Central line: supraclavicular

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Indications

  • Central venous pressure monitoring
  • High volume/flow resuscitation
  • Emergency venous access
  • Inability to obtain peripheral venous access
  • Repetitive blood sampling
  • Administering hyperalimentation, caustic agents, or other concentrated fluids
  • Insertion of transvenous cardiac pacemakers
  • Hemodialysis or plasmapheresis
  • Insertion of pulmonary artery catheters

Contraindications

Absolute[1]

  • Infection over the placement site
  • Anatomic obstruction (thrombosis of target vein, other anatomic variance)
  • Site-specific
    • Subclavian - trauma/fracture to ipsilateral clavicle or proximal ribs

Relative

  • Coagulopathy (see below)
  • Distortion of landmarks by trauma or congenital anomalies
  • Prior vessel injury or procedures
  • Morbid obesity
  • Uncooperative/combative patient

Central line if coagulopathic

  • Preferentially use a compressible site such as the femoral location (avoid the IJ and subclavian if possible)
  • No benefit to giving FFP unless artery is punctured[2]

Equipment Needed

  • CVC kit typically contains:
    • Chlorhexidine
    • Sterile drape
    • 1% lidocaine without epinephrine
    • 5 mL syringe (for lidocaine)
    • 22-ga and 25-ga needles (for lidocaine)
    • 5-10 mL syringe (for venipuncture)
    • 18-ga needle (for venipuncture)
    • Guidewire
    • Scalpel with 11-blade
    • Dilator
    • Triple-lumen catheter (or introducer catheter/Cordis)
    • Catheter clamp
    • Silk suture
  • Sterile gown, cap, mask, gloves
  • Biopatch
  • Tegaderm
  • Sterile saline flush
  • Sterile caps for lumen ports

Procedure

Landmark Guided Approach

  • Insertion Site - claviculosternocleidomastoid angle
    • 1cm Cephalad and 1 cm lateral to the junction of the lateral margin of the clavicular head and the superior margin of the clavical
  • The needle is advanced in the direction of the line that bisects the claviculosternocleidomastoid angle with elevation of 5-15 degrees above coronal plane
    • Roughly in the same direction as the contralateral nipple
  • Catheter Depth
    • 14 cm on the right side
    • 18 cm on the left side

Ultrasound Guided

  • Typically done in-plane
  • Provider can visualize where the internal jugular and subclavian vein meet
  • Limited by body habitus
  • Useful in children

Seldinger Technique

  1. Place sterile drape over target area
  2. Anesthetize insertion site
  3. Prepare catheter by flushing each lumen with sterile saline
  4. Insert needle with syringe while applying negative pressure on the syringe
  5. Intravascular access will be indicated with free flowing aspiration of blood
  6. Carefully remove the syringe from needle hub
    1. Some syringes allow for placement of wire without removal
  7. Blood flow should be non-pulsatile (arterial)
  8. Place finger over needle hub after removing syringe
  9. Remove finger and introduce guide wire
    1. Wire should progress with little resistance
  10. Remove Needle over guide wire
    1. from now on, one hand should always be holding the guide wire
  11. Using a scalpel make a small incision at the base of the wire
  12. Thread dilator over wire
  13. Remove Dilator after advancing it several cm into the vessel
  14. Pass catheter over wire until wire emerges from uncapped port
    1. Do NOT pass catheter into body until wire emerges from opposing end and can be grasped
  15. After catheter is introduced to correct depth, remove wire and cap free end
  16. Test each port with withdrawal of blood and flush
  17. Suture catheter in place
  18. Secure with tegaderm

Complications

  • Arterial puncture and hematoma
  • Pneumothorax
  • Hemothorax
  • Vessel injury
  • Air embolism
  • Cardiac dysrhythmia
  • Nerve injury
  • Infection
  • Thrombosis
  • Catheter misplacement

See Also

References

  1. Graham, A.S., et al. Central Venous Catheterization. N Engl J Med 2007;356:e21
  2. Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit. Intens Care Med 1999; 25:5
  3. Morado M.et al. Complications of central venous catheters in patients with haemophilia and inhibitors. Haemophilia 2001; 7:551–556