The document summarizes a procedure to place a femoral vascular access catheter for hemodialysis in a patient with coagulopathy, hyperkalemia, acute renal failure, and hemorrhagic anemia. After failed attempts on the left side due to inability to pass the dilator through the subcutaneous tissue, the procedure was completed successfully on the right side despite a hematoma. Potential complications included bleeding due to multiple needle insertions in a coagulopathic patient.

1. 31244363-Version:2
</DATE OF OPERATION/>
10/16/2013
</PROCEDURE PERFORMED/>
Right femoral vascular access for hemodialysis.
</PREOPERATIVE DIAGNOSES/>
1. Coagulopathy.
2. Hyperkalemia.
3. Acute renal failure.
4. Hemorrhagic anemia.
</POSTOPERATIVE DIAGNOSES/>
1. Coagulopathy.
2. Hyperkalemia.
3. Acute renal failure.
4. Hemorrhagic anemia.
</OPERATOR/>
James Leavey, MD.
</DESCRIPTION OF PROCEDURE/>
The procedure was explained to the patient as well as to her daughter who verbalized understanding and
consented to the procedure. Risks, benefits, and alternatives were described. The patient was
hypotensive. She was noted to be hyperkalemic. We ______ draw blood while doing the procedure as
the patient had no vascular access, only an intraosseous catheter in her right tibia. The area for catheter
placement was identified as the left femoral side as the right one had a hematoma from a blood draw at
the outlying facility. The area for catheter placement was cleansed with chlorhexidine, draped in a sterile
manner, infiltrated with 1% lidocaine locally. Then, an 18-guage needle was passed into the femoral vein
with return of dark red, nonpulsatile blood under ultrasound guidance. A wire was passed through the
needle. The needle was withdrawn. The skin and subcutaneous tissues were dilated with a dilator with
difficulty getting through the subq tissue. We were unable to get the dilator or the vascular catheter
through the subcutaneous tissue into the vessel. After several attempts, the procedure was aborted. The
area was broken down. A new sterile procedure setup was started on the right femoral side. This was
technically difficult due to a hematoma in the area, but with some difficulty, an 18-gauge needle was
passed beneath the skin into the femoral vein on the right with return of dark red, nonpulsatile blood. A
wire was passed through the needle. The needle was withdrawn. The skin was dilated with scalpel and
plastic dilator with some difficulty, but the catheter was able to be passed over the wire into the femoral
vein with return of dark red, nonpulsatile blood. The ports were capped, aspirated of air, injected with
sterile saline solution. The catheter was sutured in place and covered with a sterile bio-occlusive
dressing. Complications included the potential for bleeding with multiple ______ in a patient who is
coagulopathic.
Plan is for a retroperitoneal CT or ultrasound later this evening once the patient is resuscitated.