Central Venous Catheterization: Subclavian Approach (Internal Medicine)

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SAMPLE EXCERPT
- Full procedure text, video and illustrations available with the full product
PRE-PROCEDURE
INDICATIONS
  • Administration of agents into the central vasculature
  • Central circulation and intracardiac access
  • Maintenance of venous access
  • Hemodialysis and plasmapheresis
CONTRAINDICATIONS
  • Absolute contraindications
    • Adequate peripheral IV access (see Intravenous Cannulation for further details.
    • Operator inexperience
    • Uncooperative patient
  • Relative contraindications
    • Significant uncorrectable bleeding disorder
    • Injury or thrombosis in the target vessel or SVC
    • Inability to tolerate pneumothorax
    • Assisted ventilation with high end-expiratory pressure
  • Contraindications unique to the subclavian approach
    • For patients with a significant bleeding disorder, an internal jugular or femoral approach may be more appropriate
    • Surgery or trauma to the clavicle, first rib, or subclavian vessels
    • Administration of thrombolytic medication
EQUIPMENT
  • Central venous catheterization kit
    • Clear fenestrated plastic drape
    • Paper drape
    • Chlorhexidine antiseptic with applicators
    • 1% Lidocaine
    • Small anesthetizing needle (25 gauge × 1 inch)
    • Large anesthetizing/finder needle (22 gauge × 1.5 inch)
    • Introducer needle (18 gauge × 2.5 inch)
    • Several syringes, 5 mL each
    • J-tipped guidewire with housing and a straightener sleeve
    • Scalpel with a No. 11 blade
    • Skin dilator
    • Catheter (e.g., triple lumen or sheath introducer)
    • Gauze pads
    • Suture with curved needle
    • Disposable needle holder
  • Sterile gloves, sterile gown, cap, and mask with a fluid shield for each member of the insertion team **STERILE TECHNIQUE** **UNIVERSAL PRECAUTIONS**
  • Large sterile drape (half-sheet)
  • Lidocaine 1% (often provided in the kit, although extra may be required)
  • Sterile saline suitable for injection
  • Sterile dressing (e.g., Tegaderm, 3M Corporation, Huntingdon Valley, PA)
ANATOMY
  • Subclavian vein
    • As the subclavian vein crosses the first rib, it lies posterior to the junction between the medial third and lateral two thirds of the clavicle.
    • The subclavian arteries are located posterior to the veins and are separated from them by the scalene muscles.
    • The right pleural dome is lower than the left and the thoracic duct is located on the left, thus making the right side preferred over the left.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Confirmation of line placement
  • Dressing changes at least every 72 hours
COMPLICATIONS
  • Infection
  • Bleeding
  • Pneumothorax See Needle Thoracostomy for further details.
  • Thrombosis
  • Air embolization
  • Arrhythmia
  • Myocardial perforation
  • Nerve injury
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