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SAMPLE EXCERPT

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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 Catheterization: Subclavian Approach (Training Physician)

INDICATIONS

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.