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

  1. 1cm lat to scm head
  2. 1cm post to clavicular head
  3. bisect angle btwn scm & clavicle
  4. 10' angle inf to horizontal plane

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