Central line: subclavian

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 (Infraclavicular approach)

  1. Obtain informed consent when possible
  2. Supine position, arm adducted
  3. Don cap, mask, sterile gown and gloves
  4. Chlorhexidine prep the skin. Right sided approach preferred
  5. Place sterile drape over target area
  6. Anesthetize insertion site, including periosteum of clavicle
  7. Prepare catheter by flushing each lumen with sterile saline
  8. Prepare the guide wire by sliding the plastic sleeve slightly forward to straighten the curved wire tip
  9. Locate insertion site at junction of middle and medial thirds of the clavicle.
  10. Orient the bevel of the needle inferomedially to direct the wire inferiorly
  11. Insert needle with syringe toward the suprasternal notch, while applying negative pressure on the syringe
  12. Advance needle until it hits clavicle, then walk the needle down until it is able to pass posterior to the clavicle. (Other recommended approach is to insert needle slightly more lateral which can avoid "walking the needle" down the clavicle)
  13. When the needle enters the lumen, blood will be aspirated freely
  14. Stabilize the needle hub, carefully remove the syringe from the needle
  15. Confirm blood flow is non-pulsatile. Cap needle hub with thumb to avoid air embolism
  16. Insert the guidewire in through the needle hub, never letting go of the wire. If resistance is met, remove the wire and aspirate with syringe to confirm placement still in the vessel
  17. Remove the needle, keeping the wire in the vessel
  18. Make a small incision to facilitate dilator passage through the skin
  19. Thread the dilator over the wire, and advance several centimeters into the vessel, then remove, while keeping the wire in the vessel
  20. Advance the catheter over the wire, until the wire protrudes from a distal port (For introducer catheters, the dilator and larger single-lumen catheter are inserted as a dilator-sheath unit, assembled prior)
  21. Grasp the wire where it emerged from the port and advance the catheter into the vessel
  22. Remove the wire
  23. Place end cap on port
  24. Withdraw blood then flush each port/lumen with saline
  25. Suture the catheter in place
  26. Place Biopatch
  27. Cover with Tegaderm

Complications

  • Arterial puncture and hematoma
    • Non-compressible site (unlike IJ and femoral), may require vascular surgeon
  • Pneumothorax
  • Hemothorax
  • Vessel injury
  • Air embolism
  • Cardiac dysrhythmia
  • Nerve injury
  • Infection
  • Thrombosis
  • Catheter misplacement

See Also

References

  • Roberts & Hedges 6e, pp 397-431
  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