Subclavian Vein—Central Venous Access

imagesEmergency venous access for fluid resuscitation and drug infusion


imagesCentral venous pressure and oxygen monitoring


imagesInfusions requiring central venous administration (vasopressors, hyperosmolar solutions, hyperalimentation)


imagesRoutine venous access due to inadequate peripheral IV sites


imagesIntroduction of pulmonary artery catheter


imagesIntroduction of transvenous pacing wire


CONTRAINDICATIONS



imagesNo absolute contraindications


imagesRelative Contraindications


   imagesCoagulopathic patients (inability to compress)


   imagesOverlying infection, burn, or skin damage at puncture site


   imagesDistorted anatomy or trauma at the cannulation site


   imagesCombative or uncooperative patients


   imagesPenetrating trauma with suspected proximal vascular injury


   imagesPneumothorax on contralateral side (risk of bilateral pneumothoraces)


   imagesChronic obstructive pulmonary disease (COPD)


RISKS/CONSENT ISSUES



imagesPain


imagesLocal bleeding and hematoma


imagesInfection


imagesPneumothorax/hemothorax (necessitating chest tube)



imagesGeneral Basic Steps


   imagesAnalgesia


   imagesInsertion


   imagesSeldinger technique


   imagesDilation


   imagesCatheter insertion


   imagesConfirmation


   imagesFlush and secure


LANDMARKS



Right subclavian vein (SCV) approach is preferred because (1) pleural dome is lower on the right and (2) thoracic duct is on the left.


imagesInfraclavicular Approach (FIGURE 24.1)


   imagesPlace the left index finger on the suprasternal notch and the thumb on the costoclavicular junction



images


FIGURE 24.1 Infraclavicular approach to subclavian vein cannulation. Needle insertion at the bisection of the medial and middle thirds of the clavicle. Aim the needle toward the suprasternal notch.


   imagesNeedle insertion is at the bisection of the medial and middle thirds of the clavicle


   imagesAim the needle toward suprasternal notch


   imagesNeedle bevel is oriented inferomedially to facilitate wire entry


imagesSupraclavicular Approach (FIGURE 24.2)


   imagesNeedle insertion is just above the clavicle, 1 cm lateral to the insertion of clavicular head of sternocleidomastoid (SCM)


   imagesAim to bisect angle between SCM and clavicle with the needle tip pointing toward the contralateral nipple


   imagesNeedle bevel is oriented medially


SUPPLIES



imagesCentral Venous Catheter Kit


   imagesDrapes, chlorhexidine prep (2), gauze


   imagesCatheter (multiport, cordis, or hemodialysis)


   imagesGuidewire within plastic sheath


   imagesLidocaine, anesthesia syringe, and small-gauge needle


   imagesThree-inch introducer needle and syringe


   imagesDilator


   imagesScalpel


   imagesSuture


imagesSterile gloves, sterile gown, sterile cap and mask


imagesSterile drapes


imagesSterile saline flushes


imagesSterile port caps


imagesUltrasound machine (optional)


imagesSterile ultrasound probe cover with sterile gel (optional)


TECHNIQUE



imagesPatient Preparation


   imagesCardiac monitoring to detect dysrhythmias triggered by the wire being advanced into the right ventricle


   imagesSupplemental oxygen and continuous pulse oximetry monitoring


   imagesLower the head of the bed to 15 to 30 degrees in Trendelenburg position


   imagesPlace a rolled up towel or sheet in between the patient’s shoulder blades to elevate the patient’s clavicle and provide better access to the SCV (optional)



images


FIGURE 24.2 Supraclavicular approach to subclavian vein cannulation. Needle insertion is just above the clavicle, 1 cm lateral to the insertion of clavicular head of sternocleidomastoid (SCM). Aim to bisect angle between SCM and clavicle with the needle tip pointing toward the contralateral nipple. The needle tip is pointed 10 degrees above horizontal.


   imagesPlace the ipsilateral arm in abduction


   imagesSterilize clavicular insertion site, including ipsilateral neck in case subclavian vascular access fails and internal jugular (IJ) vascular access is necessary


   imagesWear surgical cap, eye protection, mask, sterile gown and gloves


   imagesDrape with sterile sheets to cover the patient’s head and legs


Note: Unless immediate emergent access is necessary, the procedure must be performed in full sterile technique (i.e., cap, eye protection, mask, sterile gown, and sterile gloves).


imagesAnalgesia


   imagesUse a small-bore needle (25 gauge) to anesthetize the skin and subcutaneous tissue with 1% lidocaine


imagesInsertion


   imagesInfraclavicular Approach


      imagesPlace the left index finger on the suprasternal notch and the thumb on the costoclavicular junction


      imagesThe needle insertion is at the bisection of medial and middle thirds of the clavicle


      imagesAim the needle toward the suprasternal notch with the bevel oriented inferomedially


      imagesAt a shallow angle to the skin, advance the needle just posterior to the clavicle at the junction of middle and medial thirds


      imagesApply posterior pressure on the needle to direct it under the clavicle, aiming toward suprasternal notch


      imagesThe needle should be parallel to the bed as it is advanced. Avoid advancing the needle posteriorly into the dome of the lung.


      imagesAspirate continuously while advancing the needle


      imagesIf redirecting the needle, always withdraw the needle to the level of skin first


      imagesOnce the vessel is located, free-flowing venous blood is aspirated


      imagesStabilize and hold the introducer needle in place with the nondominant hand


      imagesGently remove the syringe from the needle and occlude the hub with your thumb to minimize the risk of air embolism


   imagesSupraclavicular Approach


      imagesThe needle insertion is just above the clavicle, 1 cm lateral to the insertion of clavicular head of SCM


      imagesAim to bisect the angle between SCM and clavicle with the tip pointing just caudal to the contralateral nipple


      imagesDirect the needle 10 to 15 degrees upward from the horizontal plane, just posterior to the clavicle, again aiming just caudal to the contralateral nipple


      imagesThe needle bevel is oriented medially


      imagesNote that the SCV is found more superficially in the supraclavicular approach than in the infraclavicular approach


      imagesAspirate continuously while advancing the needle


      imagesIf redirecting the needle, always withdraw the needle to the level of skin first


      imagesOnce the vessel is located, free-flowing venous blood is aspirated. Successful puncture usually occurs at a depth of 2 to 3 cm.


      imagesStabilize and hold the introducer needle in place with the nondominant hand


      imagesGently remove the syringe from the needle and occlude the hub with your thumb to minimize the risk of air embolism


imagesSeldinger Technique


   imagesAdvance the guidewire through the introducer needle. The wire should pass easily. Do not force the guidewire.


   imagesAlways hold on to the guidewire with one hand. Never let go of the guidewire.


   imagesIf resistance is met, withdraw the wire and rotate it, adjust the angle of needle entry, or remove the wire and reaspirate with the syringe to ensure the needle is still in the vessel


   imagesWhen at least half of the guidewire is advanced, remove the needle over the wire. Keep one hand holding the wire at all times.


   imagesMake a superficial skin incision with the bevel of the scalpel blade angled away from wire


   imagesEnsure the incision is large enough to allow easy passage of the dilator


imagesDilation


   imagesThread the dilator over the guidewire, always holding on to the wire


   imagesAdvance the dilator through the skin into the vessel with a firm, twisting motion while holding the guidewire with the nondominant hand


   imagesRemove the dilator, leaving the guidewire in place


imagesCatheter Insertion


   imagesThread the catheter over the wire and retract the wire until it emerges from the catheter’s port


   imagesWhile holding the guidewire, advance the catheter through the skin into the vessel to the desired depth. Optimal depth depends on patient size and is typically 10 to 15 cm for the right SCV and 14 to 19 cm for the left SCV.


   imagesWithdraw the guidewire through the catheter


   imagesUse a syringe to aspirate blood from the catheter to confirm placement in the vein


imagesConfirmation


   imagesManometry


   imagesBlood gas analysis


   imagesSonographic confirmation of the catheter in the vein


   imagesPost procedure chest x-ray (CXR)


      imagesConfirm the catheter tip is in the superior vena cava just proximal to the right atrium


      imagesRule out pneumothorax


imagesFlush and Secure


   imagesAspirate, flush, and heplock all central line lumens


   imagesSuture the catheter to the skin by using silk or nylon sutures


   imagesCover the skin insertion site with sterile dressing (bacteriostatic if available)


COMPLICATIONS



imagesDysrhythmias


imagesArterial puncture or cannulation


imagesVessel laceration or dissection


imagesPneumothorax or hemothorax


imagesBrachial plexus injury


imagesPhrenic nerve injury


imagesTracheal puncture or endotracheal cuff perforation


imagesGuidewire embolism


imagesAir embolism


imagesCatheter tip embolism


imagesCatheter malposition


imagesVenous thrombosis


imagesInsertion site cellulitis


imagesLine sepsis


imagesLocal hematoma


ULTRASOUND-GUIDED CENTRAL VENOUS ACCESS



imagesUse of ultrasound guidance to place IJ and femoral central venous catheters has been shown to increase success rates and decrease complications


imagesCurrent literature suggests that the use of ultrasound guidance can be helpful when placing subclavian central venous catheters


SONOGRAPHIC TECHNIQUE



imagesPlace a high-frequency linear probe (5–10 MHz) just inferior to the middle and medial thirds of the clavicle with the probe marker pointed cephalad (a probe with a smaller footprint will allow better visualization of the subclavian anatomy)


imagesObtain a transverse view of SCV inferior to the clavicle and superior to the 1st rib. Use color flow and/or Doppler to distinguish the artery from vein (FIGURE 24.3).


imagesRotate the probe 90 degrees, visualizing the vein continuously, and obtain a longitudinal view of SCV. Because of the clavicle, the probe may need to be moved laterally to visualize the SCV as it becomes the axillary vein distal to the 1st rib.


imagesUse color flow and/or Doppler to distinguish the vein from artery (FIGURE 24.4)


imagesMaintain a longitudinal view of the SCV (stabilize the hand holding the probe on the patient’s chest to keep the probe in position)


imagesInsert the introducer needle at a 30- to 45-degree angle to the skin in line with the long axis of the ultrasound probe


imagesNote that the probe marker is facing the needle entry site and the needle should enter the skin directly next to the probe (FIGURE 24.5)


imagesThe needle must be parallel to the long axis of the ultrasound probe to be visualized


imagesThis in-plane approach allows direct visualization of the entire needle shaft and tip as it enters the vein and decreases the risk of pneumothorax and arterial puncture



images


FIGURE 24.3 A: Ultrasound probe inferior to the clavicle with probe marker pointed cephalad. B: Subclavian artery (SA, red) and subclavian vein (SCV) with color flow just superior to the 1st rib and pleural line (dashed line).

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Subclavian Vein—Central Venous Access

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