How is central venous access via the subclavian vein performed?

Updated: Aug 07, 2018
  • Author: E Jedd Roe, lll, MD, MBA, FACEP, FAAEM, MSF, CPE; Chief Editor: Vincent Lopez Rowe, MD  more...
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Answer

Open the line kit, and position the equipment so that it is easy to reach. One may want to retract the curved J-tip wire into the plastic loop sheath to facilitate direction 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 × 4 in. (10 × 10 cm) gauze soaked in a povidone-iodine solution. 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; this facilitates smooth caudal progression of the guide wire down the vein toward the right atrium.

Insert the introducer needle at the desired landmark while gently withdrawing the plunger of the syringe. Advance the needle under and along the inferior border of the clavicle, making sure that the needle is virtually horizontal to the chest wall. Once under the clavicle, the needle should be advanced toward the suprasternal notch until the vein is entered. If the vein is difficult to locate, remove the introducer needle, flush it clean of clots, and try again. Change insertion sites after three unsuccessful passes with the introducer needle.

When venous blood is freely aspirated, 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 with the J-tip directed caudally to improve successful placement into the subclavian vein. If the kit used is one that allows the wire to be placed directly through a port on the syringe, then it is not necessary to disconnect the syringe. Be aware that disconnecting the syringe gives the added benefit of allowing verification of nonpulsatile flow of venous blood.

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 cm. Holding the wire in place, withdraw the introducer needle and set it 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 exits 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 any needed samples, and then flush the line with saline and recap. Repeat this step with all lumina.

Verify proper line placement with chest radiography. 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 before suturing. Apply a clean dressing.


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