described primarily in neonates and infants,1 such additional verification of the position of the catheter may be particularly important in these groups. It is not clear whether imaging would be appropriate for confirmation of location in adults — and if so, what type of imaging — given this single case report.

Practitioners should always be mindful of toxicity when infiltrating local anesthetic. Torri argues against the use of bupivacaine because of its potential toxicity. The most conservative estimate for a toxic dose of bupivacaine without epinephrine is 2 mg per kilogram of body weight. In an adult weighing 70 kg, the maximum dose for a 0.25% concentration is 60 ml, and the maximum for a 0.5% concentration is 30 ml. Local infiltration with such doses has been reported to be safe and to result in acceptable blood levels.2,3 Markedly smaller amounts than this should be required for local analgesia for the procedure, and lidocaine with epinephrine is always an option if the practitioner prefers to avoid bupivacaine. Although plain lidocaine may last sufficiently long to complete femoral venous catheterization in the majority of cases, we have frequently observed insufficient duration of analgesia in particularly challenging cases and in instances in which learners are receiving instruction. These factors should be taken into account when selecting the appropriate local anesthetic.

Jeffrey A. Tabas, M.D.
Janet Y. Tsui, M.D.
Adam B. Collins, M.D.
San Francisco General Hospital, San Francisco, CA 94110
jtabas@sfghed.ucsf.edu

3 References

1. 1

   Filan PM, Salek-Haddadi Y, Nolan I, Sharma B, Rennie JM. An under-recognised malposition of neonatal long lines. Eur J Pediatr 2005;164:469-471
   CrossRef | Web of Science | Medline

2. 2

   Kastrissios H, Triggs EJ, Sinclair F, Moran P, Smithers M. Plasma concentrations of bupivacaine after wound infiltration of an 0.5% solution after inguinal herniorrhaphy: a preliminary study. Eur J Clin Pharmacol 1993;44:555-557
   CrossRef | Web of Science | Medline

3. 3

   Mobley KA, Wandless JG, Fell D. Serum bupivacaine concentrations following wound infiltration in children undergoing inguinal herniotomy. Anaesthesia 1991;46:500-501
   CrossRef | Web of Science | Medline