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Central Venous Line Placement

Subclavian Venipuncture, Infraclavicular Approach

5/6/0 version

Lar!e veins such as the subclavian have relativel" constant relationships to easil" i#entifiable

anatomic lan#mar$s% &his ma$es the subclavian a !oo# site for central line placement%

In#ications'

• Placement of venous access line (hen other peripheral sites are unavailable

• Placement of a lar!e)bore venous catheter in an emer!ent situation to #eliver a hi!h

flo( of flui# or bloo# pro#ucts *the flo( rate is #etermine# b" the caliber an# len!th

of the catheter, shorter an# !reater caliber catheters #eliverin! !reater volumes over

e+uivalent amounts of time

• Central venous pressure measurement

• A#ministration of sclerosin! a!ents such as chemotherapeutic a!ents,

h"peralimentation flui#s, etc%

• As an alternative to repetitive venous cannulations

• -or placement of pulmonar" (e#!e catheters

• -or placement of trans venous pacema$ers

• -or performance of hemo#ial"sis or plasmapheresis

Contrain#ications'

• Infection over the insertion site

• .istortion of lan#mar$s from an" reason

http://apps.med.buffalo.edu/procedures/index.asp

http://apps.med.buffalo.edu/procedures/index.asp



• Suspecte# inur" to the superior vena cava *e!%, SVC s"n#rome

• Coa!ulopathies inclu#in! anticoa!ulation therap"

• Pneumothora or hemothora on the contralateral si#e

• Inabilit" to tolerate pneumothora on the ipsilateral si#e

• 1ncooperative patients

• Patients unable to tolerate a &ren#elenber! position

• Prior inur" to that vein *choose the one on the other si#e

• 2orbi# obesit"

• Recentl" #iscontinue# subclavian catheter at the same location

• Planne# mastectom" on the si#e of subclavian insertion

• Patients receivin! ventilator" support (ith hi!h en# epirator" pressures *temporaril"

re#uce the pressures

• Patients (ith vi!orous, on!oin! car#iopulmonar" resuscitation

• Chil#ren less than 3 "ears *hi!her complication rates

• -racture or suspecte# fracture of ipsilateral upper ribs or clavicle



2aterials'

• 1niversal precautions material

• &ape an# #ressin!s

• IV tubin!

• IV flui#

• Central line $it

• 4ath to(el or rolle# up sheet

• Availabilit" of S&A& chest ra#io!raph"

Preproce#ure patient e#ucation'

• btain informe# consent

• Inform the patient of the possibilit" of maor complications an# their treatment %plain the maor steps of the proce#ure

• plain the necessit" of a prolon!e# &ren#elenber! position

Proce#ure *Infraclavicular Approach'

• 1se 1niversal Precautions an# sterile techni+ue

• Attach the IV tubin! to the IV vlui#s an# place at the be#si#e on an IV pole

• Place the patient in a &ren#elenber! position *75 to 0 #e!rees hea# #o(n to re#uce

the chance of an air embolism

• &urn the patient8s hea# to the si#e contralateral to the site chosen

• Place a rolle# to(el or sheet bet(een the shoul#er bla#es to ma$e the clavicles more

prominent but #o not overaccentuate this position since it mi!ht move the clavicle

closer to the first rib, ma$in! cannulation of the subclavian vein more #ifficult

• Place the arms to the si#es of the patient *restrain if necessar"



• Locate lan#mar$s

7% &he subclavian vein is a continuation of the aillar" vein

3% Subclavian vein is locate# ust #eep to the mi##le thir# of the clavical, an# runs

parallel to it *this is the onl" area (here there is a close anatomic relationship bet(een the subclavian vein an# the clavicle

% &he subclavian vein is valveless an# has a #iameter of 7 to 3 cm%

9% &he subclavian arter" is superior an# posterior to the vein an# is separate# from

the vein behin# the anterior scalene muscle%

5% &he costoclavicular li!ament connects the first rib to the clavicle

6% &he costoclavicular li!ament lies at the unction of the me#ial thir# an# mi##le

thir# of the clavicle at the point (here the clavicle ben#s sli!htl" posteriorl"

:% &he subclavian vein traverses an ima!inar" line connectin! t(o points

establishe# b" placin! ones thumb over the costoclavicular li!ament an# in#e

fin!er in the suprasternal notch

;% Conti!uous structures inclu#e the phrenic nerve, the thoracic #uct on the left

si#e an# the l"mphatic #uct on the ri!ht si#e%

<% &he left subclavian approach has a s(eepin! curve to the ape of the ri!ht

ventricle an# is the preferre# approach for temporar" transvenous pacin!



70% &he ri!ht subclavian vein approach is !enerall" preferre# because the #ome of

the pleura of the ri!ht lun! is usuall" lo(er than the left, an# the left)si#e# lar!e

thoracic #uct is less li$el" to be lacerate#

77% 4" premeasurin! the catheter len!th a!ainst the patient8s chest si=e, one can#etermine a catheter len!th that (ill place the catheter tip about 3 to cm

belo( the manubrial)sternal unction *in the superior vena cava, ust above the

ri!ht atrium

• 4efore !lovin!, mar$ a spot 7 cm cau#a# to the clavicle at the unction of the mi##le

an# me#ial thir#s of the clavicle

• Prep an# #ress the area

•

1 sin! a 35 !au!e nee#le an# 7 cc of li#ocaine, anestheti=e the spot that "ou havemar$e#

• 1 sin! a 33 !au!e nee#le an# more li#ocaine, anestheti=e the structures #eeper to the

spot mar$e#

• 1se the 33 !au!e nee#le *see$er nee#le on a cc s"rin!e to locate the vein,

aspiratin! as the nee#le is a#vance# until a flush of bloo# returns

• >ote the an!le an# #epth of the see$er nee#le an# remove it

• 1se an 7; !au!e nee#le on a 5 cc s"rin!e to follo( the path of the see$er nee#le,

aspiratin! as the nee#le is a#vance#% ntr" into the vein is mar$e# b" a flush of bloo#%

• Stabili=in! the nee#le (ith the thumb an# forefin!er, remove the s"rin!e an#

imme#iatel" occlu#e the hub of the nee#le *maintainin! a ?close# s"stem?

• &hrea# the @ (ire into the 7; !au!e nee#le leavin! about half of the (ire etru#in!

from the nee#le

• Secure the @ (ire (ith a fm!ertip an# remove the 7; !au!e nee#le over the epose#,

remainin! portion of the @ (ire

• 2a$e a small cut in the s$in a#acent to the entr" site of the @ (ire usin! a scalpel

• &hrea# the silastic #ilator over the (ire

• A#vance the #ilator full" into the chest

• Remove the #ilator (hile still leavin! the @ (ire in place

• Remove the hub from the lon! central catheter



• &hrea# the lon! central catheter over the (ire into the vein

• Leave 5 to 70 cm of the catheter outsi#e the s$in

• Carefull" remove the @ (ire

• Attach IV tubin! to the catheter

• Lo(er the IV ba! belo( the level of the patient to observe for bloo# return

• .iscontinue the &ren#elenber! position

• Secure the catheter in place usin! sutures an# ties

• Place an occlusive #ressin! over the catheter

• btain a S&A& post)proce#ure chest )ra" loo$in! for a pneumothora or

hemothora, an# loo$in! for the catheter position% &he S&A& chest )ra" shoul# be

obtaine# (hether the proce#ure is successful or not%



Complications, Prevention an# 2ana!ement'

• Pneumothroa

o Prevention' Remove patient from ventilator before a#vancin! the nee#le,choose the ri!ht si#e rather than left, avoi# multiple attempts (hen possible

o 2ana!ement' Chec$ postproce#ure )ra", if pneumothora arran!e for

thorcostom" #epen#in! on the si=e of the pneumothora

• emothora ) as above

•4ilateral Iatro!enic complications

o Prevention' If attempte# catheteri=ation is unsuccessful, tr" the ipsilateral

internal u!ular or subclavicular approach before tr"in! contralateral

subclavian catheteri=ation

• Catheter emboli=ation

o Prevention' >ever (ith#ra( a catheter past a nee#le bevel (hich mi!ht shear

off the catheter

o 2ana!ement' )ra" the patient an# contact specialist (ho can remove the

emboli=e# catheter

• Infection

o Prevention' >ever choose an insertion site that !oes throu!h infecte# tissueB

use antimicrobial)impre!nate# cathetersB avoi# the use of antibiotic ointments

*increase of fun!al contamination an# antibiotic resistant bacteria

• Car#iac #"srh"thmia

o Prevention' if available, have someone (atch monitor for #"srh"thmia (hile

the catheter is a#vance# *this comes from #irect contact of the catheter tip (ith

the m"ocar#ium of the ri!ht atrium

o 2ana!ement' reposition the catheterB treat #"srh"thmia accor#in! to ACLS

protocols%

• Air embolism

o Prevention' 2aintain a &ren#elenber! position, as$ the patient to ehale (hile"ou are a#vancin! the catheter, maintain a ?close# s"stem



o 2ana!ement' Place the patient in a left lateral #ecubitis, hea# #o(n position

to minimi=e the chances of an air embolism to the brain%

.ocumentation in the 2e#ical Recor#

• Consent

• In#ications for the proce#ure

• &he lac$ of contrain#ications

• &he proce#ure inclu#in! prep, anesthesia, techni+ue

• An" complications or ?none?

• ho (as notifie# about an" complication *famil", atten#in! ph"sician, etc%

Items for evaluation of person learnin! this proce#ure'

• Anatom" of the subclavian vein an# a#acent structures

• In#ications for this proce#ure

• Preferre# approaches for this proce#ure

• Contrain#ications for this proce#ure

• Interaction bet(een the professional an# the patient, famil", etc%

• 1se of sterile proce#ure an# 1niversal Precautions

• &echnical abilit"

• Appropriate #ocumentation

• 1n#erstan#in! of the potential complications an# their correction

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