Central Venus Line Placement: Subclavian Vein Access

Zachary Kramer, MD; Rohit Patel, MD

Keywords: central venous line, hypotension, heart failure, sepsis, subclavian central venous line, internal jugular central venous line, femoral central venous line

Indications:

· Volume replacement

· Emergent venous access

· Administration of caustic medications: vasopressors, calcium chloride, hypertonic saline, high dose of potassium

· Central venous pressure monitoring

· Transvenous pacing wire introduction

· Dialysis catheter placement (hemodialysis)

· Pulmonary artery catheterization

· Nutritional support (TPN)

· Long term antibiotics

· Chemotherapy

· Plasmapheresis

· Frequent or persistent blood draws or intravenous therapy when unable to establish peripheral access due to edema or other causes

Contraindications:

Absolute:

· Infection at site of insertion

· Distorted anatomy/landmarks (prior surgery, radiation, or history of thrombus in the specified vein)

· Trauma to the ipsilateral clavicle, anterior proximal rib, subclavian or superior vena cava vessels

Relative:

· Morbid obesity

· Agitated or moving patient

· Chest wall deformity

· COPD

· Inability to tolerate potential pneumothorax of the ipsilateral thoracic cage

· Pneumothorax or hemothorax of the contralateral thorax

· Patients receiving ventilatory support with high end expiratory pressures (temporarily reduce the pressures)

· Children less than 2 years (higher complication rates)

· Coagulopathy (direct pressure to achieve hemostasis cannot be applied to the subclavian vein or artery due to their location beneath the clavicle)

Materials and Medications (some of these items may be located in tray or bundle):

· Central Venous Catheter tray or bundle (single/double/triple/quad lumen, dialysis catheter, large bore introducer (for transvenous pacing or pulmonary artery catheter kit)

· Sterile gloves

· Sterile drapes or towels

· Sterile gown

· Hat/hair cap and mask with eye protection

· Antiseptic solution with skin swabs (ie chlorhexidine)

· Sterile saline flushes (30ml or x3 10ml syringes)

· Lidocaine 1%

· Sterile gauze

· No. 11 blade scalpel

· Dressing (sterile waterproof transparent dressing or sterile or sterile 4x4 gauze with tape)

· Sterile biopatch

· Suture material with needle driver if needed

· Transducing line (optional)

· Sterile probe cover (if using ultrasound guidance)

Procedure:

1. Obtain informed consent if not emergently indicated.

2. Raise bed to comfortable height for the operator.

3. Place patient in supine position and position so patient’s head is at the top of the bed.

4. Place patient in 15-20º of Trendelenburg position if tolerated to reduce risk of air embolism. Studies show this will also increase the size of the subclavian vein. Do NOT place towel between shoulder blades (arch shoulder back) as this has been shown to decrease vein diameter and affect reliability of accessibility. Keep shoulders at anatomical location (forward).

5. Prep area chosen from the anterior neck, clavicle, and upper chest (above nipple line) with chlorhexidine prep or iodine.

6. Open kit and place at easily reachable area close to operator’s dominant hand to allow for easy access. Diameter of catheter/kit used based on clinical situation. Introducer or large bore if

7. Operator should now prepare him/herself with all aseptic techniques (e.g., hand washing) and maximal barrier precautions (e.g., sterile gowns, sterile gloves, caps, masks covering both mouth and nose, eye protection, and full-body patient drapes.

8. Now that the operator is sterile and able to touch the inside of the CVL kit, one may want to retract the curved J-tip wire into the plastic loop sheath for easy directing into the introducer needle. Also, uncap all distal lumens, and flush all ports with 3-5cc of the sterile NS syringes to ensure no defects in the lumen of the catheter. Close all ports except the distal tip port (usually marked with words ‘distal tip’) with the slide clamp

9. Prep area chosen (right or left side) from the anterior neck, clavicle, and upper chest (above nipple line) with sterile chlorhexidine prep. (2nd cleaning)

10. Place full body drape over patient with opening over selected side where needle will be inserted

11. Needle insertion site options: One centimeter inferior to the junctions of the middle and medial third of the clavicle; Just lateral to the midclavicular line, with the needle perpendicular along the inferior lateral clavicle; One fingerbreadth lateral to the angle of the clavicle (see Figure 1)

12. Anesthetize needle insertion site with 5-10 mL of 1% lidocaine superficially (make sure to pull back on needle syringe to ensure operator is not in the vein or artery).

· Never place equipment on a patient

13. Prepare the needle and syringe by placing the long needle on the syringe. Make sure to break seal of syringe by pulling back on the plunger of the syringe prior to making incision with needle.

14. Direct patient’s head turned opposite of the side the operator is placing CVL and retract ipsilateral shoulder down to improve clavicle-vein relationship. The retraction of the arm can be done in a few steps earlier and can use person or tape/restraints to keep in position.

15. Direct the insertion needle toward sternal notch in the coronal plane at an angle no greater than 10-15º while gently withdrawing the plunger of the syringe. Keep bevel of the needle facing up and in line with the numbers on the syringe until operator enters skin, then face bevel caudally to facilitate smooth progression of the guide wire down the vein toward the right atrium

· It helps to place non-dominant hand (not holding the needle) on the sternal notch so operator can feel where sternal notch is and direct needle in that direction (see Figure 1)

· NEVER increase the angle of the needle greater than 15º as PTX may ensue

16. Advance the needle under and along the inferior border of the clavicle, making sure the needle is virtually horizontal to the chest wall. Aim medially in the direction of the suprasternal notch, attempting to first aim for the clavicle then “walk” the needle below the clavicle

17. Once under the clavicle, continue to advance the needle in a plane almost parallel to the skin approximately 2-3 cm until venous blood is freely aspirated into the syringe

18. When venous blood is freely aspirated, disconnect the syringe from the needle, and immediately occlude the lumen to prevent air embolism, and insert the guide wire. 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

· At this point the hand holding the needle should be “set in stone.” Use the patient’s chest wall as a base to keep needle completely still as to not inadvertently advance or retract needle out of the vein

19. Insert the guide wire through the needle into the vein with the J-tip directed caudally to improve successful placement into the subclavian vein

· 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

20. 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

21. If the wire does not pass easily, remove the wire, reattach the syringe, and confirm that the needle is still in the lumen of the vein before reattempting. The J-tip can be straightened with a pinching motion (see Figure 2)

· Alternatively, one can use the catheter/syringe found in most kits to use as a bridge to guidewire placement. For the author this has improved success when difficulty wire placement. Use the same steps above with the catheter (see Figure 3) and when you have return of blood advance the angiocath into the vein and then use the guidewire through the angiocath. This is especially useful in moving/agitated patients, patients who have collapsible veins due to hypovolema, and patients who have abnormal anatomy and may have veins that take an abnormal angle shortly past the introducer tip

22. Use the tip of the scalpel to make a small incision just against the needle to enlarge the catheter entry site for the dilator and catheter

23. Holding the wire in place, withdraw the introducer needle and place in needle holder

24. Thread the dilator over the wire and into the vein with a firm and gentle twisting motion while maintaining constant control of the wire. If a large bore introducer is placed, the dilator/introducer goes in one step, after the introducer is inserted, hold the wire in place and remove the dilator.

· If operator is having difficulty threading the dilator, the skin incision with the scalpel may have been too superficial or small. It may help to enlarge this incision to avoid having the dilator get caught on superficial skin or connective tissue

· It is helpful to have one of the sterile gauze handy to apply pressure with the hand not holding the wire as the vein will now bleed profusely from around the wire secondary to dilation

25. Thread the catheter until it is close to the skin insertion site. Then pull back on the guidewire until it shows outside of the distal port. Grasp the wire outside of the distal port and thread the catheter while holding onto the guidewire. Usually catheters are inserted 15-16 cm from the right side and 18-20 cm from the left side (see Figure 4)

26. Hold the catheter in place and remove the wire. After the wire is removed, occlude the open lumen.

27. Attach sterile saline syringe to the hub and aspirate blood. Take needed samples and then flush the line with saline and recap. Repeat this step with all lumens.

28. Place biopatch on skin around the intersection with the lumen of the catheter.

29. Suture the line in place.

30. Enclose central venous line site with sterile waterproof transparent dressing.

31. Confirm placement by CXR. Tip of catheter should be in the lower 3rd of the SVC at the insertion of SVC into right atrium (tip at right bronchiotracheal angle or up to 2.5cm below bronchiotracheal angle).

Alternatively ultrasound can be used for subclavian line access but only a few limited studies have confirmed this as to date so will not describe in detail (see below for typical ultrasound technique used). See references for more information.

Pearls and Pitfalls:

1. Inadequate landmark identification. Operator should always palpate for landmarks and check anatomy prior to starting the procedure

2. Improper insertion position

3. Insertion of needle through periosteum. Operator should NOT increase angle of needle to avoid the clavicle bone (this can cause a PTX). Instead, operator should press on needle with downward pressure on chest wall to allow needle to maneuver under the clavicle without changing the angle of insertions of the needle

4. Taking too shallow a trajectory with needle.

5. Aiming the needle too cephalad, aim for sternoclavicular junction.

6. Failure to keep needle in place for wire passage. Hand holding the needle should be planted on patient’s chest for stabilization

Complications:

1. Pneumothroax/Hemothorax:

· Prevention: Remove patient from ventilator before advancing the needle, choose the right side rather than left, avoid multiple attempts when possible.

· Management: Check postprocedure x-ray, if pneumothorax, arrange for thoracostomy depending on the size of the hemo/pneumothorax

2. Catheter embolization:

· Prevention: Never withdraw a catheter past a needle bevel which might shear off the catheter.

· Management: x-ray the patient and contact specialist who can remove the embolized catheter

3. Arterial puncture: the subclavian artery cannot be compressed; so, the subclavian approach should be avoided in anticoagulated patients.

4. Hematoma: usually requires monitoring only

5. Thrombosis: this complication may lead to pulmonary embolism

6. Local site or systemic infection: using maximal sterile precautions has been shown to greatly decrease rate of infection

7. 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

8. Dysrhythmias: 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. One should always place a central venous catheter with cardiac monitoring.

9. Lost guide wire. If the operator is not careful about maintaining control of the guide wire, it may be lost into the vein. This requires retrieval by interventional radiology or surgery and is an emergency.

10. Catheter tip too deep. Check the postprocedure chest xray for this complication, and pull the line back if the tip disappears into the cardiac silhouette

11. Catheter in the wrong vessel. Check the postprocedure chest xray for this complication; Remove catheter and try again.

Ultrasound guided cannulation (general tips for each approach)

· Venous anatomy is best visualized using high frequency (5-10 MHz) linear probe. Higher frequencies generate less penetration but better resolution.

· You can use the ultrasound to identify the location of the vessel prior to the procedure and utilize external landmarks during the procedure itself (static technique), or you can use the ultrasound to visualize cannulation of the vessel during the procedure (dynamic technique).

· Static view is advantageous is that the ultrasound transducer is not needed during the sterile portion of the procedure, but it does not allow for direct visualization of cannulation and guidance during the procedure.

· Dynamic view (preferred) allows for direct visualization during the procedure, but requires more technique and requires use of transducer during the sterile portion of the procedure.

· The dynamic technique can be used in either a short axis view, where a cross sectional view of the vessel and needle is used, or a long axis view, where a longitudinal view of vessel and needle is used.

· The long axis view allows for full visualization of the needle throughout the procedure and allows for better visualization and adjustment of needle depth. It is more difficult for lateral changes in positioning and tends to be technically more difficult.

· Key in this view is that once a good section of vein is obtained, do not move probe to visualize the needle, move the needle into the ultrasound view by slightly adjusting trajectory.

· The short axis view allows for lateral changes in position but is not as good at visualizing depth throughout the procedure, as visualization of the needle is in cross-sectional imaging. Perforation of the posterior wall is more common in this view.

· When using the short axis view, remember to position the ultrasound probe such that the field of the ultrasound intersects the vessel (IJ, femoral, subclavian) at the anticipated site of insertion of the needle into the vein. Remember that the needle is only visualized as it intersects the plane of the ultrasound.

· When using the long axis view, make sure to visualize the vessel with the ultrasound such that you can see the greatest diameter of the vessel along the entire length of the ultrasound probe. Keep the ultrasound steady during the procedure and insert the needle at an angle at the lateral edge of the ultrasound probe. Using this technique, one can visualize the entire length of the needle

Removing a Central Line:

1. Place patient in supine or Trendelenburg position.

2. Remove suturing and dressing.

3. Have patient exhale and pull the line during the exhalation.

· Exhalation increases intrathoracic pressure as compared to atmospheric pressure, thereby reducing the risk of air thromboembolism.

4. Hold pressure for approximately one minute to stop bleeding.

5. Dress with a sterile dressing.

6. If central line-related infection is suspected, cut off the tip with sterile scissors and send for culture.

References

Subclavian Vein:

1. 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.

2. Fortune JB, Feustel P. Effect of patient position on size and location of the subclavian vein for percutaneous puncture. Arch Surgery 2003 Sep;138(9):996-1000; discussion 1001.

3. Fragou et al. Real time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: A prospective randomized study. Crit Care Med 2011 Vol. 39, No7: 1-6

4. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. Mar 20 2003;348(12):1123-33.

5. Kilbourne MJ, Bochicchio GV, Scalea T, Xiao Y. Avoiding common technical errors in subclavian central venous catheter placement. J Am Coll Surg. Jan 2009;208(1):104-9.

Figure 1: Subclavian vein approach: anatomy and wrong/correct angles to take when making skin puncture

Figure 2: J tip straightening using pinching motion

Figure 3: Angiocath that can be used in difficult to cannulate/wire patients

Figure 4: Length: marking seen on typical central venous catheters, number indicates in centimeters from distal tip