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:

• Placement of venous access line when other peripheral sites are unavailable
• Placement of a large-bore venous catheter in an emergent situation to deliver a high flow of fluid or blood products (the flow rate is determined by the caliber and length of the catheter, shorter and greater caliber catheters delivering greater volumes over equivalent amounts of time)
• Central venous pressure measurement
• Administration of sclerosing agents such as chemotherapeutic agents, hyperalimentation fluids, etc.
• As an alternative to repetitive venous cannulations
• For placement of pulmonary wedge catheters
• For placement of trans venous pacemakers
• For performance of hemodialysis or plasmapheresis

 

Contraindications:

• Infection over the insertion site
• Distortion of landmarks from any reason
• Suspected injury to the superior vena cava (eg., SVC syndrome)
• Coagulopathies including anticoagulation therapy
• Pneumothorax or hemothorax on the contralateral side
• Inability to tolerate pneumothorax on the ipsilateral side
• Uncooperative patients
• Patients unable to tolerate a Trendelenberg position
• Prior injury to that vein (choose the one on the other side)
• Morbid obesity
• Recently discontinued subclavian catheter at the same location
• Planned mastectomy on the side of subclavian insertion
• Patients receiving ventilatory support with high end expiratory pressures (temporarily reduce the pressures)
• Patients with vigorous, ongoing cardiopulmonary resuscitation
• Children less than 2 years (higher complication rates)
• Fracture or suspected fracture of ipsilateral upper ribs or clavicle

Materials:

• Universal precautions material
• Tape and dressings
• IV tubing
• IV fluid
• Central line kit
• Bath towel or rolled up sheet
• Availability of STAT chest radiography

 

Preprocedure patient education:

• Obtain informed consent
• Inform the patient of the possibility of major complications and their treatment . Explain the major steps of the procedure
• Explain the necessity of a prolonged Trendelenberg position

 

Procedure (Infraclavicular Approach):

• Use Universal Precautions and sterile technique
• Attach the IV tubing to the IV vluids and place at the bedside on an IV pole
• Place the patient in a Trendelenberg position (15 to 30 degrees head down) to reduce the chance of an air embolism
• Turn the patient's head to the side contralateral to the site chosen
• Place a rolled towel or sheet between the shoulder blades to make the clavicles more prominent but do not overaccentuate this position since it might move the clavicle closer to the first rib, making cannulation of the subclavian vein more difficult
• Place the arms to the sides of the patient (restrain if necessary)
• Locate landmarks

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)

• Before gloving, mark a spot 1 cm caudad to the clavicle at the junction of the middle and medial thirds of the clavicle
• Prep and dress the area
• U sing a 25 gauge needle and 1 cc of lidocaine, anesthetize the spot that you have marked
• U sing a 22 gauge needle and more lidocaine, anesthetize the structures deeper to the spot marked
• Use the 22 gauge needle (seeker needle) on a 3 cc syringe to locate the vein, aspirating as the needle is advanced until a flush of blood returns
• Note the angle and depth of the seeker needle and remove it
• Use an 18 gauge needle on a 5 cc syringe to follow the path of the seeker needle, aspirating as the needle is advanced. Entry into the vein is marked by a flush of blood.
• Stabilizing the needle with the thumb and forefinger, remove the syringe and immediately occlude the hub of the needle (maintaining a "closed system")
• Thread the J wire into the 18 gauge needle leaving about half of the wire extruding from the needle
• Secure the J wire with a fmgertip and remove the 18 gauge needle over the exposed, remaining portion of the J wire
• Make a small cut in the skin adjacent to the entry site of the J wire using a scalpel
• Thread the silastic dilator over the wire
• Advance the dilator fully into the chest
• Remove the dilator while still leaving the J wire in place
• Remove the hub from the long central catheter
• Thread the long central catheter over the wire into the vein

·        Leave 5 to 10 cm of the catheter outside the skin

• Carefully remove the J wire
• Attach IV tubing to the catheter
• Lower the IV bag below the level of the patient to observe for blood return
• Discontinue the Trendelenberg position
• Secure the catheter in place using sutures and ties
• Place an occlusive dressing over the catheter
• Obtain a STAT post-procedure chest x-ray looking for a pneumothorax or hemothorax, and looking for the catheter position. The STAT chest x-ray should be obtained whether the procedure is successful or not.

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

 

• Hemothorax - as above
• Bilateral Iatrogenic complications

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

• Catheter embolization

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

• Infection

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)

• Cardiac dysrhythmia

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.

• Air embolism

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