Central Venous Catheterization: Subclavian Approach (Internal Medicine)
Please select only one answer for each question.
Question - A 48-year-old woman with anorexia related to treatment for ovarian cancer requires parenteral nutrition via central line. She has no history of cardiopulmonary disease. Although she has undergone recent chemotherapy, a complete blood cell count is significant only for mild anemia.

Which of the following statements is true regarding subclavian vein anatomy and relationships?
A 48-year-old woman with anorexia related to treatment for ovarian cancer requires parenteral nutrition via central line. She has no history of cardiopulmonary disease. Although she has undergone recent chemotherapy, a complete blood cell count is significant only for mild anemia.

Which of the following statements is true regarding subclavian vein anatomy and relationships?
a.The subclavian vein crosses the first rib posterior to the junction of the lateral third and medial two thirds of the clavicle.
b.The vein is less likely to collapse during hypovolemia than the internal jugular vein or femoral vein, because of connective tissue fixing the vein to the first rib and clavicle.
c.The subclavian artery lies directly posterior to the subclavian vein.
d.The domes of the pleurae of the lungs are usually higher on the right than the left, making the left subclavian approach preferable to the right.
e.Trauma to the thoracic duct is a risk for either right or left subclavian vein catheter placement.

Question - What are some disadvantages of using the subclavian approach for a central venous catheter?
What are some disadvantages of using the subclavian approach for a central venous catheter?
a.There is less risk for pneumothorax than with the internal jugular approach.
b.Acute bleeding is difficult to compress if bleeding develops.
c.The right subclavian approach has a risk of injuring the thoracic duct.
d.The airway is likely to be threatened if a hematoma forms.

Question - What should be done routinely after central line placement?
What should be done routinely after central line placement?
a.Chest radiography to verify line placement.
b.The occlusive dressing should be left alone until the line is changed to avoid dislodging the line.
c.The central line should be changed to a new position periodically to reduce the risk for infection.
d.Prophylactic antibiotics are useful to reduce the risk for infection.

Question - Which patient might benefit from a central line?
Which patient might benefit from a central line?
a.A young patient with pneumonia who has a patent 18-gauge peripheral line in place.
b.A stable patient undergoing evaluation for cardiac output.
c.A patient in chronic renal failure who needs access for long-term dialysis.
d.A patient requiring treatment with a chemotherapy agent.

Question - Which of the following are characteristics of a sheath introducer catheter?
Which of the following are characteristics of a sheath introducer catheter?
a.It has three lumens to allow simultaneous infusion of fluids and measurement of central venous pressure.
b.The sheath is designed to accept transvenous pacemakers and pulmonary artery catheters.
c.It is not possible to infuse large volumes of fluid rapidly.
d.The sheath introducer catheter is preferred over a triple-lumen catheter.

Question - A 48-year-old woman with anorexia related to treatment for ovarian cancer requires parenteral nutrition via central line. She has no history of cardiopulmonary disease. Although she has undergone recent chemotherapy, a complete blood cell count is significant only for mild anemia.

A subclavian line is placed with the patient under local anesthesia with sedation, without apparent complication. Which of the following statements is true regarding follow-up care?
A 48-year-old woman with anorexia related to treatment for ovarian cancer requires parenteral nutrition via central line. She has no history of cardiopulmonary disease. Although she has undergone recent chemotherapy, a complete blood cell count is significant only for mild anemia.

A subclavian line is placed with the patient under local anesthesia with sedation, without apparent complication. Which of the following statements is true regarding follow-up care?
a.As long as blood is easily aspirated from the catheter, it is safe to begin drug infusions in the catheter without further testing.
b.A chest radiograph is not necessary if arterial oxygen saturation has not changed.
c.The finding of a pneumothorax on chest radiograph after central line placement requires placement of a chest tube.
d.The dressing should be changed at least every 72 hours to reduce risk for infection.
e.Heparin infusion should be started through the catheter to reduce the risk for clot formation.

Question - A 72-year-old woman is seen with lower gastrointestinal bleeding complicated by hypotension. A central line is desired for central pressure monitoring and to guide fluid resuscitation. The patient's blood pressure is 85/60 mm Hg, pulse 120 beats/min, and arterial oxygen saturation 92% with 6 L/min of oxygen delivered by nasal prongs. The patient has a history of emphysema, and is status post neck dissection and neck radiation for a previous diagnosis of oral squamous cell cancer.

Which of the following is true regarding approaches to central venous catheter placement?
A 72-year-old woman is seen with lower gastrointestinal bleeding complicated by hypotension. A central line is desired for central pressure monitoring and to guide fluid resuscitation. The patient's blood pressure is 85/60 mm Hg, pulse 120 beats/min, and arterial oxygen saturation 92% with 6 L/min of oxygen delivered by nasal prongs. The patient has a history of emphysema, and is status post neck dissection and neck radiation for a previous diagnosis of oral squamous cell cancer.

Which of the following is true regarding approaches to central venous catheter placement?
a.The internal jugular approach offers the lowest risk for pneumothorax.
b.The subclavian approach is preferred because of distorted neck anatomy.
c.The femoral vein approach is least desirable in this patient because it had the highest risk for infection.
d.Femoral vein placement has the lowest risk for accidental arterial puncture.
e.Catheter-related infection is least frequent with the subclavian approach.

Question - A 48-year-old woman with anorexia related to treatment for ovarian cancer requires parenteral nutrition via central line. She has no history of cardiopulmonary disease. Although she has undergone recent chemotherapy, a complete blood cell count is significant only for mild anemia.

During attempt at right subclavian vein central catheter placement, air is freely aspirated into the syringe. Which of the following is the best action to take?
A 48-year-old woman with anorexia related to treatment for ovarian cancer requires parenteral nutrition via central line. She has no history of cardiopulmonary disease. Although she has undergone recent chemotherapy, a complete blood cell count is significant only for mild anemia.

During attempt at right subclavian vein central catheter placement, air is freely aspirated into the syringe. Which of the following is the best action to take?
a.Remove the needle, check the patient's vital signs and status, and obtain a chest radiograph.
b.Remove the needle, and prep the other side for left subclavian line placement.
c.Call a surgeon for chest tube placement.
d.Remove the needle, check the patient's vital signs, and, if the patient is stable and without symptoms, reattempt line placement on the same side.
e.Stop and intubate the patient.

Question - Which of the following is FALSE regarding iatrogenic pneumothorax resulting from placement of a subclavian catheter?
Which of the following is FALSE regarding iatrogenic pneumothorax resulting from placement of a subclavian catheter?
a.Pneumothorax is an uncommon but life-threatening complication of line placement.
b.The risk for pneumothorax is higher with cannulation of the internal jugular vein than with the subclavian vein.
c.Maintaining a shallow angle during needle insertion can reduce the risk for pneumothorax with subclavian vein insertion.
d.Symptoms of iatrogenic pneumothorax include dyspnea and hyperresonance on the same side.