| Patient Education |
|
Click here for patient education.
|
|
You are in: eMedicine Specialties >
Clinical Procedures > Vascular Techniques
Central Venous Access, Subclavian Vein, Supraclavicular 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, supraclavicular approach, 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. 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 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 supraclavicular approach is an underused method for gaining central access, and it offers several advantages over the infraclavicular approach to the subclavian vein. At the insertion site, the subclavian vein is closer to the skin, and the right-sided approach offers a straighter path into the subclavian vein. Also, this site is often more accessible during CPR, and chest compressions can continue while the procedure is performed. Lastly, in patients who are obese, this anatomic area is less distorted.
Nevarre et al published a review of the literature and his own series of 178 supraclavicular line placements. He reported 1 pneumothorax, 1 malposition, and 2 instances of inability to thread the wire. The overall complication rate was 0.56%. This site is likely among the safest approaches for central venous access (but note that an experienced surgeon performed the procedures reported by Nevarre).5
A study by Muhm et al of 208 supraclavicular lines in 168 hemodialysis patients focused on large bore catheters such as may be needed for hemodialysis or resuscitation of patients with trauma or sepsis. Complications included 1 pneumothorax, 7 arterial punctures, and 2 thoracic duct punctures without sequelae. Catheter malpositions occurred only sporadically (1%). Thus, even with large bore catheters, the supraclavicular approach may be a preferable route of placement.6
These studies are encouraging, especially considering that a large percentage of the studied patients represented a situation in which the line placement was complicated or difficult. However, the number of patients included is still small, and the operators were experienced with this technique.
- 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 supraclavicular approach
- Local anesthesia using 1% lidocaine is required.
- The amount of lidocaine provided in central venous catheter kits is often 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 swabs
- 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.
- Needle insertion site options include the following:
- One centimeter lateral to the lateral border of the clavicular head of the sternocleidomastoid muscle and one centimeter superior to the clavicle (The needle approach should bisect the angle of the muscle border and the clavicle.)
- One centimeter medial and one centimeter superior to the midpoint of the clavicle (Direct the introducer needle to the ipsilateral sternoclavicular joint.)8
- Just posterior to the clavicle at the middle/medial third junction of the clavicle (Direct the needle toward the ipsilateral sternoclavicular joint with the needle oriented parallel to the coronal plain.)9
- Options for directing the needle include the following:
- Contralateral nipple: The contralateral nipple may be used as a target for directing the introducer needle.
- Sternal notch: A point just superior and posterior to the sternal notch may be used as a target for directing the introducer needle.
- 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 within easy reach. One may want to retract the J-wire into the plastic loop sheath for easy directing into the introducer needle. Also, uncap the distal lumen, which is typically 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 initial 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, infiltrate the skin and subcutaneous tissue.
- Position the bevel of the introducer needle in line with the numbers on the syringe. On insertion, orient the bevel to open caudally so as to facilitate the caudal progression of the guide wire down the vein toward the right atrium.
- While continuing to aspirate with the syringe, insert the introducer needle along the 45° bisection of the approximately 90° angle formed by the superior aspect of the clavicle and the lateral border of the sternocleidomastoid muscle. The needle should be virtually parallel to the chest wall in the coronal plane.
- 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 a few sonometers.
- 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 control of the wire. Holding the wire in place, remove the dilator. To estimate the distance from the insertion site to the subclavian vein just over the atrium, the catheter can be held over the patient’s chest.
- Thread the catheter over the wire; then, thread the wire out of the distal (brown) lumen and grasp the wire. Continue to thread the catheter into the vein to the desired length.
- Hold the catheter in place, remove the wire, and 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 catheter 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 anesthetize this area with lidocaine first.
- Apply a clean dressing.
- The key to a successful line placement is meticulous preparation and setup before starting or donning sterile garb. This includes consideration of what equipment may be needed if complications arise.
- Use the same preparation technique every time this procedure is performed.
- Prepare a sterile field 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 without epinephrine.
- 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 by aspirating an easy blood return. Then, reattempt the procedure.
- Beware a return of red or 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 necessary.
Complication Rates of Central Venous Catheterization5, 6, 10, 7, 11
| | Internal Jugular | Subclavian | Femoral | Supraclavicular | | Arterial puncture | 6.3-9.1 | 3.1-4.9 | 9.0-15.0 | 3.36 | | Hematoma | <0.1-2.2 | 1.2-2.1 | 3.8-4.4 | N/A | | Hemothorax | N/A | 0.1-0.6 | N/A | N/A | | Pneumothorax | <0.1-0.2 | 1.5-3.1 | N/A | 0.48-0.56 | | Thrombosis | 7.6 | 1.9 | 21.5 | N/A | | Total | 6.3-11.8 | 6.2-10.7 | 12.8-19.4 | 0.56 |
- 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 requires monitoring only.
- Arterial puncture: As in other central venous catheter approaches, lacerating the subclavian artery is theoretically possible. Also, the subclavian vein cannot be compressed; therefore, this approach should be avoided in patients who are anticoagulated.
- Hemothorax: Check the chest radiograph for evidence of a hemothorax. If evidence is found, consult a surgeon immediately, and consider tube thoracostomy.
- Air embolism: An air embolism is caused by negative intrathoracic pressure, with inspiration drawing air into an open line hub. Be sure the line hubs are always occluded, and note that placing the patient in the Trendelenburg position lowers this risk. If air embolism occurs, the patient should be placed in the Trendelenburg position with a left lateral decubitus tilt, which may prevent the movement of air into the right ventricle and onward. One hundred percent oxygen should be administered to speed the resumption of air. If a catheter is located in the heart, aspiration of air should be attempted.
- Dysrhythmias: Dysrhythmia is due to cardiac irritation by the wire or catheter tip. 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 might 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 usually deviates cranially up the internal jugular instead of down the subclavian vein. This complication is rare with the supraclavicular approach.
- 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].
- Nevarre DR, Domingo OH. Supraclavicular approach to subclavian catheterization: review of the literature and results of 178 attempts by the same operator. J Trauma. Feb 1997;42(2):305-9. [Medline].
- Muhm M, Sunder-Plassmann G, Apsner R, et al. Supraclavicular approach to the subclavian/innominate vein for large-bore central venous catheters. Am J Kidney Dis. Dec 1997;30(6):802-8. [Medline].
- McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. Mar 20 2003;348(12):1123-33. [Medline].
- Conroy JM, Rajagopalan PR, Baker JD 3rd, Bailey MK. A modification of the supraclavicular approach to the central circulation. South Med J. Oct 1990;83(10):1178-81. [Medline].
- MacDonnell JE, Perez H, Pitts SR, Zaki SA. Supraclavicular subclavian vein catheterization: modified landmarks for needle insertion. Ann Emerg Med. Apr 1992;21(4):421-4. [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].
- 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].
- 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].
Central Venous Access, Subclavian Vein, Supraclavicular Approach excerpt Article Last Updated: Jun 19, 2008
Topic originally published: Jun 19, 2008
|
