| Patient Education |
|
Click here for patient education.
|
|
You are in: eMedicine Specialties >
Clinical Procedures > Vascular Techniques
Central Venous Access, Subclavian Vein, Subclavian Approach
Article Last Updated: Jun 19, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: John P Gullett, MD, Staff Physician, Department of Emergency Medicine, Chilton Medical Center, University of Alabama
John P Gullett is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Emergency Medicine Residents Association
Coauthor(s):
E Jedd Roe lll, MD, MBA, FACEP, FAAEM, MSF, CPE, Chair, Department of Emergency Medicine, William Beaumont Hospital
Editors: Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
central venous access, CVC, central line, central venous catheterization, central line placement, central vein, subclavian vein, SCV, central venous catheter, subclavian vein catheter, subclavian catheter, subclavian line, venous catheter, central vein catheter
First described in 1952, central venous catheterization is a time-honored and tested technique of quickly accessing the major venous system that empties into the right atrium. Its benefits over peripheral access include greater longevity without infection, line security in situ, avoidance of phlebitis, larger lumens, multiple lumens for rapid administration of combinations of drugs, a route for nutritional support, fluid administration, and central venous pressure monitoring. Central vein catheterization is also referred to as a central line placement.
Overall complication rates range up to 15%,1, 2, 3, 4 with mechanical complications reported in 5-19% of patients,5, 6, 7 infectious complications in 5-26%,1, 2, 4 and thrombotic complications in 2-26%.1 These complications are all potentially life-threatening and, invariably, consume significant resources to treat. Placement of a central vein catheter is a common procedure, and house staff require substantial training and supervision to become facile with this technique. A physician should have a thorough foreknowledge of the procedure and its complications before placing a central vein catheter.
The subclavian approach is the most commonly used, as it is generally considered to be the simplest approach; its advantages include consistent landmarks, increased patient comfort, and lower potential for infection or arterial injury. The physician’s experience and comfort level with the procedure, however, are the main determinants as to the success of the line placement in cases with no other patient-related factors that may increase the incidence of complications.
- Volume resuscitation
- Emergent venous access
- Nutritional support
- Central venous pressure monitoring
- Transvenous pacing wire introduction
- Hemodialysis
- Pulmonary artery catheterization
- Contraindications to central venous access
- Distorted anatomy (eg, vascular injury, prior surgery, radiation history)
- Infection at insertion site
- Presence of anticoagulation or bleeding disorder
- Patient who is excessively underweight or overweight
- Uncooperative patient
- Current or possible thrombolysis
- Contraindications to the subclavian approach
- Local anesthesia using 1% lidocaine is required.
- Often, the amount of lidocaine provided in central venous catheter kits is inadequate, and additional lidocaine should be acquired ahead of time. For more information, see Local Anesthetic Agents, Infiltrative Administration.
- Central venous catheter tray (line kit)
- Sterile gloves
- Antiseptic solution with skin swab
- Sterile drapes or towels
- Sterile gown
- Sterile saline flush, approximately 30 mL
- Lidocaine 1%
- Gauze
- Dressing
- Scalpel, No. 11
- Place the patient in the supine position.
- If possible, the bed should be raised to a comfortable height for the operator so bending over is unnecessary.
- Do not place towels between the shoulder blades. This narrows the opening between the clavicle and first rib, compressing the subclavian vein.5
- Many believe that placing the patient in the Trendelenburg position distends the vessel. This is less true for the subclavian approach (than for the internal jugular approach) because the vessel is fixed within the surrounding tissue. The primary reason for assuming the Trendelenburg position is to reduce the risk of air embolism.
- Needle insertion site options include the following:
- One centimeter inferior to the junctions of the middle and medial third of the clavicle
- Inferior to the clavicle at the deltopectoral groove
- Just lateral to the midclavicular line, with the needle perpendicular along the inferior lateral clavicle
- One fingerbreadth lateral to the angle of the clavicle
- Sternal notch: Direct the insertion needle toward this target in the coronal plane.
- Explain the procedure, benefits, risks, and complications to the patient and/or the patient's representative, and obtain a signed informed consent.
- Position the patient.
- Identify landmarks.
- Open the line kit, and position the equipment so it is easy to reach. One may want to retract the curved J-wire into the plastic loop sheath for easy directing into the introducer needle. Also, uncap the distal lumen, which is commonly the brown lumen.
- Prepare the insertion site with the iodine or alcohol solution provided in the kit. This amount of preparation is often inadequate, and a wide area around the insertion site should be liberally prepared with 4 x 4 cm gauze soaked in a povidone iodine solution (eg, Betadine). Prepare the neck as well, in case the subclavian approach fails and another approach must be attempted.
- Put on sterile mask, gown, and gloves.
- Drape the patient in a sterile fashion, with the insertion site exposed.
- Using a generous amount of lidocaine 1%, infiltrate the skin, subcutaneous tissue, and, possibly, the clavicular periosteum.
- Position the bevel of the introducer needle in line with the numbers on the syringe. Upon insertion, orient the bevel to open caudally, which facilitates smooth caudal progression of the guide wire down the vein toward the right atrium.
- While continuing to aspirate with the syringe, insert the introducer needle at a shallow angle at the chosen landmark. The needle should be virtually parallel to the chest wall. An increased angle increases the likelihood of creating a pneumothorax. To reduce the chance of a pneumothorax, some clinicians prefer to insert the needle parallel to the chest wall and advance until reaching the clavicle, then “walk” the needle posteriorly until it goes beneath the clavicle. If the vein is difficult to locate, remove the introducer needle, flush it clean of clots, and try again. Change insertion sites after 3 unsuccessful passes with the introducer needle.
- When venous blood is aspirated in a copious rush, disconnect the syringe from the needle, immediately occlude the lumen to prevent air embolism, and reach for the guide wire.
- Insert the guide wire through the needle into the vein.
- Advance the wire until it is mostly in the vein or until ectopy is seen on the cardiac monitor. Then, retract the wire 3-4 centimeters.
- Holding the wire in place, withdraw the introducer needle and set aside.
- Use the tip of the scalpel to make a small stab just against the wire to enlarge the catheter entry site.
- Thread the dilator over the wire and into the vein with a firm and gentle twisting motion while maintaining constant control of the wire. After the introducer is inserted, hold the wire in place and remove the dilator.
- Thread the catheter over the wire until it exits the distal (brown) lumen and grasp the wire as it exist the catheter. Continue to thread the catheter into the vein to the desired length.
- Hold the catheter in place and remove the wire. After the wire is removed, occlude the open lumen.
- Attach a syringe with some saline in it to the hub and aspirate blood. Take needed samples and then flush the line with saline and recap. Repeat this step with all lumens.
- Verify line placement with chest radiograph. The tip of the line should end in the vena cava at the manubriosternal angle, not in the right atrium.
- Suture the catheter in place. For patient comfort, the clinician may need to infiltrate this area prior to suturing.
- Apply a clean dressing.
- The key to a successful line placement is meticulous preparation and setup before starting or donning sterile garb.
- Prepare a sterile site from the jaw to several fingerbreadths below the clavicle.
- The amount of lidocaine provided in most kits is often inadequate. The authors recommend supplementing the kit with a 10-mL syringe and a bottle of 1% lidocaine.
- If the wire does not pass easily through the needle down the vein, remove the wire, reattach the syringe, and confirm that the needle is still in the lumen of the vein before reattempting.
- Beware a return of red pulsatile blood. If this occurs, the wire is in an artery.
- Beware aspirating air bubbles through the probing introducer needle. This indicates a pneumothorax. (For details, see eMedicine article Tube Thoracostomy.)
- Anesthetize the suture site as well as the insertion site.
- Some clinicians find it useful to remove the contents of the line kit and lay them out in the order and configuration that they will be used.
- Never place equipment on a patient.
- Antibiotic ointments are contraindicated. Transparent dressings are not beneficial.
Complication Rates of Central Venous Catheterization Approaches6, 8, 7
| | Internal Jugular | Subclavian | Femoral | | Arterial puncture | 6.3-9.1 | 3.1-4.9 | 9.0-15.0 | | Hematoma | <0.1-2.2 | 1.2-2.1 | 3.8-4.4 | | Hemothorax | N/A | 0.1-0.6 | N/A | | Pneumothorax | <0.1-0.2 | 1.5-3.1 | N/A | | Thrombosis | 7.6 | 1.9 | 21.5 | | Total | 6.3-11.8 | 6.2-10.7 | 12.8-19.4 |
- Local site or systemic infection: Multiple studies have shown lower infection rates with the use of maximal sterile-barrier precautions, including mask, cap, sterile gown, sterile gloves, and large sterile drape. This approach has been shown to reduce the rate of catheter-related bloodstream infections and to save an estimated $167 per catheter inserted.6
- Pneumothorax: Check a chest radiograph when finished or before switching to the contralateral side after failed insertion on one side.
- Hematoma: A hematoma usually bears monitoring only.
- Arterial puncture: Lacerating the subclavian artery is, theoretically, possible, but the risk of this complication is higher with other approaches. The subclavian artery cannot be compressed; therefore, the subclavian approach should be avoided in anticoagulated patients.
- Hemothorax: Check the chest radiograph for evidence of a hemothorax. If evidence is found, consult a surgeon immediately.
- Air embolism: An air embolism may be caused by negative intrathoracic pressure, with inspiration by the patient drawing air into an open line hub. Be sure the line hubs are always occluded. Placing the patient in the Trendelenburg position lowers the risk of this complication. If air embolism occurs, the patient should be placed in Trendelenburg position with a left lateral decubitus tilt, which may prevent the movement of air into the right ventricle and onward into the left side of the heart. One hundred percent oxygen should be administered to speed the resorption of the air. If a catheter is located in the heart, aspiration of the air should be attempted.
- Dysrhythmias: Dysrhythmia is due to cardiac irritation by the wire or catheter tip. This can usually be terminated by simply withdrawing the line into the superior vena cava. Placing a central venous catheter without a cardiac monitor is unwise.
- Atrial wall puncture: This complication leads to pericardial tamponade.
- Lost guide wire: If the clinician is not conscientious about maintaining control of the guide wire, it may be lost into the vein and require retrieval by interventional radiology.
- Anaphylaxis: Patients who are allergic to antibiotics may experience anaphylaxis upon insertion of an antibiotic-impregnated catheter.
- Catheter-related thrombosis: This complication may lead to pulmonary embolism. (Click here to complete a Medscape CME activity on recommended hospital length of stay for pulmonary embolism.)
- Catheter tip too deep: Check for this complication on the postprocedure chest radiograph, and pull the line back if the tip disappears into the cardiac silhouette.
- Catheter in the wrong vessel: When the subclavian catheter is not in the correct position, it most often deviates cranially up the internal jugular instead of down the subclavian vein.
- Thoracic duct laceration: This complication is possible on the left side.
- Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. Aug 8 2001;286(6):700-7. [Medline].
- Sznajder JI, Zveibil FR, Bitterman H, et al. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med. Feb 1986;146(2):259-61. [Medline].
- Veenstra DL, Saint S, Saha S, et al. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection: a meta-analysis. JAMA. Jan 20 1999;281(3):261-7. [Medline].
- Mansfield PF, Hohn DC, Fornage BD, et al. Complications and failures of subclavian-vein catheterization. N Engl J Med. Dec 29 1994;331(26):1735-8. [Medline].
- Elliott TS, Faroqui MH, Armstrong RF, Hanson GC. Guidelines for good practice in central venous catheterization. Hospital Infection Society and the Research Unit of the Royal College of Physicians. J Hosp Infect. Nov 1994;28(3):163-76. [Medline].
- McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. Mar 20 2003;348(12):1123-33. [Medline].
- Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. Apr 1994;15(4 Pt 1):231-8. [Medline].
- Timsit JF, Farkas JC, Boyer JM, et al. Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis. Chest. Jul 1998;114(1):207-13. [Medline].
Central Venous Access, Subclavian Vein, Subclavian Approach excerpt Article Last Updated: Jun 19, 2008
Topic originally published: Jun 19, 2008
|
