passing a 2.5Fr, 2.5-cm catheter (or IV catheter) over the wire and into the arterial lumen FEMORAL ARTERY/VEIN PUNCTURE Indications Arterial or venous blood sampling during resuscitation Venous blood sampling in infants with inadequate peripheral veins Contraindications Avoid femoral punctures in children hypercoagulable states, or cardiac shunts who have coagulation defects, Complications Hematoma of femoral triangle Thrombosis—femoral artery or vein Superficial infection Osteomyelitis/arthritis—proximal femur, hip joint Equipment Butterfly needle (1-in, 21- to 23-gauge needle in a child to years of age or older); syringe on 1.5-in, 19- or 21-gauge needle when child is to 10 years of age or older; 5- to 10-mL syringe; povidone-iodine or chlorhexidine antiseptic solution; 70% alcohol; sterile gauze; blood sample containers Ultrasound may be useful to locate vessel and guide advancement of needle (see Chapter 131 Ultrasound ) Procedure If time allows, apply topical or local anesthetic over the expected puncture site to achieve local anesthesia of the superficial skin Have an assistant restrain the infant This can be done using one of two methods The first method is illustrated in Figure 130.4A , whereby the trunk and contralateral leg are restrained by the assistant and the ipsilateral leg is restrained by the operator The second method is diagrammed with the illustration for suprapubic bladder aspiration (see Procedure in Suprapubic Bladder Aspiration section), in which the assistant leans over the infant with arms pressing on the infant’s arms above and holding the distal thighs below in the frog-leg position Gently flex the knee and externally rotate the hip to identify the landmarks of the femoral triangle Locate the inguinal ligament, and gently palpate midway between the anterior-superior iliac spine and pubic symphysis The femoral artery lies halfway between the two landmarks; the vein lies 0.5 to cm medially ( Fig 130.4B ) The empty space between flexor and extensor muscles of the medial thigh will also reveal the location of the vessels Alternatively, ultrasound can be used to identify the vessels Cleanse the femoral triangle circumferentially with antiseptic solution several times and allow to dry With the palpating index finger, relocate the femoral artery approximately cm below the inguinal ligament Use the palm of this hand to control the movement of the child’s leg If possible, minimize the infant’s agitation and movement which make the abdominal musculature taut and the transmitted pulse difficult to palpate FIGURE 130.4 Femoral artery/vein puncture Direct the needle 60 to 75 degrees from the horizontal, just cephalad on the leg to the palpating finger, as shown in Figure 130.4C Puncture the skin over the pulsatile femoral artery or 0.5 cm medially for the vein, whichever is desired Apply constant suction to the syringe as the needle is advanced into the thigh to ensure blood is obtained on entering the vessel The assistant should work to avoid uncontrolled leg movements by the infant leading to loss of alignment of the needle and vessels If unsuccessful, withdraw the needle to just below the skin surface and reattempt vessel puncture after shifting the medial or lateral alignment of the needle tip After obtaining the sample, stop suction on the syringe After needle withdrawal, the assistant should apply constant manual pressure on the puncture site for minutes with sterile gauze PERCUTANEOUS FEMORAL VEIN CATHETERIZATION Indications Emergency access to central venous circulation See Chapter 131 Ultrasound for discussion of ultrasound guidance The femoral vein is more accessible than the internal jugular or subclavian veins during resuscitation Complications Inadvertent arterial catheterization Arterial or venous laceration Infection (especially if placed in an emergency situation without reliable use of infection control technique) Hematoma Catheter or wire fragment in central circulation Equipment Commercial tray containing introducer needle, 5- to 10-mL syringe, guide wire, no 11 blade scalpel, dilator, and catheter; 3Fr (younger than years of age) or 4Fr (2 to years old) or 5Fr (older than years of age); sterile drapes and gloves; povidone-iodine or chlorhexidine antiseptic solution; sterile gauze pads; use larger single-lumen set in trauma patients; ultrasound machine if available Procedure If time allows, apply topical or local anesthetic over the expected puncture site to achieve local anesthesia of the superficial skin Restrain the lower extremities and trunk of the child Externally rotate the hip to facilitate palpation of the femoral triangle Consider use of a towel roll under the gluteal muscle to improve exposure of the vein Palpate the femoral artery 1.5 cm below the inguinal ligament, halfway between the anterior-superior iliac spine and symphysis pubis ... puncture site for minutes with sterile gauze PERCUTANEOUS FEMORAL VEIN CATHETERIZATION Indications Emergency access to central venous circulation See Chapter 131 Ultrasound for discussion of ultrasound... Inadvertent arterial catheterization Arterial or venous laceration Infection (especially if placed in an emergency situation without reliable use of infection control technique) Hematoma Catheter or wire