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Billing Codes

CPT codes:

36557	Insertion of tunneled, centrally inserted central venous catheter; younger than 5 years
36558	Insertion of tunneled, centrally inserted central venous catheter; 5 years or older

ICD-9 codes:

89.62

Central venous pressure monitoring

Central Venous Catheterization: Subclavian Approach

Editor(s): Todd W Thomsen, MD, Gary S Setnik, MD, FACEP
Section Editor(s): Phillip M Harter, MD
Contributor(s): Carmie Chan, MD

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.

Figure 1 : Subclavian central venous catheter

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Table 1 : Advantages and disadvantages of the subclavian approach

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Figure 6 : Equipment

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Figure 10 : Subclavian anatomy

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PROCEDURE

Explain the procedure to the patient. **OBTAIN CONSENT**
Prepare the patient.
- Oxygen, a pulse oximeter, and a cardiac monitor
- 15- to 30-degree Trendelenburg position
Gather the equipment.
Sterilize the field. **STERILE TECHNIQUE** **UNIVERSAL PRECAUTIONS**
Prepare your equipment.
- Flush all ports, and attach end caps to the proximal and middle ports.
Identify landmarks.
- Palpate the subclavian as it bends at the junction of the medial third and lateral two thirds of the clavicle.
- Select an insertion point.
Anesthetize the insertion site. See Local Anesthesia for further details.
Locate the vein with the introducer needle (infraclavicular approach).
- Insert the introducer needle 1 cm inferior to the junction of the middle and proximal third of the clavicle while aiming slightly cephalad. Maintain a 5- to 10-degree angle relative to the chest wall.
- Insert the needle with the bevel directed inferiorly.
Locate the vein with the introducer needle (supraclavicular approach).
- Insert the introducer needle 1 cm lateral to the SCM and 1 cm superior and posterior to the clavicle.
- Aim toward the contralateral nipple.
- Insert the needle with the bevel directed medially.
Advance the guidewire into the vessel.
Hold the guidewire and remove the introducer needle.
Nick the skin with the scalpel to enlarge the puncture site.
Triple-lumen catheter insertion:
- Advance the dilator over the guidewire, and then remove it.
- Advance the catheter over the guidewire.
- Remove the guidewire.
- Withdraw blood from the port to confirm location within lumen of a vein.
- Flush the line and ports with sterile normal saline.
To insert a sheath introducer:
- Fully insert the dilator into the sheath introducer before advancing it.
- Advance the dilator and sheath introducer as a unit over the wire and into the vessel.
- Remove both the dilator and the guidewire as a unit.
- Confirm placement and flush the line with saline.
Final steps
- Secure the catheter at the insertion site with suture.
- Cover the site with a sterile transparent occlusive dressing.
- Order a chest radiograph.