Central Venous Catheterization: Subclavian Approach (Internal Medicine)

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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
  • 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.

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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