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Central Venous Line Placement

Subclavian Venipuncture, Infraclavicular Approach

 

5/6/03 version

Large veins such as the subclavian have relatively constant relationships to easily identifiable anatomic landmarks. This makes the subclavian a good site for central line placement.

 

Indications:

 

Contraindications:


Materials:

 

Preprocedure patient education:

 

Procedure (Infraclavicular Approach):

1. The subclavian vein is a continuation of the axillary vein

2. Subclavian vein is located just deep to the middle third of the clavical, and runs parallel to it (this is the only area where there is a close anatomic relationship between the subclavian vein and the clavicle)

3. The subclavian vein is valveless and has a diameter of 1 to 2 cm.

4. The subclavian artery is superior and posterior to the vein and is separated from the vein behind the anterior scalene muscle.

5. The costoclavicular ligament connects the first rib to the clavicle

6. The costoclavicular ligament lies at the junction of the medial third and middle third of the clavicle at the point where the clavicle bends slightly posteriorly

7. The subclavian vein traverses an imaginary line connecting two points established by placing ones thumb over the costoclavicular ligament and index finger in the suprasternal notch

8. Contiguous structures include the phrenic nerve, the thoracic duct on the left side and the lymphatic duct on the right side.

9. The left subclavian approach has a sweeping curve to the apex of the right ventricle and is the preferred approach for temporary transvenous pacing


10. The right subclavian vein approach is generally preferred because the dome of the pleura of the right lung is usually lower than the left, and the left-sided large thoracic duct is less likely to be lacerated

11. By premeasuring the catheter length against the patient's chest size, one can determine a catheter length that will place the catheter tip about 2 to 3 cm below the manubrial-sternal junction (in the superior vena cava, just above the right atrium)

        Leave 5 to 10 cm of the catheter outside the skin


Complications, Prevention and Management:

        Pneumothroax

o       Prevention: Remove patient from ventilator before advancing the needle, choose the right side rather than left, avoid multiple attempts when possible

o       Management: Check postprocedure x-ray, if pneumothorax arrange for thorcostomy depending on the size of the pneumothorax

 

o       Prevention: If attempted catheterization is unsuccessful, try the ipsilateral internal jugular or subclavicular approach before trying contralateral subclavian catheterization

o       Prevention: Never withdraw a catheter past a needle bevel which might shear off the catheter

o       Management: x-ray the patient and contact specialist who can remove the embolized catheter

o       Prevention: Never choose an insertion site that goes through infected tissue; use antimicrobial-impregnated catheters; avoid the use of antibiotic ointments (increase of fungal contamination and antibiotic resistant bacteria)

o       Prevention: if available, have someone watch monitor for dysrhythmia while the catheter is advanced (this comes from direct contact of the catheter tip with the myocardium of the right atrium)

o       Management: reposition the catheter; treat dysrhythmia according to ACLS protocols.

o       Prevention: Maintain a Trendelenberg position, ask the patient to exhale while you are advancing the catheter, maintain a "closed system

o       Management: Place the patient in a left lateral decubitis, head down position to minimize the chances of an air embolism to the brain.

 

Documentation in the Medical Record

        Consent

        Indications for the procedure

        The lack of contraindications

        The procedure including prep, anesthesia, technique

        Any complications or "none"

        Who was notified about any complication (family, attending physician, etc.)

 

Items for evaluation of person learning this procedure:

        Anatomy of the subclavian vein and adjacent structures

        Indications for this procedure

        Preferred approaches for this procedure

        Contraindications for this procedure

        Interaction between the professional and the patient, family, etc.

        Use of sterile procedure and Universal Precautions

        Technical ability

        Appropriate documentation

        Understanding of the potential complications and their correction